n July 2010, the Wisconsin Department of Health Services published the most recent version of Healthiest Wisconsin 2020: Everyone Living Better, Longer. A strategic state health plan, Healthiest Wisconsin 2020 (HW2020) was the result of extensive community engagement, assessment, and analysis in order to determine the current state of health and the changes that need to be pursued to improve upon that state. This paper will provide an analysis of the strategic planning process utilized in the creation of HW2020 and the resultant plan.

Vision, Goals, Mission, & Values
The vision, goals, mission, and values of HW2020 are presented collectively at the beginning of the document, with additional explanation provided throughout the text. When viewed in conjunction with the associated explanations, these statements provide a strong representation of what the leaders and contributors to HW2020 envisioned for the future state of health in Wisconsin. However, on individual analysis, these statements are quite broad and leave several pertinent points unanswered. The vision, which is presented throughout the document, reads “Everyone Living Better, Longer.” The statement gives a clear sense of what the long-term goal is. However, without reading the accompanying explanation, the pertinence of the word everyone can be easily overlooked. This word embodies the health inequities that plague Wisconsin and is pertinent to the foundation of the overall plan. Stressing this sentiment would have been beneficial. This vagueness may have been missed secondary to the time course of vision development. Based on plan, it seems that the HW2020 committee chose to start with vision development. Issel (2009) feels that creating a vision should be the first step in planning (p. 100). However, Bryson (2011) mentions that vision statements can be created at several points in the process, with those created early on often providing less detail (p. 63, p. 69). Readdressing the vision at the completion of the plan may have provided the hindsight necessary to make the vision more specific. In addition, while broadly describing what the future should look like, the vision statement does not outline how one would know when the vision is met nor does it depict how the organization should behave in fulfilling its mission (Bryson, 2009, p. 127). Goals are established as an extension of the vision, and these help address the former point of how we would know when the vision is being achieved, but they still do not give credence to how the organization should behave in fulfilling its mission. Nonetheless, the goals are a strong addition to the vision. They provided a basis for many of the priorities established throughout the plan and are often referred back to, providing a thread for various parts of HW2020 to be weaved together.
The goal of a mission statement is to provide a sense of purpose. I think the mission of HW2020 succeeds in doing so; however, the purpose supplied still remains vague. “Assuring conditions” is the terminology used, but what those conditions may be are left open to interpretation if the reader is not privy to the additional explanation provided: “They include these health factors or determinants: a healthy economic and social environment and strong educational system, an efficient system of health services, a healthy and safe physical environment, and healthy behaviors and skills (HW2020, 2010, p. 73).” When breaking the mission down into the six components Bryson provides, additional parts of the mission are also called into question. The first component of a mission statement per Bryson (2011) is to supply a sense of “who we are (p.138).” While the document itself mentions who was involved in the creation of HW2020, the mission statement does not include this information. Had the mission been viewed alone, there would be no indication of who’s mission was being presented. The second condition is successfully met in that the social problems the organization exists to meet are spelled out. However, how these needs are to be addressed is not. (The core values give some insight into this aspect). Key stakeholders are not mentioned in the mission statement, aside from the community members themselves. Values, another Bryson criteria, are not incorporated into the mission statement, and lastly, the sixth component, uniqueness of HW2020 is not highlighted. Similar to the vision, the mission was put together prior to the plan and may have benefitted from a revision at plan completion to ensure that the true essence of HW2020 was represented. As for values, while they are not included within the mission itself, they are included separately within the plan. I think the values are a major strength of the plan. They are broad in their coverage, in line with health improvement at the population level, and provide clear guidance as to what is necessary for success. They serve as the foundation upon which the vision, goals, and mission have been built and provide an excellent basis with which community partners can start to identify when trying to determine how their own visions and missions fit with that of HW2020.

