In 2008, Walt Ekard, the Chief Administrative Officer for San Diego County, asked Nick Macchione, the newly-promoted director of the county’s Health and Human Services Agency, to address a complex and significant question: “How do we help San Diego become a healthier region for the entire county, representing more than three million residents?” Macchione responded by engaging his staff and an array of county, city, and community partners to develop a health strategy, which elected officials used as a launching point for what would become Live Well San Diego, a multi-pronged “vision for a region that is building better health, living safely, and thriving.” To achieve these goals, the county team planned to employ a variety of core strategies, including strengthening the service delivery system, effecting policy and environmental change, supporting positive choices, and improving the culture from within one’s organization. They also identified areas of influence (e.g., health and knowledge) to be measured by a set of key indicators. Above all, the fate of this initiative would hinge on the ability of the county team to establish trust and build an ecosystem that spanned organizational and jurisdictional boundaries, moving beyond politics. Macchione emphasized, “It’s about relationships. It’s about beliefs. It’s about integrity. It’s about legitimacy. It’s all about improving lives.”
While the vision for Live Well San Diego was inspirational, achieving it would require this team and their partners to address challenging questions. Could they create momentum and draw on lessons from related reform efforts of comparable government organizations? Could they improve synergy within the Health and Human Services Agency? Would the full community engage? Would Macchione and his colleagues be able to broach political topics and assuage the concerns of skeptics? Could they scale the Health and Human Services Value Curve and build a more efficient, coordinated, and thriving ecosystem that would make San Diego a safer and healthier region for decades to come?
Stretching from the Pacific Ocean in the west to the mountains and desert in the east to the world’s busiest international border crossing to the south to the Camp Pendleton military base to the north, San Diego County is a large, diverse jurisdiction that faces significant health and human services challenges. In 2017, the region was home to 3.3 million residents spread over 4,500 square miles of urban, suburban, rural, and agricultural communities. Across this diverse terrain, the region wrestled with a range of health and human services issues, including homelessness, poverty, the spread of infectious diseases, and health and wellness in military installations and sovereign Native American communities.
As Macchione and his colleagues leapt into action, they focused in part on how to build upon the progress achieved from earlier organizational reforms. San Diego’s journey along the Health and Human Services Value Curve had begun in 1998 when the county’s Board of Supervisors made two critical decisions. First, they introduced a general management system that established core business principles for the entire county government. According to Macchione, this positioned San Diego in the Health and Human Services Value Curve’s regulative stage. Second, they approved the merger of six separate county health and human services departments into a single agency. Completed in 1998, this massive merger helped San Diego advance to the collaborative stage of the Health and Human Services Value Curve by combining the six departments that had long worked on related issues, often for the same client populations, but could now coordinate more closely and effectively on strategy, priorities, and resource distribution. Ten years later, officials felt ready to take additional steps, but they recognized that they had to sustain the diligent spirit that had animated previous progress. “We have to be experts in the regulative space,” said Macchione. “We have one hand on regulative and the other stretched all the way to the generative stage while we manage everything in between.”
As the county team considered how to achieve real transformation, they realized that they needed a broader vision. As Macchione noted, the county’s reform push in the late-1990s had been driven by sweeping reforms in federal welfare policy, coupled with severe budget deficits. By 2008 and 2009, San Diego County was dealing with some profound challenges, including a growing number of adults and children struggling with chronic disease and rising healthcare costs. The skyrocketing cost of “sick care,” childhood obesity, diabetes, heart disease, strokes, cancers, and respiratory problems was costing billions of dollars in direct medical care expenditures within the county alone. The vast majority of these health problems were related to behavior and the environment in which one lives. At this time, the Health and Human Services Agency adopted a simple, actionable message and strategy: “3-4-50,” where three unhealthy behaviors (poor nutrition, lack of exercise, and tobacco use) led to four diseases (cancer, heart disease/stroke, diabetes, and respiratory illnesses) that were responsible for over 50 percent of deaths countywide. As the federal government debated health care reform, Macchione and his team decided to cast their net widely and focus not just on health reform but instead on emphasizing “wellness” via community engagement. Macchione explained, “We said, ‘We don’t want to do this by institution only. We want to take the opportunity now to do this with a real community-wide social movement.’” With the full backing of the Board of Supervisors, this is how the blueprint for Live Well San Diego took shape.
