Transformation Project Report

Transformation
Project
Results and
Recommendations
Office for State, Tribal, Local,
and Territorial Support
(OSTLTS)
May 2010

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Table of Contents
Background ....................................................................................................................................... 3
Approach........................................................................................................................................... 5
Phase 1: Assessment .......................................................................................................................... 5
Phase 2 and 3: Analysis and Feedback ................................................................................................ 8
Analysis ............................................................................................................................................. 9
Introduction ...................................................................................................................................... 9
Findings ............................................................................................................................................. 9
Leadership................................................................................................................................ 9
Structure ................................................................................................................................ 11
Process ................................................................................................................................... 13
Workforce .............................................................................................................................. 15
Recommendations ........................................................................................................................... 17
Concluding Thoughts ....................................................................................................................... 20
Appendix ......................................................................................................................................... 21
Shared Behaviors Analysis................................................................................................................ 21
Interview and Focus Group Guide..................................................................................................... 28

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I.

Background

The Office for State, Territorial, Local and Tribal Support (OSTLTS) mission is to improve the performance
and capacity of the public health system. OSTLTS was formed in 2010 as the result of the Centers for
Disease Control and Prevention’s (CDC) Organizational Improvement efforts. As OSTLTS further establishes
its operational structure, it will face the challenges of improving linkages and relationships with STLT public
health agencies, while also creating a sense of shared ownership of public health policy and practice.
The Office has the opportunity to lead CDC through this transitional period in its history. A significant
challenge is to identify the areas where improvements can be made to shift CDC’s culture toward
constructive relationships with State, Tribal, Local, and Territorial (STLT) health agencies. In order to identify
the strategic and operational areas for improvement and better understand the relationship dynamics,
OSTLTS contracted with Deloitte Consulting to lead a cultural transformation project.
The objective of the project is to identify cultural dimensions and to develop high-level recommendations
to address any areas of improvements. The project commenced on February 18, 2010 with a stakeholder
assessment of a cross-section of STLT health agencies, national partner organizations, and CDC leadership
and staff. The project team facilitated 33 interviews and 19 focus groups with 134 stakeholders. This
report is the output of the stakeholder assessment and represents a best effort to reflect the tone,
substance, and key themes from the separate facilitated sessions.
Defining Culture for the Purposes of This Project
Culture as a social construct has many definitions and meanings depending on the circumstances in which
the term is being used.
•

•

•

•

Culture is shared: there are no cultures of one“Culture eats strategy for breakfast.”
culture is defined as shared, learned behaviors
- Mark Fields, President
among members of a group.
The
Americas
Ford Motor Company, 2006
Culture is learned: it amounts to those rules,
norms, and practices that we teach and
perpetuate.
Culture is complex: it is an amorphous component of an organization that is not easily defined or
gauged; there are sometimes multiple layers of cultures and sub-cultures that could exist within an
organization.
Culture is hidden: a major aspect is the unwritten rules that govern how individuals interact with
one another, including how employees or partners work together and behave with one another in
pursuit of their work.

Culture encapsulates unique shared values, beliefs, and practices, and influences the acceptance and
adoption of behaviors, procedures, policies, and other social constructs. Therefore, culture plays a major
role in the success or failure of interventions by affecting the way people perceive and respond to a
message or strategy.
For the purposes of this report, organizational culture is defined as the set of shared attitudes, values,
goals, and practices that characterizes an institution, organization, or group. Since culture is shared, there
are three ways a person learns a culture: direct teaching (being told what is “right” or “wrong” in a given
context); observation (watching others operate within the culture and imitating or emulating that
behavior); and subconsciously (through events and behaviors that prevail in the given culture). All three
avenues happen simultaneously and rather continuously. But just as culture impacts organizations, there
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are a variety of ways that an organization can influence culture. For the purposes of this report, these
influencers are called organizational levers and they include: leadership, structure, process, workforce, and
rewards. These drivers can act as levers to impart cultural changes, by emphasizing or deemphasizing
elements of each to modify behaviors and outcomes.

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II. Approach
As illustrated in Deloitte’s Assess and Sustain Culture Methodology in Figure 1, a cultural transformation
effort is based on a comprehensive and iterative approach. The current effort only explored the first stage
with the phases of: Assess; Analyze; and Feedback. The assessment included activities such as gathering
data, conducting interviews / focus groups, and developing an initial
hypothesis. The analysis identified the implications and
opportunities presented in the data and examined implicit
values and shared beliefs.
Finally, the findings are
aggregated and provided as feedback to the organization in
question.
In order to sustain and develop culture, leaders must next
Plan and Mobilize changes to behaviors, symbols, and
systems, Adopt and Accelerate these efforts to instill a
sense of urgency in the changes required, and embed
them in the organizational fabric though the use of the
organizational levers. Lastly, leaders must make the resource
commitments and investments to Make it Stick for the longterm. Understanding and driving culture change, or sustaining a
positive culture, is an intentional and deliberate process.

Phase I: Assessment

Figure 1-Assess and Sustain Culture Methodology

The first phase of this initiative was designed to provide in-depth insight into the connections between and
across CDC, State, Tribal, Local, and Territorial health agencies. The assessment data were gathered
through interviews and focus groups. This first phase set the stage for the subsequent analysis and
feedback phases, allowing the project team to identify and document the following:
•
•
•

Perception of current relationships within CDC and between CDC and STLTs.
Perceptions of systemic partnership issues and challenges between CDC and STLTs.
Recommendations for improving partnerships.

Description of Stakeholders
Individual and focus group interviews were conducted with a subset of three stakeholder constituencies
(each described below):
•
•
•

Internal CDC staff
State, Tribal, Local, and Territorial health department staff
National partner organizations

CDC Internal Staff
Stakeholders in this category were selected for participation based on their position within the Agency and
the level of involvement with State, Tribal, Local and Territorial public health activities. Individual
interviews were conducted with Directors from CDC Offices that have frequent interactions with various
STLTs.
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Focus groups were convened with Division Directors and critical program staff from these same Offices.
Interview and focus group participation for the CDC internal staff were as follows:
Stakeholder Type
Center/Office Directors
Division Directors
Program Staff
TOTAL

# of Interviews
14
1
0
15

# of Focus Groups
0
2
2
4

# of Participants
14
18
22
54

State, Tribal, Local and Territorial Health Agencies (STLT) Stakeholders
STLT stakeholders were selected for participation based on the following criteria:
•
•
•
•
•