Stakeholder Engagement
It is evident that HW2020 is the result of the ideas, knowledge, and dedication of numerous stakeholders throughout Wisconsin. Every aspect of the document detailing the plan makes sure to highlight the contributors and the importance that their insight provided in leading to the creation of the twenty- three focus areas. The dedication to collaboration and stakeholder engagement is reinforced by the provided definition of the public health system: “…the people, programs, structures, and other resources that work together to provide conditions that support the health of a population. This includes state and local governmental public health departments, but also other government agencies, community-based organizations, health care systems, businesses, educational institutions, faith organizations and others (HW2020, 2010, p. 37).” The stakeholder categories considered by the leadership in their stakeholder analyses are depicted within the plan through the presentation of a stakeholder map (HW2020, 2010, p. 56). The 18 stakeholders included cover a broad range of key players who qualify as “…organizations, networks, and collaboration in which individuals and groups contest for control of attention, resources, and output (Bryson, 2011, p. 134).” This is the first point set forward by Bryson in his discussion of stakeholder analyses. Bryson’s second point relates to the identification of stakeholders at the right level of aggregation. Given the broad scope of HW2020, I think the level of identification provided within the map was reasonable. However, providing one additional outer layer with further breakdown into smaller subsets would have been beneficial. According to Bryson (2011), “In general, stakeholders should be further differentiated if doing so would make a difference in expectations placed on the organizations and the responses it might make (p. 135).” There are multiple categories within the map where the two groups have different expectations and needs, despite a common overall value for health. For example, state and local elected officials are included within one category. While state officials must account for all state constituents, local officials have a specific responsibility to the residents within their district. Appreciating the differences these stakeholders bring to the table and their varying needs is an important consideration to take into account early on. “If an organization does not know who its stakeholders are [or misclassifies them]…there is little likelihood that the organization will know what to do to satisfy its key stakeholders (Bryson, 2011, p. 132).”
Despite not breaking the stakeholders down within the diagram, I believe that the leaders of HW2020 did indeed know their stakeholders well at a differentiated level, which was a strength of stakeholder engagement. This is evidenced by the extensive documentation of contributors in Appendix A. A review of the organizations represented provides evidence for the broad base of views that were sought to ensure that the plan was based on the true needs of the community and involved the expertise of as many individuals as possible. In addition, to the listed individuals, community forums were held in-person and through the web and surveys were passed out statewide to seek opinions on proposed objectives.
While concerted efforts were made to be all-inclusive, two major stakeholders were overlooked in the stakeholder selection process, as evidenced by their lack of inclusion in the stakeholder map and appendices. The first group is future generations. As detailed by Bryson (2011), “…organizations (and especially governments) have an obligation to leave the world in as good shape as they found it, if not better (p. 135).” While I believe that future generations were considered, given the focus on improving infant mortality and statements about the health of future generations, the lack of clear distinction of future generations as a stakeholder may have lead to insufficient strides to satisfy this group. Similarly, media was another group not included within the map. The media is key to spreading public health messages and their lack of involvement at the table can lead to spread of misinformation or cause undue chaos in the general public when public health scares arise. A member outside the health department with a media position could have been a key addition to the Communications and Marketing Advisory Team as well as the Communicable Disease Prevention and Control Team. Including them in the conversation on the frontend could improve media-public health relations as well as provided the public health realm with tactful advice about how best to communicate health messages to the people of Wisconsin.

