My office in the health department had a large white board on which I kept an ever-changing “to do” list. Only one thing permanently resided on that board: my favorite 2X2 table (Figure 1), adapted from the “Eisenhower Matrix.” The matrix served as a constant reminder for our leadership team to try to ensure that as much of our time was spent in the quality quadrant as possible. Not surprisingly, doing so was a perennial challenge, especially in late summer and early fall, when every week seemed to bring a new public health threat to our community.    

	Urgent	Not Urgent
Important	NECESSITY Take Action!	QUALITY Be proactive/ schedule time
Not Important	DECEPTION Delegate	WASTE  Eliminate whenever possible

Figure 1: An Adaptation of the Eisenhower Matrix           

Necessity

“Necessity” takes on many forms in a local health department. Every day brings the potential for a new adventure in public health. We never really know what the day is going to bring in local public health. Late summers in Upstate New York were an ever-revolving door of investigating food borne outbreaks associated with clam bakes; looking for common sources for small clusters of legionella; closing beaches for algae blooms or the presence of E.coli; and weighing in on whether, or when, to do aerial spraying of a nearby swamp to combat eastern equine encephalitis. For many of us in public health, events in the “necessity” quadrant represent what is most fun about public health. Sometimes they provide us with the opportunity to be disease detectives, crunching the numbers, putting pieces of the puzzle together, finding the culprit, and employing the solution. (See JPHMP Direct’s “Backstories in Epidemiology” for some fascinating stories of disease detectives.) Sometimes they provide us with the opportunity to avert disease by taking action against an imminent environmental health threat. Sometimes, when something completely unexpected occurs, they provide us with the opportunity to learn about something we never imagined having to manage.                           

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As energizing as it often was to be in the “necessity” quadrant, after each event for which we had to spring into action, once the excitement died down, we would inevitably start questioning whether there was more that we could have done to prevent the event from happening in the first place. Such questioning in turn would, at least temporarily, inspire us to remember the importance of making time to spend in the quality quadrant.          

Quality

While some of us thrive on the energy of living in the moment of necessity, others thrive on the stability and satisfaction that accompanies authentic and continuous quality improvement. The quality quadrant is, and must be, the cornerstone of all organizations. In public health, ensuring that our leadership teams spend as much time in the quality quadrant allows us to invest in our community partnerships; prepare for or maintain PHAB accreditation; engage in quality improvement and quality assurance activities; do our budget preparations; spend meaningful time and energy in program evaluation; apply for and implement new grants; consider new policies to improve health; and so much more. The more effort we put in to protect and optimally utilize time in this quadrant, the better we can serve our communities. Regardless of our intentions though, often time in the quality quadrant is diverted to the other quadrants, including the quadrant of deception.              

Deception

How many times have you been interrupted to address an “urgent important matter” only to find that urgency and importance are in the eyes of the beholder. More often than not, for our team, these interruptions were associated with political power. Summertime in our health department inevitably included the call from the County Executive’s Office about an unfavorable summer camp inspection for an establishment owned by a supporter. The email marked “urgent” from a local legislator who had a constituent who was unhappy that the health department did not perform “nuisance” spraying for mosquitoes. The call from a prominent local figure whose husband’s cousin hadn’t adequately prepared for a summer cruise and now urgently needed a birth certificate from the Office of Vital Statistics. Of course, maintaining the integrity of the health department’s roles and responsibilities was always paramount in such situations but doing so while still being responsive to the political reality took valuable time and energy. As with events in the “necessity” quadrant, events in the “deception” quadrant often prompted us to consider how we could avert such interruptions in the future. For example, we would try to determine whether these events were indicators that we needed to improve communication with the County Executive’s Office or with our local legislators or with the general public about specific programs or services. In other situations, we tried to use the events to improve the way we delegated certain responsibilities so that when such calls came in, we could minimize the extent of the disruption.

Waste

I think that in most situations, events in this quadrant occur at the individual level rather than at the organizational level. It is not uncommon that in the lull between bursts of activity in the other quadrants, we find ourselves just chatting with others or perhaps mindlessly staring at the computer in front of us. My take on the “waste” quadrant is that a little bit of “down” time, chatting with the people with whom I work about non-work related topics can build relationships and therefore should not be considered “waste.” As with so many other things, the concept of “waste” is rooted in the details. Is your activity during a lull productive in any way, even if it doesn’t fit neatly into the “necessity” or “quality” quadrant? If not, perhaps it is time to consider how to motivate yourself to move into one of those quadrants.

Today, there are so many tools to help us be the most effective, efficient leaders that we can be. For our leadership team, even during the busy-ness of late summer in a local health department, the simple and commonly applied 2X2 table, inspired by a former president’s quote, was the tool that we needed.

You Might Also Enjoy These Articles in the Journal of Public Health Management and Practice:

• Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience
• Implementation of a Legionella Ordinance for Multifamily Housing, Garland, Texas
• The 2015 New York City Legionnaires’ Disease Outbreak: A Case Study on a History-Making Outbreak

Read all columns in this series:

• Measles in New York: The Outbreak, the Response, and the Potential Unintended Consequences
• Trust: An Essential Ingredient for Becoming a Chief Health Strategist 
• Introducing Boots on the Ground: Narratives from Today’s Local Public Health Workforce

As with community health improvement, we are stronger if we work together. If you are interested in sharing your story, please contact Dr. Cynthia Morrow at cbmorrow@vt.edu.