Total FY09 grant funding received by the STLT agency through CDC
Length of relationship with CDC
Geographic representation (per the HHS regions)
Input from CDC Tribal Liaisons
Other subjective factors (e.g., the project team sought a mix of participants who would likely
provide a variety of perceptions of CDC/STLT relationships, ranging from favorable to unfavorable)

Individual interviews were conducted with Directors from STLT health agencies. Following the interviews,
Directors were asked to nominate program staff with frequent CDC interaction to participate in focus
groups. The following table provides a geographical representation of the STLT participants from the
interviews and focus groups:
Stakeholder Type
States
Territories
Localities
Tribes
TOTAL

# of Interviews

# of Focus Groups

# of Participants

6
2
7*
1
14

3
0
6
3
14

20
2
31
12
65

*Includes pilot interview with New York City

National Partner Organizations (NPO) Stakeholders
National partner organizations were selected for participation based on their extensive knowledge of
relationships between CDC and STLT agencies. The interview list included both leadership and key program
managers from the following organizations:
•
•
•
•

Association of State and Territorial Health Officials (ASTHO)
National Association of City and County Health Officials (NACCHO)
Council of State and Territorial Epidemiologists (CSTE)
Public Health Informatics Institute (PHII)

Interview and focus group participation for the NPO stakeholders was as follows:

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Stakeholder Type

# of Interviews

# of Focus Groups

# of Participants

4
4

1
1

9
9

NPO
TOTAL
Interview and Focus Group Structure

At the onset of the project, the Acting Director of OSTLTS distributed communications via email to the
selected stakeholders, outlining the purpose of the project and requesting their participation in the effort.
Following the initial announcement, staff from OSTLTS and Deloitte contacted stakeholders individually to
confirm their participation and schedule interviews based on availability.
Stakeholders were then asked a series of 14 questions designed to elicit various dimensions of culture, such
as:
•
•
•
•

Norms: The social groups’ expectations concerning appropriate behavior.
Attitudes: Collection of beliefs with an evaluative aspect; tendency of mind/relatively constant
feeling toward a certain category of objects, persons, or situations.
Beliefs: A conviction that a phenomenon or object is true or real.
Values: Justification of one's actions in moral or ethical terms (right/wrong; good/bad).

To assist in identifying cultural attributes for further examination, interview and focus group questions also
gathered information related to the enabling organizational levers that have significant impact on culture.
These levers below are instrumental to making cultural adjustments in organizations, helping to impact the
actions and behaviors of individuals operating within the system of interest:
•

•

•

•

•

Leadership: Direction and strategy reflected in the
style of conduct and the overall alignment of
alignment between CDC and the STLT agency
leaders.
Structure: Power and decision making consisting of
the governance, controls, roles and responsibilities,
and the formalization of the working relationship
between (for our purposes) CDC and the STLTs
agencies.
Processes: Information and communication
regarding the policies, processes, and procedures
within CDC and between CDC and the STLTs
agencies.
Workforce: Skills and attitudes of the diverse set of
individuals at each level of the public health system
whose prime responsibility is the provision of core
public health activities.
Rewards: Motivation (not included in the project per
OSTLTS direction).

Leadership

Rewards

Structure

Culture
Transformation

Workforce

Process

Figure 2-Organizational Levers

Each facilitated session included a Deloitte interviewer teamed with a note taker. The interviewers
introduced themselves and explained all ground rules to the participants. Respondents were informed
their participation was voluntary, and their responses would be kept confidential. Note takers documented
the sessions, capturing the key themes rather than capturing a full-fledged transcript of the meeting.
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For focus group candidates, CDC and STLT interview stakeholders were asked to recommend program staff
that could provide insight on the relationships between CDC and STLT agencies. If a stakeholder was
unavailable to interview, the primary stakeholder identified a secondary contact for potential participation.
In 3 separate instances, the project team was unable to conduct an interview or focus group with the
program staff due to participant non-responsiveness (specifically California, Hawaii, and Louisiana). Overall,
the participation rate from stakeholders was favorable: 100% for interviews and 86% for focus groups
across all stakeholders between planned and actual participation.
Leveraging existing, established relationships with CDC staff members and STLT agencies, Deloitte and
OSTLTS staff managed logistics and communications with stakeholders. Similarly, the CDC Tribal Liaison
worked with Tribal governments to identify participants and determine their availability. Each participant
was sent a “thank you” email following the conclusion of their session with a point of contact for any
questions.

Phase II and III: Analysis and Feedback
The second phase involved identifying, documenting, and synthesizing the gathered data into overall
observations. This effort incorporated standard qualitative stakeholder assessment practices. After each
interview or focus group session, note takers and interviewers conducted an inter-rater reliability review of
all session notes, and confirmed with members of the content review team that interpretations were valid
and reliable. Interviewers and subject matter experts completed a comprehensive review of the data for
each facilitated session. The information was tagged and translated into relevant, associated cultural
dimensions (i.e., norms, attitudes, beliefs or values). A presentation of this analytic process is provided in
Appendix 1. As interviews and focus groups continued, conceptual groupings across the dimensions were
then aggregated into themes and sub-themes.
Finally, the project team synthesized the interview and focus group discussions into findings and
recommendations presented in this report. The characterizations listed thematically below reflect the
“sentiment” of many of the sessions (sometimes providing the participants’ actual words as verbatim
quotes). Comments and quotes are presented for illustrative purposes to evoke the overall perceptions
and ideas conveyed by participants.

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III. Analysis
Introduction
Traditionally, culture is observed from either emic or etic perspectives, or a combination of the two. An
emic perspective comes from the insider, from the established member of the culture in question. CDC
staff and leadership interviewed by the project team provided this internal perspective in their answers. An
etic perspective, on the other hand, represents the outsider point of view. Staff and personnel from the
STLTs provided the outsider’s perspective in their answers and comments. An etic perspective is important
in that it allows the culture to be seen with “fresh eyes,” and allows for biases to be identified and
addressed. This project purposefully included both emic and etic perspectives to attempt to identify
cultural attributes at work within CDC and in the dynamic between CDC and the STLTs.
Organizationally, entities with strong cultures work diligently to align cultural attributes to their operating
strategies. Successful organizations leverage their cultures to design systems, process, policies, and
performance metrics in ways that reinforce the values, behaviors, and norms at work within the
organization. When properly aligned, a strong organizational culture can be a primary catalyst for
outstanding performance and results. When misaligned, culture becomes a source of resistance and a
hindrance to successfully executing against strategy. Thus, identifying these attributes and the
accompanying enculturation and acculturation phenomenon at work can allow OSTLTS to address
opportunities that encourage strong collaborations and obstacles that hinder them.
Below, the findings have been expanded to indicate the thematic elements that emerged through recurring
responses from our interviewees and focus group participants. Findings are followed by a set of
recommendations that emerged from synthesis of the results of our data collection and are meant to be
considered alongside the other components of this report. Recommendations range from general, broad
areas to more explicit, specific, and actionable suggestions.
No single organization can bring these recommendations to fruition solely; rather, a strategic cooperation
with all stakeholders is critical in order for CDC to achieve its objective of strengthening relationships with
STLTs. Collaboration and partnership are core fundamental messages of this report; it is recommended
that further action planning be conducted alongside various groups and stakeholders, with each taking
responsibility for key actions in order to drive change across the public health system.