Environmental Scan (SWOC Analysis)
A formal environmental scan of the State of Wisconsin health was not presented in the document for HW2020. Through reviewing the plan, however, strengths, weakness, opportunities, and challenges (SWOC) for health in Wisconsin were identified. Strengths of Wisconsin health should definitely be applauded as strategic planning over the past several decades has facilitated strides towards better health. In fact, Wisconsin was recently ranked first in health care quality (HW2020, 2010, p. 55). This honor is the result of multiple improvements, including an increasing focus on preventable risk factors for disease, injury, disability, and premature death (HW2020, 2010, p. 41), areas that were previously overlooked. Other strengths are more disease-specific, with rates of tobacco smoking and exposure to environmental tobacco smoke declining, rates of immunization compliance increasing, and lower rates of workplace deaths (HW2020, 2010, p. 41, p. 45). From a collaboration standpoint, mature partnerships and coalitions have formed statewide, leading to combined efforts and programming throughout the state. Health insurance coverage has also increased, with Wisconsin having one of the most complete rates of medical insurance coverage in the nation (rates of child health insurance rose from 88 percent in 2000 to 93 percent in 2008, HW2020, 2010, p. 41).
While large gains in health status have been achieved over the past several decades for Wisconsin residents, improvements are still necessary in multiple areas. Weaknesses identified in HW2020 that helped shape the plan are first and foremost related to health disparities. For example, infant mortality in African Americans is three times as high as that of White infants (HW2020, 2010, p. 16). Mortality secondary to diabetes in American Indians is almost three times that of Whites (HW2020, 2010, p. 16). Suicidal ideation is twice as high in homosexual youths compared to heterosexuals (HW2020, 2010, p. 16). While teen pregnancy rates are not high in Wisconsin compared to other states, Wisconsin African American women had the second highest rate of teen pregnancies among all states (HW2020, 2010, p. 47). Other health weaknesses relate to elevated rates of sexually transmitted diseases, with Milwaukee having the second highest rate of Chlamydia in 2007 among U.S. cities. Alcohol use is also a problem, with poor rankings for adult and youth binge drinking, alcohol use in youth, and youth riding with intoxicated drivers. Poor lifestyle choices extend to youth and lack of exercise, with Wisconsin having the sixth lowest proportion of children exercising regularly in 2007 (HW2020, 2010, p. 46). From an infrastructure perspective, weaknesses also arise in SWOC analysis. Budget for public health in Wisconsin is below the national average. In 2009, Wisconsin was listed as lowest of the 50 states for per-capita state funding of public health, spending approximately one-third of the national average. Infrastructure issues also extend to lack of synergism between committees working on separate focus areas whose activities could have benefited from common policies and systems work (HW2020, 2010, p. 75).
Many opportunities exist within the Wisconsin public health sphere or on a national level that can used to the benefit of Wisconsin health. The Affordable Care Act provides several of these opportunities as health care reform has demanded that preventive services be included in insurance plans universally and that additional funding be put towards preventive health and expanding the public health workforce. It has also lead to the expansion of healthcare, removing access as a barrier for many residents. Electronic health records provide another opportunity, as new information systems can allow for a higher degree of efficiency and effectiveness not previously conceivable. New public health institutions within Wisconsin have also been developed, allowing for increases in the number of eligible trained workers who are savvy to the system and an increased capacity to perform academic research that forges the way for additional best practices and programming. Lastly, the strong emphasis on collaboration opens the door for outside organizations and individuals to become involved in health department initiatives, opening the door to new ideas and partnerships.
Many of these same opportunities pose challenges as well. The Affordable Care Act, while opening new doors, also comes with additional mandates that require money and manpower to achieve. Manpower in itself is a huge challenge, given the gap in demand and supply, while additional funding seems impossible to secure, given the already budget stressed public health system within the state. Similarly, new technology requires additional time and training to acquire and incorporate into practice, again requiring vital scare resources. Other challenges relate to the changes in demographics of population, with aging leading to a larger need to focus on chronic health issues such as diabetes. Lifestyle choices have lead to rampant problems with obesity, another predisposing factor for numerous chronic diseases. Challenges are also presented secondary to global travel and commerce, unforeseen natural disasters, disease epidemics, and terrorism threats.

Strategic Issues
As HW2020 is the third version of Wisconsin’s State Health Plan, the strategic leadership team had a good foundation from which to build the most recent plan. Assessing past successes and challenges, the team initially created a vision and set of goals based on a core set of values agreed upon by the leadership. Thus, it appears that a goals approach was utilized in the identification of objectives, strategic issues, and plans for addressing issues. The goals of HW2020 were to improve health across the life span and eliminate health disparities and achieve health equity. Based on these two goals, 23 focus areas were decided upon. According to Bryson (2011), a strategic issue is a fundamental policy question or challenge affecting an organization’s mandates, mission and values, product or service level and mix, clients’ or users, cost, financing, organization, or management (p. 185). I believe that the 23 focus areas chosen all fit well within this definition. Bryson goes on to provide three rules for how an adequate strategic issue should be described. The first criterion is that an issue should be phrased as a question and that this question should be addressable in more than one fashion. It is unclear from the documentation whether or not the focus areas were initially posed as questions within their committees. However, in its current form, HW2020 poses each issue as a statement with matching objectives to be met. No question is provided, nor are potential solutions consistently included within the focus area description. The second criterion is that the reason behind why the issue is strategic should be provided (relation to vision, mission, mandates, SWOC). While explanations are provided for each issue, connections are not directly made, but they are easily inferred by the reader. Similarly, Bryson’s third criterion is that a strategic issue should articulate the consequences if the issue is not addressed. For some issues, the current status quo is spelled out, allowing the reader to understand the magnitude of lack of action. However, in other cases this must be inferred. Again, this inference is easy to make based on the explanation provided. An additional point made by Issel (2009) is that objectives should convey only one idea within them so that each statement can be related to only one measure (p. 219). Several objectives involved two or more outcomes or disease states. For example, one objective read as follows: “By 2020, reduce smoking and obesity among people with mental health disorders”). Combining these ideas may lead to an objective not being “met,” despite great strides in one of the two outcomes measures. Based on Issel’s reasoning, it would be beneficial to keep objectives narrow in their scope to ensure achievability.