Over the next two years, using the focus on wellness and community engagement as guiding tenets, the county team completed the Live Well San Diego playbook. Pictorially captured in a pyramid, the framework illuminates the Live Well San Diego vision (“building better health,” “living safely,” and “thriving”); implementation strategies; areas of influence; and key indicators, the two most important of which, according to Macchione, are life expectancy and quality of life. (See sidebar for more details on the pyramid framework.) Macchione and his team—along with community partners, local economists, and researchers—then established metrics for each of these indicators. Displayed on an online performance dashboard and data access portal, these metrics allow the county to “measure the collective impact of efforts by the county, community partners, and stakeholders over the short and long term.” The framework allowed the county and its partners both to drill down into granular details and also to convey the program’s objectives with what Macchione characterized as “potent simplicity.” The goal was clear: help cut through complexity to see and achieve practical innovation.
He added, “That’s simply San Diegans helping San Diegans live well.”
The county team next faced the challenge of implementing their approach. From Macchione’s perspective, this first demanded implementing the Live Well San Diego vision in his 6,000-person agency. Macchione reflected, “We needed to realize, very importantly, what we were going to do with folks in the community, we had to do ourselves as well. This was very, very important because it was forcing us to change our culture from how we were operating inside government.” To facilitate this shift, Macchione introduced an action strategy focused on five key principles: “keep it simple”; “keep it local”; “keep it connected”; “keep it real”; and “keep it positive.” This required maintaining a sharp focus on Live Well San Diego’s overarching goal, promoting local wellness. It also involved introducing a new cutting-edge knowledge integration program, ConnectWellSD, to facilitate technological data systems integration and place an early focus on some of the region’s most-pressing problems. Above all, it entailed identifying ways to grow and remain upbeat in the face of adversity. Macchione therefore encouraged his team repeatedly to ask themselves— “How do we harmonize to humanize?”—and at the same time to remember that enduring “mockery by the present” will yield a payoff: “the betterment of the future.”
As Macchione and his colleagues generated internal momentum within the Health and Human Services Agency and then the entire county government, they shifted their focus to identifying community partners—including municipal governments, companies, and non-profits—that could help them to realize Live Well San Diego’s vision. Macchione and his team sought to partner with organizations that would pledge to advance the Live Well San Diego framework; support Live Well events (e.g., the Live Well San Diego 5K and health and safety fairs); and participate in community leadership teams, improvement plans, and leadership academies. , Establishing these partnerships entailed reconceiving the agency’s role as not just a service provider but also a trusted convener in a broader ecosystem. To illuminate this, Macchione introduced the metaphor of a wheel in which the Health and Human Services Agency was the hub and had spokes that extended to local partners. This embodied Macchione’s belief that, “We don’t consult with the community. We collaborate with the community in order to transcend and to get integrated in the generative space.”
Achieving this collaborative dynamic also required capitalizing on concrete opportunities. For example, in 2011, the mayor of Oceanside, a city in San Diego County, reached out about the possibility of partnering with the Health and Human Services Agency. To Macchione, this seemed odd because there was no working relationship between Oceanside and the county government over health and human services policies. Nonetheless, the county established a partnership with Oceanside—which was wrestling with serious health issues, including obesity—because it would help to advance the Live Well San Diego vision. Looking back, Macchione suggested that this helped to illustrate the advantages of having an inclusive platform. He reflected:
That opened our eyes to say, ‘Look at the resources we had and the remarkable effort of having a city not actively engaged and working in health in all policies, come along as wellness being the unifier.’ … We said, ‘It’s about all San Diegans living well and that we could only live well if we all live well.’