Findings
1. Leadership
• Direction and strategy reflected in the style of conduct and the overall priorities alignment
between CDC and the STLT agency leaders.
a. Dr. Frieden’s establishment of OSTLTS and
overtures toward STLTs is a positive sign
and STLTs are cautiously optimistic about
improving relations. STLTs appreciate
communication and interaction from senior
level CDC Leadership since Dr. Frieden
became Director. However, they are
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“The very fact that CDC is tapping into
the broad range of expertise and public
health knowledge around States to
gather input sends a strong signal that
the Agency is serious about establishing
successful relationships with States.”
- State Health Department Participant
9

cautiously optimistic to see if this is a fleeting attempt or a sustained practice. CONTRIBUTING
STAKEHOLDERS: States, Locals, Tribes
b. CDC should connect STLTS with other federal agencies to help build the link between
detection and intervention. These linkages take time to create and require dedication from
CDC Leadership; however, the payoff of these collaborations can be enormous. For example,
The National Center for Environmental Health collaborates with HUD and EPA to eradicate child
lead poisoning. Children in low income housing may be screened by their Local health
department for lead poisoning, but prevention can occur by changing the housing situations
through groups like HUD. Linking such programs is critically important and STLTs look to CDC to
facilitate these linkages. CONTRIBUTING STAKEHOLDERS: CDC, States, National Partner
Organizations
c. Frequent changes in priorities and approaches lead to breakdowns in relationships. STLT
long-term planning is difficult due to a lack of continuity of public health priorities. Credibility
will erode if CDC begins a pattern of priorities that are the result of political pressures and not
rooted in the public health mission. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals,
National Partner Organizations
d. STLTs appreciate “face time” with CDC Leadership. Site visits from CDC Leadership are met
with positive response from STLTs, particularly when they are collaboratively planned and
conducted with upfront design input from the STLTs. CONTRIBUTING STAKEHOLDERS: CDC,
States, Locals, National Partner Organizations
e. STLTs want to see CDC serve as the “facilitator.” STLTs reported that CDC does not need to
serve as the sole entity responsible for setting
“OSTLTS should play the role of
priorities, but rather recognize the role of the
facilitator and not the “superstructure”
STLTs in their own priority setting and serve to
role that State and Local public health
facilitate the development of health and
departments find burdensome.
program priorities to be implemented through
- CDC Participant
collaboration. STLT collaboration is difficult in
the absence of formalized mechanisms and
conveners. CDC is positioned to facilitate best practices sharing amongst STLTs. CONTRIBUTING
STAKEHOLDERS: CDC, States, Locals, Tribes
f.

Breaking down the silos within CDC requires strong endorsement and support from CDC
Leadership. Cross-Agency collaboration is difficult; it is much easier to work within
programmatic silos. CDC Leadership has prioritized collaboration, but it will take continued
endorsement from the most senior levels of the organization to bring about changes in the way
CDC staff operate. CONTRIBUTING STAKEHOLDERS: CDC

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g. Unique public health priorities exist for Tribes, which are often overlooked in the
establishment of national public health priorities. Priority setting fails to recognize and
incorporate unique cultural aspects of Tribes and life on reservations in Indian Country. CDC
has a history with Tribes of being “sympathetic” to issues on reservations, but there is a need
for more tangible commitment to addressing specific health issues. CONTRIBUTING
STAKEHOLDERS: Tribes
2. Structure
• Power and decision making consisting of the governance, controls, roles and responsibilities,
and formalization of the working relationship between (for our purposes) CDC and the STLT
agencies.
a. STLTs are looking for true collaboration from CDC and not transaction-oriented interactions.
STLTs reported relationships were less successful when CDC played a more authoritative role
(e.g., as “bean counters” or the “big brother from an ivory tower”) rather than collaborating on
public health issues or programs. STLTs view CDC as approaching public health issues from a
federal perspective, rather than a national perspective (i.e., perspective that integrates all
levels of public health and their unique roles). STLTs appreciate transparency and frequent
communication from CDC, and a customer service orientation. CONTRIBUTING STAKEHOLDERS:
CDC, NPOs, States, Locals, Territories, Tribes
b. Weak internal CDC collaboration has downstream effects on STLT relationships. Programs
within CDC are siloed, and there is a perception that CDC does not recognize cross-cutting
public health initiatives. For example, there are strong linkages between the cancer and
tobacco programs within CDC, but there are not shared performance measures between these
programs that promote holistic health outcomes. CONTRIBUTING STAKEHOLDERS: CDC, States,
Locals
c. STLTs look to CDC for support in basic public
health capacity building activities for which
they do not have funding and resources.
Examples of these basic public health capacity
activities are policy, evaluation, research, and
technical assistance. STLTs value CDC’s
contribution to building this capacity.
CONTRIBUTING STAKEHOLDERS: CDC, States,
Locals

“At the Local level we don’t have
statistical support, and the fact that
CDC isn’t able to provide this, is a big
problem.”
- Local Health Department Participant

d. One size does not fit all when CDC implements grant requirements and programs. There is
great variation among STLT public health priorities due to regional economic, demographic, and
cultural differences, and STLTs perceive CDC as ignoring those differences in favor of a “one size
fits all” approach. For example, urban health issues are very different between east and west
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coast cities, and may require different approaches to achieve the same health outcome. While
there are winnable battles that can be applied across geographic areas, the approaches used to
achieve success may be different. LHDs feel since their focus is on implementation, their
perspective should be taken into account when addressing these winnable battles. In addition,
compliance with grant requirements is not always realistic for some Tribes with resource
constraints. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals, Territories, Tribes
e. STLTs have difficulty navigating the CDC hierarchy. In times of crisis, STLTs have had
difficulties contacting the appropriate individuals within CDC. There is a general lack of
awareness and working familiarity of the structure and hierarchy of the Agency. CONTRIBUTING
STAKEHOLDERS: CDC, States, Locals
f.

