Boston Public Health Commission: A Story of Growth and Change

Author’s Note: At the time of this interview in summer 2015, Dr. Huy Nguyen served as interim executive director at BPHC. Monica Valdes Lupi was hired as the new executive director in 2015. Dr. Nguyen currently serves as medical director.

A Path to Public Health

Dr. Nguyen didn’t follow a straight path to public health. He grew up in New Jersey, came to Boston for college, and stayed for medical school. He wanted to do primary care in an urban setting, returned to Boston, and worked at Dorchester House—Dot House—Boston’s leading community health center, which served a large Vietnamese-American population. “I’m Vietnamese-American, so that was an attractive clinical setting for me.” Starting in 2003, he served as a primary care doctor. “There was a point in time actually when I was a resident, my residency clinic was at Harborview, which is the county hospital in Seattle. So all my preceptors were public health guys and gals. And they actually wanted me to do one of these Robert Wood Johnson fellowships, and I resisted; I just wanted to practice medicine.”

Perhaps his foray into public health was inevitable: “I was asked to give a talk about the work my health center was doing in implementing pediatric asthma treatment guidelines in an ethnically diverse patient population, and it was at that community health meeting, hosted by the Boston Public Health Commission, that I met my former boss, Dr. Barbara Ferrer. She brought me onto the team at a time when she was working on the integration of public health and primary care…. And primary care, which was once kind of the stepchild of medicine, is now being looked at as one avenue for healthcare reform. She was interested in bringing on a medical director that had some experience in primary care as we tried to look for opportunities to integrate our work both from a content and a programming standpoint, but also from a funding standpoint, into the kind of ongoing primary care transformation happening in Boston.” Dr. Nguyen became the part-time director in 2003, and still does pediatric care two days a week. When Dr. Ferrer left, he became the medical director, a post he held since 2014.

The Style of a Leader

Dr. Nguyen looks to past strong leaderships for guidance in those strong, visionary, goal-setting departments that are models of excellence. The importance of leadership across an organization is vital, and adopting a performance-improvement philosophy often requires a shift in thinking. For Dr. Nguyen, he had to make a shift from individual care to administration, yet not lose focus on care and the natural curiosity that drives him. A future leader must also be a generalist, maintaining conviction and commitment.

“I have been very fortunate that I have joined teams with a very strong workforce at the Boston Public Health Commission,” said Dr. Nguyen. “My particular style is to support staff to do their best work and to really try to bring staff from different service areas together to collaborate as much as possible. I have a particular perspective, having been in healthcare, so here in Boston, I have been working with staff to think about where we need to be, vis-à-vis the healthcare changes in our particular local public healthcare system in the next ten or fifteen years.”

For a medium-sized city, BPHC is a large- to medium-sized health department. It has 1,100 full-time employees (FTEs), and 300-320 members of its EMS service. “But I think one of the challenges of a rather larger local public health department is that we have large management teams, middle management teams, senior leadership teams.” When he first joined, under the leadership of Dr. Ferrer and then-mayor Tom Menino, they had been pushing for a health equity framework—not only at the Commission, but externally, with their partners throughout the city and in government, in the community and in healthcare. “Over the time I’ve been here, I have seen that mission or commitment mature. We’ve also had a number of opportunities for senior leadership of different service areas (we call them bureaus) for us to work very closely together.”

Some of that work has been driven by grants, including one from the CDC; large grants for chronic disease, and some of that has been driven by crises. “Here in Boston, one of our service areas is homeless emergency housing, so we have an emergency shelter, about 1,000 adults. They’re on an island in Boston Harbor, and one of our bridges went down—it was my third day on the job, so we had to relocate those services, and that required the coordinated effort of senior leadership of our teams and staff across the organization. From Boston EMS to IT to communications, and homeless and addiction services, we all had to work closely to get out of that crisis. And over the time I’ve been here, I think people here have had more opportunities to get to know each other and work together.”

For any shift—either incremental or seismic—to occur, what had to change for BPHC to incorporate the critical equity piece? How does leadership and the health department reinforce those changes? “Part of it has been just a shared understanding, and with that, a shared language or lexicon around what we’re talking about when we talk about health equity. What are we talking about when we use the word racism, or white privilege? And part of that has just been organizational culture. So becoming comfortable with a lexicon. All of us, both individually but also as service areas, as an organization, reflecting on our own biases, I think that’s kind of an ongoing process.