Summary & Recommendations
As a whole, I think the creators of HW2020 put together a comprehensive plan for the State of Wisconsin that truly reflects the views of the people it hopes to effect. It is clear throughout the plan that significant time and effort were spent in ensuring that the community was able to engage in the process and that stakeholders viewpoints were not just heard but also wholeheartedly incorporated. The importance of collaboration did not go understated. The goals of the plan were visible throughout the document, with focus areas and objectives related back to their effect on health across the lifespan and eliminating health disparities. The repetitiveness of these goals allowed for continued connections to be formed about why specific issues were viewed as pertinent and to keep one’s sight on the bigger picture. The values, the foundation of the plan, were also referred back to throughout the text, allowing for the same. Another strength of HW2020 relates to the goals and focus areas being related to past Healthiest Wisconsin plans. Continuing to work from a foundation that has been going strong for several decades, plan contributors made it clear that building upon past strengths and addressing weaknesses was the utilized approach. This step-wise methodology allowed for continued progress where necessary, rather than a turn in direction prior to past goals being cemented. Lastly, it was clear that the plan was based on multiple types of data, which is key when assessing the health of a community, as described by Issel (2009, p. 137). Throughout the document, archival, public, primary – extensively qualitative, observational, and published references were presented and/or alluded to. This broad scope of references used is evidence that leadership wanted to ensure future programming and interventions were evidenced-based when possible. Lastly, Appendix F provides ideas are provided to jumpstart stakeholder into action, providing ideas that can be put into effect fairly easily, providing motivation and confidence to stakeholders that change is plausible.
While the plan was able to communicate what steps need to be taken and the ultimate goals for HW2020, there were several areas where additional details would have been beneficial. One of these areas was the representative statements for the plan, namely the vision and mission statements. Within the plan, both of these statements are given explanations of their meaning. However, standing alone, they undersell the depth and richness of the plan. Readdressing these at the end of the process would likely have lead to reconstruction of these statements so that they better represent HW2020. Additionally, it is unclear who was involved in the creation of the vision, goals, mission, and values. It seems that leadership put these together. It would be good to know whether stakeholders were given the chance to give their input on these statements and/or how the process of creation was run. Another weakness was the titling of the infrastructure issues and health focus issues both as focus areas. The infrastructure issues seem to serve as a foundation for the health focus issues (as depicted by the diagram on HW 2020, 2010, p. 77), yet the way they are titled makes the reader question the hierarchy that exists between them. I think readdressing how to label these two sets of issues will allow stakeholders to more clearly visualize where their efforts should start and what role they may play in implementing these focus area changes within their own organizations.
Additional recommendations that would lead to the increased likelihood that the plan is put into action relate to the presentation of the focus areas. Each focus area is presented along with a paragraph of why it is important. However, several key pieces of information are missing within the text. Statistics providing a foundation for the focus area are not routinely provided nor is how the area specifically fits in the vision, goals, missions, or value. While this information can be inferred based on the remainder of the plan, a clear connection within the text would make plan utilization easier as this information is key to stakeholders trying to incorporate objectives and goals into their own organizations and ensure that these changes are making an impact in the way intended. A formal presented SWOC analysis would have also made these connections more clear. Lastly, providing more specific objective goals, such as percent attainment rather than using words such as decrease or improve, allows stakeholders to better understand whether they are successful or not (Issel, 2009, p. 219). Authors did mention that more detailed information including baseline data targets would be published separately (HW2020, 2010, p. 97). Including these details in the main document would allow stakeholders to more easily access them as well as to have a better sense of what objectives are achievable for their organization.

References:

  1. Bryson, J. M. (2011). Strategic Planning for Public and Nonprofit Organizations (4th edition). San Francisco: Jossey-Bass.

  2. Issel, L. M. (2009). Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health (2rd edition). Boston: Jones and Bartlett Publishers.

  3. Wisconsin Department of Health and Family Services. (2010). Healthiest Wisconsin 2020: Everyone Living Better Longer. Retrieved from http://www.dhs.wisconsin.gov/hw2020/report2020.htm.