By the end of 2014, Live Well San Diego had forged 51 community partnerships, and in the process, it had helped to foster an atmosphere of accelerated trust that gave Live Well San Diego a vital attribute for ascending the Health and Human Services Value Curve: legitimacy. Macchione elaborated, “Live Well San Diego is about improving lives and helping people live well, and that’s good for the Live Well partners because then there’s legitimacy. Public trust fosters an environment of empathetic listening and understanding and can translate into meaningful action and community benefit.”
Over the next two years, Macchione and his team deepened Live Well San Diego’s impact in their agency and across the community, where they helped to forge more than 250 additional partnerships. However, they also realized that to reach the generative stage of the Health and Human Services Value Curve, they needed to integrate Live Well San Diego into the county government’s broader strategy. This was challenging because, even though senior county officials had supported the creation of the Live Well San Diego framework, county staff still were learning what Live Well meant and how it was reflected in their work. Macchione—who noted that some community stakeholders still did not believe in Live Well San Diego’s impact—explained, “Mockery lane for me included some good friends and key community partners.”
Macchione and his staff addressed this skepticism in several ways. First, they evinced what Macchione characterized as “fierce determination and integrity,” rooted in their “conviction that what they were doing was not for themselves, but their whole families and neighborhoods.” Second, when attempting to persuade community stakeholders to integrate Live Well San Diego into a broader countywide strategy, they communicated strategically. Instead of discussing sensitive issues and programs (e.g., poverty and minimum wage), they framed wellness in economic terms likely to resonate with all of the stakeholders. “It’s the healthy bottom line,” Macchione said. “Healthy people, healthy communities, [and a] healthy economy.”
Through persistence and open communication, county officials saw the value in incorporating Live Well San Diego into the county’s fiscal year 2016-17 budget. This was critical because, as Macchione said, an organization’s “budget is a reflection of [its] strategy.” What’s more, this facilitated the creation of enterprise-wide performance indicators and outcomes that the county could impact. This was because Live Well San Diego “us[ed] a shared measurement system [that] allows all partners to focus collective efforts and track collective progress.”
Specifically, individual county departments could now craft strategies and performance metrics that fed into the overall metrics, enterprise performance indicators, and areas of influence identified in the Live Well San Diego framework. For example, one of the enterprise performance indicators is economic wellbeing; this is measured in part by housing affordability (i.e., the percentage of the population spending less than a third of household income on housing). With this goal and metric explicitly identified in the county framework, the county’s Land Use and Environmental departments, Health and Human Services Agency, and Public Safety departments began amplifying and coordinating their respective efforts to issue new housing permits, build new housing units, and provide housing-related community services and supports. Several county agencies were working together to realize an integral objective in the Live Well San Diego framework.
Of the significance of these new cooperative efforts, Macchione added, “That has been a colossal shift, that we now have an inclusive vision with an understanding of what we’re all attempting to do in helping San Diegans live well by building better health, living safely, and thriving, and defining the strategic approaches about delivery systems.”
Seven years after launching Live Well San Diego, Macchione and his colleagues recognize that fully realizing this vision means that it will continue to evolve and essentially be an ongoing work in progress. Demographics, political leadership, public policy, and economies are dynamic. Live Well San Diego stakeholders understand that there will therefore always be a need for repositioning, course correcting, and refreshing their efforts in continual pursuit of the Live Well San Diego vision. For example, San Diego continues to face significant health issues, such as a recent hepatitis A outbreak. The Live Well San Diego movement also continues to evolve, now developing a generative governance model and connecting siloed data systems.
Nonetheless, Live Well San Diego has already made an extraordinary impact. As of November 2017, Live Well San Diego had 331 partners, allowing the movement to touch over 75 percent of county residents. Many of the key performance indicators exceed state and national averages. Above all, the county team has demonstrated how a collaborative ecosystem can propel a community along the Health and Human Services Value Curve. Macchione concluded, “Government can’t do it alone. Non-profit can’t do it alone. For-profit can’t do it alone. But, collectively, we can.”
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