“We’re still challenged by continuing to make progress as an organization, and that has to do with making sure our internal policies are equitable. So as we move forward to make sure our services are high-performing, we also have to ensure that the systems serves both quality and equity services. We’re very conscience that our metrics are able to both measure and support us in making progress around equity, as well as health outcomes and wellness.”

In doing this work, so much involves listening. BPHC follow a very traditional framework, and try to persuade with the available local data that we have. “How that representation gets made, however, is very different… Boston is very healthy; we have good coverage rates and use of primary care. But where we fall down is in working with groups in the city, including communities of color. And then it becomes a conversation about people having an opportunity to reach their maximum health.”

“It’s challenging, there’s nothing easy about it, because we’re talking about issues at both the institutional level, interpersonal level, and in the end, it does come down to an individual bias, and the work that needs to be done.”

The Nexus of Equity and Healthcare

Everyone has a role to play at BPHC. Taking into account the Ten Essential Public Health Services, Dr. Nguyen believes that ensuring personal and population health is a key service. “I think people often wonder, ‘what’s the role of public health? Some people think of public health as just government, and what’s government doing, trying to local government trying to be involved in health care?’ That’s just one example, but we still have work to do in explaining the interconnectedness of the local public health system. Yes, in this particular regulation, we’re looking at healthcare quality, but if we’re looking at healthcare quality in terms of outcomes, like say, controlling blood pressure, I’ll be the first to say local public health has role in that. We have a role as local public health to make that gap improve. Let’s first create the infrastructure and the data to find the problems, and then let’s work together as a local public health system to make progress there.”

A Healthy Future

Boston’s story is one shared by many public health departments, and many of the questions are universal: * If accountable care organizations (ACOs) are forming, what are the possibilities? * Are the opportunities for us to be a part of global payment structure? * How do we address the challenges of payment reform? * How do we engage in behavioral health to address issues? * What is our role as a local public health department as community convener, provider and interpreter of data, and for finding solutions through the equity lens?

BPHC’s strategic plan is helping to answer these questions, as it considers growth and the investments it needs to make to be the health department of the future. BPHC is incorporating a full range of “health voices” — everyone from public health institutes to the schools to healthcare organizations. Taking a leadership role, the health department strives to speak authoritatively about the priorities of Boston residents, focusing on everything from data analysis to participating in community health planning. Health equity is a big part of the plan, starting with internal policies and then externalizing those policies to forge new partnerships, using a Health in All Policies approach.

“So in addition to responding to this need to have continuous quality improvement and performance management for accreditation, it’s clear to us, particularly in Massachusetts where were moving toward value-based payment models in healthcare, to participate in those plans or systems, we have to do a better job of having infrastructure to improve and to measure and demonstrate our value,” said Dr. Nguyen. “The other piece is informatics and surveillance. So as we have been working with the quality and health I.T. experts at the hospitals and community health centers around this data collection regulation, it’s been increasingly clear to us that we need to match the ability to produce population health data and analyses that healthcare is increasingly able to do. We’ve had lots of conversations around understanding meaningful use, and trying to update our surveillance capacity to respond to the healthcare I.T. environment here in Boston.”

Dr. Nguyen cited workforce development, which is one of BPHC’s strengths. To support a workforce that meets the needs of the community, the desire of our workforce to meet the needs of our community, which includes skill development and being able to retain a workforce that is representative of Boston.

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What drives you?

“I think that the team here and the staff at all levels is very much committed to the work. So I think that love of commitment to me is very inspiring. On days that I feel like I haven’t achieved anything, I do look to the great work that’s being done all around me, and that reinvigorates me and gives me a little boost for the next day.”

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When asked how he holds himself accountable, Dr. Nguyen said, “I think ultimately, it’s going to be setting goals and targets and making them known to people… I think the other part of it to surround yourself with people who are truly excellent and at the top of their game. You hold each other accountable for your work. But being explicit about your goals and what you’re trying to achieve is a very important step. And I think that’s what we’re moving toward as an organization and I certainly try to do that as an individual leader.”