OSTLTS needs to demonstrate value to internal and external stakeholders. STLTs and CDC
staff expressed concern that the creation of a new Office (OSTLTS) will add an additional layer
to CDC bureaucracy instead of supporting and improving existing processes. On the other
hand, Locals, Tribes, and Territories were eager to have a voice within CDC, which they see as
core function of the new Office. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals

g. States and Locals have differing perspectives on the appropriate method to engage and
support Local health departments. States
“It is problematic to have multiple
often believe Localities should not supersede
funding lines to States and cities. This
established hierarchies in the funding chain,
sets up a geopolitical battle.”
applying directly to CDC for their funds.
- State Health Department Participant
Conversely, Locals feel they should receive
direct support and engagement from CDC.
Locals believe that the way CDC funds States and Locals can unintentionally create
disadvantages for large Local health departments. For example, there is a perception that in
decentralized States, State health departments spend most of their time and energy working
with the least capable Local health departments. This results in little time and available budget
for larger Local health departments. CONTRIBUTING STAKEHOLDERS: States, Locals
h. Many of the U.S. Territories are autonomous and operate as an “all-in-one” public health
agency. CDC treats Territories like States; however, they do not have local jurisdictions that
perform public health functions. Territories are not given adequate funding to meet the same
requirements and expectations as States, which often means they have a greater need for
technical assistance. CONTRIBUTING STAKEHOLDERS: Territories
i.

The structure of Tribal governance differs greatly from how CDC operates. The use of more
junior CDC staff to build relationships with Tribal leadership is incompatible with Tribal cultural
practices and norms (e.g., Chiefs interact with Chiefs, and anything less than that is perceived
as disrespectful). CDC sometimes attempts to address issues individually with a Tribe, while

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many Tribes have organized in multi-Tribal organizations providing consolidated services.
CONTRIBUTING STAKEHOLDERS: Tribes
j.

Tribal funding through the States assumes Tribal geography is roughly equivalent to that of a
Local, which is often inaccurate. Tribes often span State borders, and currently Tribes have to
receive funding from all the States of which it is a part. Within a State, there may be multiple
Tribes, all with unique needs. CONTRIBUTING STAKEHOLDERS: Tribes

k. Local health departments generally have little interaction with CDC. Outside of a few large
jurisdictions, CDC does not have direct
“For most Local health departments, CDC is
working relationships with Local health
an impenetrable black box; no more real
departments (LHDs). LHDs frequently
than the CDC logo on a poster.”
reported an absence of interaction with
- Focus Group Participant
CDC, which by its very nature precludes the
potential for partnership. The majority of
Local health departments rely on State health departments to engage with CDC staff or
programs. CONTRIBUTING STAKEHOLDERS: Locals

3. Process
• Information and communication regarding the policies, processes, and procedures within CDC
and between CDC and the STLTs agencies.

a. Long term planning is difficult for STLTs who
“It takes a certain infrastructure to write an
are dependent on grant funding. The federal
effective grant and develop the statewide
appropriations process is not conducive to
program. When there are mandatory
long term planning for STLTs who are
furloughs, budget cuts, and personnel cuts,
there is not a realistic opportunity to write
dependent on these funds. Changing CDC
several grants.”
priorities impact the continuity of funding and
hinder effective long term planning,
- Local Health Department Participant
specifically since programs are not informed
of funding cuts until later in the process. The
administrative process of using carryover dollars from previous fiscal years is burdensome and
affects STLTs’ ability to effectively use grant funding. CONTRIBUTING STAKEHOLDERS: CDC,
States
b. STLTs want complete, accurate, and explicit grant guidance with flexibility to adapt funding
to localized needs/circumstances. STLTs want specificity in terms of what CDC expects, but
also want CDC to allow for flexibility in the
“CDC does its best when it provides
approach they take to implement. STLTs
broad guidance, expertise and it does
believe too much specificity in grant
its worst when it micromanages STLT.”
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- Local Health Department Participant

13

implementation guidance hinders their ability to be innovative. When guidance is too general,
STLTs often do not have the capacity or thorough understanding of CDC’s expectations to
translate into practical activities. CDC also does not actively incorporate external factors (such
as the economy) into grant program
“If money is given with too few
requirements, which can impact grantee’s
guidelines, it tends to diversify to
ability to successfully implement programs.
relatively ineffective activities. There
When STLTs are required by their executives to
needs to be a balance of oversight and
cut budgets, positions, or discretionary funding,
support.”
they are less able to meet grant requirements
- CDC Participant
for funding staff positions, or conducting other
activities. CONTRIBUTING STAKEHOLDERS: CDC, States, NPOs, Locals
c. There is a lack of consistency in the sharing of data with and across STLTs. CDC has access to
large data sets, but a standardized process for proving this data to STLTs when it is needed does
not exist. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals
d. Grants management is administratively
burdensome on STLTs and diminishes their
“Managing the grant isn’t the job; it is
ability to do true public health work. Grants
just the mechanism for improving
health outcomes.”
requirements for staffing and program
management often reduce the availability of
- State Health Department Participant
funds for actual programmatic work. These
tasks, required by various funding streams, can also duplicate existing roles within STLTs.
Multiple staff positions across programs and silos between CDC programs often lead to multiple
layers of communication channels with the same STLT grantees. As a result, confusion and
inefficiencies exist in the grants management process. Grantee efforts are dedicated toward
administrative aspects of individual grant activities, rather than focusing on holistic public
health outcomes. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals
e. STLT capacity-building is neglected in favor of
“Silos need to be broken down and CDC
siloed, disease-specific grant programs. STLTs
should recognize that public health is a
reported significant programmatic and
continuum and not separate entities.”
relationship benefits when CDC committed to
- State Health Department Participant
significant capacity building investments. The
positive relationship outcomes of capacity
building emerged from intense focus from CDC experts with a smaller group of funding
recipients. CONTRIBUTING STAKEHOLDERS: CDC, States, Local, Tribes, Territories
f.

CDC must work to find balance between scientific standards of perfection and useful program
information. While many at CDC see the value of and a role in providing scientific and
evidence-based practice recommendations to the States, CDC’s admirable focus on strong
scientific research sometimes minimizes its role in dynamic situations. CDC must be responsive,

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even if it means putting out a solution that will evolve and change. Advocating piloting efforts
can enhance response time. While STLTs
seek CDC support for innovation, they often
“From an attitude and process aspect,
CDC has a way of stifling new ideas and
feel CDC’s focus on science takes
innovation.”
precedence over innovation assistance.
Some interviewees viewed CDC’s support
- CDC Participant
for innovation (when applicable) as a sign of
trust and support for collaboration. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals,
National Partner Organizations
g. CDC grant programs require seemingly disconnected and confusing performance metrics,
even when health outcome goals are related. Public health outcomes, such as decreasing
childhood obesity, often incorporate related CDC programs that may have separate process
measures. The disparate measures can lead to poor results in collecting and comparing
program performance. CONTRIBUTING STAKEHOLDERS: CDC, Locals
h. Tribal surveillance activities and data sharing and ownership protocols are not well
established. Results and applied actions based on those surveillances are not appropriately
established or executed. There were specific issues in obtaining H1N1 funding for resources
and vaccination. Tribal data is often too generic and not Tribe-specific, being controlled by the
States and not the Tribes themselves. Data sometimes is shared externally before being shared
with Tribal groups, which represents a profound cultural clash and undermines the Tribes’ trust
of CDC. CONTRIBUTING STAKEHOLDERS: Tribes
i.

National Partner Organizations should be included in the policy decision-making processes.
CDC has been successful when it has collaborated, included, and made a sincere commitment
to share information and policy-making authority with National Partner Organizations (e.g.
H1N1). As a conduit to CDC and their STLT membership, NPOs can serve as a mechanism for
relaying information and identifying emerging trends and issues. NPOs expressed a willingness
to align priorities, measures, and outcomes with OSTLTS. CONTRIBUTING STAKEHOLDERS:
National Partner Organizations

4. Workforce
• Skills and attitudes of the diverse set of individuals at each level of the public health system
whose prime responsibility is the provision of core public health activities.
a. Each member of the public health system represents different perspectives and skill sets.
A consistently reoccurring theme that emerged from all stakeholder groups was the need for
CDC to engage stakeholders in the formative stages of strategy development, and then
acknowledge and leverage the unique expertise that resides in STLT health departments.
CONTRIBUTING STAKEHOLDERS: CDC, States, Locals, Territories, Tribes
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15

b. CDC must demonstrate respect for STLT
“In outbreak investigations, there is a
expertise “on the ground.” STLTs reported
perspective that CDC takes is patronizing.
only a few success stories where CDC
They come in and take over roles and
engaged them in a meaningful way to learn
responsibilities, and it becomes very
what was happening “on the ground.” STLTs
messy. This happens often, so it makes
almost universally said such interactions
Locals very reluctant to want to
represent a key barrier to true collaboration
cooperate.”
between CDC and STLTs. Many STLT and CDC
- Local Health Department Participant
respondents touted CDC’s response to H1N1
as a successful example of the type of
collaboration STLTs are seeking. They reported that during the H1N1 response, CDC
consistently engaged with State and Local health departments and accepted their perspective
as valid and equal to CDC’s own. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals
c. Positive perceptions of interactions with CDC are often built on strong personal relationships
at the individual level. STLTs and CDC
“Having an EIS Officer has changed
experiences with strong relationships are most
everything”.”
often based on the personal relationships that
- Local Health Department
staff on either side may have, rather than on any
Participant
one defined process that helps these
relationships to succeed. CONTRIBUTING
STAKEHOLDERS: CDC, States, Locals, Tribes, Territories
d. STLTs struggle with the Project Officer’s role
“Project Officers seem to rotate out of
and process. At CDC, Project Officers (POs) often
projects in about 6-9 months. This
are mainly focused on the administrative aspects
practice is not effective in building
of the grants which creates a disconnect
relationships; right as the Project
Officer learns about the program,
between STLTs and CDC regarding the role of the
they rotate out to another project.”
PO. In such circumstances, STLTs may develop
the impression the CDC POs do not have
- State Health Department Participant
requisite public health insights. If the right
people are in place and they are focused on the right things (such as the STLTs priorities), the
PO structure works very well. However, frequent turnover in POs due to CDC organizational
decisions impacts STLT relationships with CDC. Additionally, having multiple POs assigned
within one STLT can cause undue challenges to clear communications (by adding multiple layers
and players to such interactions). CONTRIBUTING STAKEHOLDERS: CDC, States, Locals, Tribes,
Territories
e. The State Management Official role has not been widely implemented. There is inconsistency
in how SMOs are perceived within State and Locals, as well as at CDC. Many within CDC
consider SMOs to be a valuable aspect of the Futures Initiative, and States with exposure to
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SMOs provided positive feedback. However, many CDC staff and States also had little
interaction and experience with the SMOs, indicating that the program was not consistently
implemented. CONTRIBUTING STAKEHOLDERS: CDC, States, Locals

Recommendations
Transformation projects usually alter structures, work processes, systems, relationships, leadership styles,
and behaviours that together create what we know as organizational culture. A modified culture stems
from the agency’s overall strategies, can gain strength through its norms and behaviors, and is typically
reinforced by day-to-day systems and processes. OSTLTS has the opportunity to support CDC and STLTs in
transformation towards a more mutually positive culture through the recommendations outlined below.
Recommendations are grouped into three categories: collaborative engagement, process improvement,
and workforce development. Statements that support the need and approach to achieve the
recommendations are included for each category.
1. Collaborative Engagement
• Problem Statement: STLTs are not consistently part of the decision-making, receive
inconsistent communication, and do not understand CDC requirements and organization
• Need: Establish purposeful and consistent collaborative engagement
• Approach
- Evaluate interactions: 1) Level/Quality, 2) Comparison of routine versus
catastrophic events, 3) Nature and frequency, 4) NPOs vs. STLTs
- Establish interventions based on evaluation such as consistent partnership
coordination protocols and function across each office (example: OSTLTS to provide
toolkit and training)
- Define expectations and criteria of a successful working relationship between STLTs
and CDC
- Leverage existing or new forums to engage STLTs (example: CoP forums on
winnable battles)
- Develop standard communication plan and disseminate across offices (example:
OSTLTS to develop communication dos and don’ts, checklists, templates and tools)
- Launch yearly customer satisfaction and pulse check surveys with STLTs and NPOs
to inform CDC of unique needs or current issues
2. Process Improvement
• Problem Statement: CDC’s processes are administratively burdensome to both agency
FTEs and STLTs
• Need: Prioritize and execute upon the process improvements previously identified with the
Organizational Issues Committee (OIC) and the Business Services Improvement Project
(BSIP)
• Approach
- Analyze grant improvement initiatives identified by OIC and BSIP to identify barriers
to adoption and define options for moving forward
- Determine inconsistencies in guidance provided by similar federal programs
- Examine requirements of grants programs across CDC to identify potential
synergies and reduce duplication
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-

-

-

Explore the integration of funding streams, programs and performance measures
to achieve holistic, cross-cutting public health outcomes (example: obesity and
diabetes dollars working together to achieve mutually beneficial outcomes)
Evaluate administrative burden of grants management on both CDC and STLT staff
and explore process improvement solutions (automation, a consolidated shared
services model, etc)
Break down silos amongst internal CDC grants management systems and integrate
data for increased analytics and to tie project performance, public health
outcomes, and budget information

3. Workforce Development
• Problem Statement: A mutual lack of knowledge and understanding of organizational
intricacies and needs exists between STLTs and CDC
• Need: Focus on workforce development by increasing skills, knowledge and cultural
competencies of CDC/STLTs touch points
• Approach
- Provide training to CDC to increase knowledge of the complex public health
landscape (e.g., individual tribal considerations, geographical, regional, cultural,
and jurisdictional differences, and issues of health departments’ size vs. capacity).
- Develop tutorials, computer based training, directories, and educational materials
for STLTs that provide information about CDC’s structure, resources, and how CDC
conducts business as a federal agency
- Launch educational workshops and seminars to STLTs on emerging federal trends
and issues that impact the greater public health system
- Implement workforce development initiatives to standardize CDC’s Project Officer
training programs and gather input from the STLTs on the role of a project officer
- Provide customized grants and performance management trainings that meet the
diverse cultures and needs of tribes and territories
- Develop continuity/succession plans and create knowledge transfer processes to
minimize the impacts of CDC staff transitions on the STLT relationships

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IV. Concluding Thoughts
The findings from the culture assessment revealed ample hope among CDC staff and STLT leaders for
renewed focus on CDC’s key stakeholder groups. Challenges remain, however, and OSTLTS has the
opportunity to lead and organize CDC’s collective approach toward meaningful engagement of STLTs.
Respondents reported issues across a variety of domains from strategy to operations, while OSTLTS faces
the challenge within CDC to demonstrate its value in supporting programs.
The themes and recommendations detailed within this report represent a critical first step in transforming
culture towards the desired state. Next steps for transforming culture include:
•

Plan and mobilize – Develop action plan with solutions, timelines, resources, and measurable
outcomes.

•

Adopt and accelerate – Align all people-related initiatives to help foster the new culture. Establish
the right leadership models and introduce new words and vocabulary that highlight the desired
behavior.

•

Make it Stick – Revisit action plan regularly with leaders and validate progress with stakeholders.

“Change leaders throughout organizations make change stick by nurturing a new culture. A new
culture - group norms of behavior and shared values – develops through consistency of successful
action over a sufficient period of time.”
John Kotter, Harvard Business School professor and co-author of The Heart of Change

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Appendix 1: Shared Behaviors
Throughout the assessment phase of the project, stakeholder participants demonstrated many shared
beliefs and values across the organizational levers. The following section depicts the behavioral
characteristics that help define the culture of each participating stakeholder group (CDC, States, Locals,
Tribes, Territories, and National Partner Organizations). The characteristics indicated below recurred more
than once throughout the interviews and focus groups. Observed behavior characteristics include:
•
•
•
•

Norms: The social groups expectations concerning appropriate behavior.
Attitudes: Collection of beliefs with an evaluative aspect; tendency of mind/relatively constant
feeling toward a certain category of objects, persons, or situations.
Beliefs: A conviction that a phenomenon or object is true or real.
Values: Justification of one's actions in moral or ethical terms (right/wrong; good/bad).

Stakeholder Group – CDC
Norms

Attitudes

Beliefs

• STLTs input is needed in developing solutions toward overall public health
outcomes
• STLTs rely on CDC for support in basic public health capacity building activities
for which they do not have funding, such as policy, evaluation, research, etc
• STLTs need to know how to navigate CDC
• STLTs rely on CDC for technical assistance
• Cross-Federal Agency collaboration is important
• STLTs need an advocate at CDC
• Cross-Agency collaboration requires sponsorship from CDC Leadership
• Many believe there is an “us vs. them” relationship between CDC and STLT
agencies
• STLTs view CDC as having an “ivory tower perspective” that often doesn’t
translate at the ground-level
• OSTLTS cannot become another bureaucracy barrier instead of a resource
• The business relationship with STLTs is damaged
• If STLTs don’t succeed, then CDC won’t succeed
• Grant guidance needs to be a balance of oversight and support
• Individual Project Officer relationships dictate STLT relationships
• It is critical now that CDC Leadership “walk the walk”
• Frequent changes in priorities and approaches lead to break-downs in
relationships
• There is not consistency in messaging and communications from CDC to STLTs
• There is expertise available at the STLT level
• Creating new Offices within the CDC hierarchy means additional layers of
bureaucracy
• OSTLTS vision has not been communicated across CDC

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Values

• CDC lacks internal coordination and communications across Divisions and
programs
• The federal funding cycle limits STLTs ability for effective budget planning
• CDC grant and procurement management damages STLT relationships
• States appreciate “face-time” with CDC Leadership
• Some public health functions should be achieved by the CDC and some should
remain at the STLT-level
• STLTs do not appreciate constantly changing priorities
• CDC Leadership does not incentivize cross-Agency collaboration
• Service-oriented culture, innovation, transparency, early engagement of
stakeholders, frequent and consistent communication
• Limited bureaucracy, shared accountability
• Cross-Agency collaboration, efficiency, clear communications
• Credibility, trust across different environments and people

Stakeholder Group – States
Norms

Attitudes

Beliefs

• State departments are part of a larger public health system, and not just
discrete entities
• Improved communications are needed between CDC and STLTs
• States appreciate the role of a convener who will bring them together
• States rely on CDC for clear guidance and expertise on expected outcomes from
grant awards
• Localities should not be allowed to supersede funding chain and apply for funds
directly from CDC.
• Frequent communication from Leadership and direct access to Leadership
empowers the States to achieve their activities
• New Leadership and the H1N1 response effort have improved CDC’s credibility
with States
• CDC is at its best when it is working in collaboration with STLTs
• CDC was created to support State and Local public health agencies in program
operations
• Success of a relationship often depends on the personality, effectiveness, skill
and expertise of individual Project Officers
• Continuity affects relationships, CDC priorities change based on flavor of the
day.
• States need mutual support from the program side and procurement office of
CDC
• There should be the perspective that CDC is about science and not politics
• Political pressures must never overwhelm the public health mission
• There are valuable and unique public health skill sets available at the State level
• The customer service aspect within CDC has eroded
• Credibility will erode if CDC begins a pattern of decisions and actions that are
not determined through scientific-based evidence
• OSTLTS should not act as a gate-keeper to CDC Leadership

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Values

• Application of the Project Officer and State Management Official role has been
inconsistent
• CDC knows very little at the Local level since they primarily deal with the States
• CDC should not bypass States to fund Locals, as it creates a geopolitical battle.
• The grants management process within CDC is cumbersome
• New CDC Leadership feels they have something to prove
• Changes in priorities makes long-term planning difficult for States
• Programs within CDC are siloed and there is no congruent cooperation and
awareness that public health is cross-cutting
• States appreciate access to CDC Leadership
• Innovation, flexibility, engagement in setting public health strategy, openness,
trust, and transparency
• Open and frequent communications, access to CDC Leadership
• States have unique capabilities and prefer to be innovative when possible, and
value responsiveness and information exchange with CDC

Stakeholder Group – Locals
Norms

Attitudes

Beliefs

• Local public health should be involved in priority setting
• Clear duties from CDC OD will enable OSTLTS
• Restructuring the grant process will lead to more effective STLT interactions
• Best practices sharing with State and Local health departments will improve
their relationships with each other
• Specific outcomes and how it will be measured will help Locals implement grant
funding more effectively
• Locals should be engaged by the CDC in the same manner as States
• Support and commitment is from CDC Leadership to improve the public health
system
• There is expertise at the Local level that may not exist at the State or federal
level.
• CDC has the misconception that the real activity lies at the State level, but in
reality it’s at the Local level.
• Local jurisdictions cannot be painted with “broad strokes”, there are many
variables amongst the 3,000 Local health departments across the U.S.
• Outside of a few large jurisdictions, CDC doesn’t have direct working
relationships with Local health departments
• Frequent reorganization efforts at CDC cause disruptions in field
• Public health issues are a “national” problem that effects the entire system,
versus a “federal” one
• The best public health capacity may not always be at the State level
• Funding bureaucracy hinders effective implementation
• Leaders need to take action and not just say things are going to change
• CDC is not aware of Local’s needs
• CDC cannot count on the direction and messaging it provides to States to be
properly translated down to Local health departments

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Values

• CDC has not done a good job of articulating outcomes expected from grant
activities and instead has been micromanaging process
• Channels of communication directly between CDC and the Locals are almost
non-existent
• The presence of the State health departments as the middlemen discourages
Locals from contacting CDC directly
• There is a need for standards in data collection and data sharing
• There needs to be more flexibility in funding vehicles
• Having a structure of governance that can evolve over time is important
• OSTLTS will add to CDC bureaucracy
• Local leaders must acknowledge the need for improvements to the Local health
systems nationally
• CDC Leadership has been inconsistent and distant
• Acknowledge and respect specialized skill sets within Local public health, early
engagement in priority setting
• Limited bureaucracy, responsiveness, shared accountability
• Flexibility in funding approaches, direct support and engagement from CDC to
Locals
• Knowledge, credibility, innovation

Stakeholder Group – National Partner Organizations:
Norms

Attitudes

Beliefs

• There is a structure in place for State, Local and federal public health, each with
its own focus
• Public health organizations are CDC’s main customer
• Relationship is as much about behaviors as it is science
• STLTs are an entity and not a collection of programs
• CDC program staff are linked to the broader public health system
• There is a public health system that dictates how entities interact
• NPOs have a say in the public health decision-making processes
• CDC leadership builds and maintains interpersonal relationships with NPOs and
STLT
• CDC “thinks they know best” about public health policy without consulting Local
perspective
• CDC liaison to STLT is ceremonial and lacking authority
• All parties in public health system should share accountability
• Adhering to a standard of perfection minimizes CDC’s role in dynamic situations
• OSTLTS Leadership must avoid becoming a gate-keeper to the Agency Director
• There is a wealth of talent at STLT agencies in regards to best practices
• CDC is credible on science, but lacks the “on the ground” credibility because
they operate as if they understand what is going on at the Local level
• Relationship with CDC is weak as a result of grants management processes
• The Local perspective is different than the State perspective

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Values

• The Local perspective is as important as the State perspective
• Response management should be dynamic and flexible
• CDC will not a put a solution until they feel it is perfect
• There is a leadership focus on categorical disease programs rather than
integrating programs towards holistic health outcomes
• Accessibility is key to strong STLT relationships
• Success is dependent upon CDC Leadership and funding
• First-hand experience, respect, service-orientation
• Shared accountability, respect, collaboration
• Interpersonal relationships and accessibility to leadership
• Collaboration, inclusion, and sincere commitment to share information

Stakeholder Group – Territories:
Norms

Attitudes

Beliefs

• Each territory has different needs and different capacity levels
• A high level of cultural competency and experience is needed when working with
Territories
• Territories are autonomous and operate as an all-in-one public health agency
• Territories expect flexibility in guidance and structure
• Training from CDC improves Territories’ ability to lead programs
• Territories have strong relationships with Project Officers and Senior
Management Officials
• CDC leadership will provide guidance and direction to Territories
• Territories benefit from the support of Public Health Advisors
• CDC does not have a strong understanding of the public health infrastructure and
development within Territories
• Some areas in CDC have too many layers within the division
• Territories are not given adequate funding to meet the same requirements and
expectations as States
• Need for technical assistance is greater in Territories than in States that are
receiving more funds and technical support
• CDC’s reorganization is confusing, especially when project officers are reassigned
• Content with leadership skills that has been demonstrated within CDC staff
• Reorganization of CDC leadership causes confusion
• It takes time to cultivate relationships with CDC
• Consistency over time is important
• Successful partnerships are dependent upon relationship building between CDC
and Territories
• Territories are encouraged by the establishment of the office
• Current CDC partnering relationships work
• Territories are viewed the same as States by CDC in regards to funding
mechanisms
• There is a lack of collaboration between HHS and CDC during events

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Values

• Technical assistance is not sufficient for Territories
• All information should be consistent when communicated to partners
• Respect of heterogeneity, cultural competency, experience, consistency over
time
• Respect and understanding of heterogeneity, equal expectations of
performance, clarity of structure
• Interpersonal relationships, collaboration, eliminate confusion, strengthen
training opportunities, reliance on technical assistance
• Consistent and frequent communication, strong leadership skills, clarity in roles
and responsibilities

Stakeholder Group – Tribes:
Norms

Attitudes

Beliefs

• Unique public health priorities exist for Tribes
• Many Tribes health needs are addressed through a multi-Tribal organization that
consolidates services
• Tribes often span State borders and have to receive funding from all the States of
which it is a part
• Within a State there may be multiple Tribes, all with unique needs
• CDC cannot address health needs for some individual Tribes as these are
consolidated under a multi-Tribal health organization
• The use of more junior CDC staff to build relationships with Tribal Leadership is
incompatible with cultural practices and norms
• Data sometimes is shared externally before being shared with Tribal groups
• CDC is sympathetic to issues on Reservations
• Tribal needs are often overlooked in the establishment of national public health
priorities
• The resources to address Reservation public health issues are lacking
• Tribal-operated Epidemiology Centers have been a strategic resource and
investment from CDC
• Tribal data is often too generic and not Tribe specific, being controlled by the
States and not the Tribes themselves
• Asymmetry of Reservations and CDC create conflict of
resources/capacities/expectations of what Tribes can do
• Surveillance activities and data sharing/ownership are not good or thorough so
results and applied actions based on those surveillances are not appropriately
established or executed
• CDC has not made a strong commitment to Tribal health needs
• Magnitude of public health problems is different on Reservations
• Tribes have troubled history with the federal government and federal agencies
• Compliance with grant requirements is not always realistic for some Tribes
• The structure of Tribal governance is very different then the way CDC operates
• Priority setting does not recognize and incorporate unique cultural aspects of
Tribes and life on Reservations
• Tribal funding through the States assumes that Tribal geography is equivalent to

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Values

that of a Locale, which is often inaccurate
• Specific health issues will need a tangible commitment by CDC leadership
• Understanding of uniqueness of needs and priorities
• Understanding of uniqueness of structure, needs and priorities, realistic
expectations
• Understanding and compatibility with structure, geography and culture, stronger
and more specific data, collaboration and open communications
• Sympathy to unique needs, strong commitment by leadership

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Appendix 2: Interview and Focus Group Questions

OPENING REMARKS

•

We appreciate you taking the time to speak with us today. My name is _____ and I am here with
Deloitte working on behalf of CDC’s Office of State, Tribal, Local, and Territorial Support (OSTLTS).

•

We are working with CDC to gain a better understanding of how CDC and STLT health departments
work together on public health programs and issues, and the role that the new OSTLTS has in ensuring
efficient and effective programs.

•

Ground rules: This is an open environment. The more honest you can be, the more you will help us.
All information shared during and after this interview/focus group will remain confidential. To ensure
we are accurately capturing information, _________ is here taking notes. Again, anything you share
will remain confidential.

•

The results of our conversation will be noted, but summarized when presented to our client. This
means that any information collected will be in consolidated summary form; nothing will be attributed
to specific individuals, unless it is agreed upon prior.

•

The data we gather throughout this process will be used to understand the current organizational
culture between CDC and State/Locals that will then be applied to create a plan to enhance that
relationship.

•

Today’s conversation will start with a brief discussion of your background with some general
questions, your current working relationship with CDC/within CDC/with STLT agencies, and any ideas
you have about opportunities for the future.

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QUESTIONS
I’d like to begin by getting a better understanding of how you see CDC and STLT health departments
currently working together. [How the organization responds to the external environment.]
General: Initial question to provide background of our stakeholders and their subsequent responses.
1) Can you please describe your position with __________ [Agency/Center/Division]? [Interviewer Note:
Capture Name, department, position, and a brief history of what programs they have worked with.]
Questions address concepts of shared beliefs, norms, behaviors, and assumptions between CDC/STLT
agencies
2) Please give us examples of both successful and unsuccessful relationships that you have had between
CDC and STLT agencies.
a) What were the key differences in these relationships that contributed to success?
b) What are the most valuable aspects of these relationships?
c) In what ways, if any, do you think these relationships support the work of all involved?
d)

Is there openness and trust within CDC and between CDC and STLT agencies? Can you please
provide an example?

e) From your perspective, what constitutes an effective working long-term relationship?
3) Please give us examples of both successful and unsuccessful relationships that you have had within CDC
(use same probes as above).
4) Do you consider CDC to be credible? Please elaborate (Only ask for STLT Interviews)
5) What would change your opinion? (Only ask for STLT Interviews)
6) What do you see as the public health priorities that will require strong CDC/STLT collaboration?
a) What role do you see CDC having?
b) Do you think that OSTLTS is poised to support these priorities? How?
This section examines concepts of governance, controls, and the working relationship between CDC/STLT
agencies.
7) How has the establishment of OSTLTS impacted your working relationship with STLT? (or the other way
around when asking STLT)
8) What can OSTLTS do to help improve or change the dynamics between STLT and CDC?
9) In the past, CDC has attempted to create a similar office to OSTLTS. What do you think worked or
didn’t work in that effort?
Questions address concepts of the policies, processes, and procedures around the communications/flow
of information between CDC/STLT agencies.
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10) What do you do to ensure that your relationship (CDC and STLT) is at strong as it can be?
a) Is it effective and why?
b) Is it consistent across all of your interactions?
c) Who/what defines your working relationship?
d) How is it assessed?
11) What is the top thing that CDC can do to improve relationships with STLT?
a) In terms of leadership, what are the specific and actionable changes would you like to see made to
CDC/STLT relations?
12) What is the one thing you would change in your own work that would impact the relationship between
CDC and STLT health departments?
Addresses the style of conduct & overall priorities alignment between CDC/STLT agency leaders, and the
expectations of the role of leaders in support of relationships.
13) When you hear the word “Leadership” in the context of CDC’s commitment to strengthening the
relationships with STLT agencies, what are the words, thoughts, or images that come to mind? Please
give an example.
a) Who are the people/levels at CDC that exhibit this leadership?
b) How would you describe CDC’s current leadership in addressing relationships within CDC/between
CDC and STLTs?
c) In your opinion, how do leaders at CDC and STLT agencies work to ensure each others’ goals and
priorities align?
d) What actions should leaders champion to make improvements to the working relationship of
CDC/STLT agencies?

WRAP-UP/CLOSING

Let me just summarize a few main key points that I heard today. [Interviewer note: Provide a short oral
summary of the discussion]
14) Is there anything we did not discuss that seems relevant or important that you would like us to
know?
15) We are meeting with a number of people who serve in roles such as yours. Are there others that you
believe we should talk to get more information?
Thanks again for all your comments today. May we contact you for a follow-up once we have compiled
feedback from everyone? Please do not hesitate to contact me if you have further thoughts on what we
discussed today. [Interviewer Note: Hand out business card as applicable].

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