Tobacco Control Programs Use Business Process Mapping to Strengthen Workforce

June 03, 2024 | Amy Ciarlo

Since the beginning of the COVID-19 pandemic, public health agencies have experienced significant turnover across leadership and staff throughout various programs, including tobacco control. Between 2021 and 2023, nearly 30% of all state and territorial program managers were experiencing turnover (e.g., in some cases, vacancies lasted months) or were new to this role, having less than two years of experience. This decline in workforce reduces capacity to address tobacco use—the nation’s number one cause of preventable disease, disability, and death.

Tobacco control program staff require a level of knowledge that can take time to build, including:

• Historical context of tobacco industry marketing influence.
• Policy, systems, and environmental change strategies.
• Emerging products and changing regulations.
• The complexity that goes into helping people who use tobacco to quit.

Finding qualified applicants that will stay in these roles long term has been challenging across jurisdictions. In response to this need, the Tobacco Control Network, in collaboration with CDC’s Office on Smoking and Health, convened a nine-month learning community with three state tobacco control programs (Alaska, Arizona, and New Jersey) to address hiring and onboarding challenges, which concluded in March 2024. Subject matter experts Health Management Associates (HMA) supported by educating participants on business process improvement (BPI) methods, facilitating business process mapping workshops, and consulting on the development of individual state implementation plans to address key challenges identified during the mapping processes. A similar model with specific OD2A grant recipients focused on procurement, contracting, and helping address spend-down of funding.

Business Process Mapping and Implementation Planning

Each state participated in a two-day, in-person BPI workshop to outline all steps, from filling a vacancy to completing the onboarding of new hires. This was a lengthy exercise, as agencies often have many elaborate processes in place, due to an organizational requirement, an expectation held by leadership, or a past purpose that is no longer relevant. Understanding why the process happens and visualizing the steps in sequential order helped teams identify “waste” or areas for improvement, including overwork (e.g., too many meetings), waiting (e.g., on an approval, for a training to become available), extra processing (e.g., duplicating efforts), and unused talent (e.g., insufficient training and alignment of skillsets).

States then drafted implementation plans to address key issues, outlining steps with detailed timelines and tasks assigned to individuals to increase accountability. Each state team finalized their plans as part of the learning community, with some activities in progress or already completed. However, all three varied in their processes, their approaches to solutions, and the activities outlined in their implementation plans:

• One state’s BPI workshop focused on grantees at the county-level and streamlining onboarding, as counties lacked consistency in their hiring and onboarding approach. Their implementation plan focuses on a team of state health agency staff and local partners establishing a guidance document that assists new local staff in their first three months.
• Another state’s BPI workshop centered on addressing challenges in building a diverse workforce, with goals to establish a standardized practice for job postings and reduce re-posting of vacancies. The mapping process allowed collaboration across multiple departments and with health agency leadership.
• During the final state BPI workshop, the team identified excess meetings as a pain point and are reworking them to reduce redundancy and streamline the onboarding process. The implementation plan also prioritizes making training materials more engaging and better understanding training needs among new program staff.

Lessons Learned

The state teams gathered to share key takeaways from the learning community, as reported by HMA, informing recommendations for other programs looking to address hiring and onboarding challenges.

Successes

• Participation led to team building and a mutual understanding of the process.
• Participants trusted one another to share with transparency.
• The mapping activities remained agnostic by highlighting inefficiencies in the process and not the people.
• Individuals with new perspectives had the opportunity to comment on system improvements.
• Teams recognized the numerous demands on team members and grantees, how much duplication existed across processes, and the number of approvals or layers in the hiring procedures.
• Teams created clearly identified roadmaps to improve hiring and onboarding staff.
• The learning community brought together partners across the state to address challenges that impacted their work but were not part of their everyday tasks.

Challenges

• Staff representatives from HR or Grants Management were not present during the mapping workshops, causing gaps in information during these sessions.
• Power dynamics created difficulty for all participants to contribute equally.
• There was a lack of consideration for equity and challenges from new hire perspectives.
• More structured technical assistance and check-ins following the development of implementation maps were needed to support follow-through.
• Some participants had a sense of ownership or attachment to the established process and were protective of maintaining the status quo.

Recommendations

• Ensure all participants understand the vision by providing an example of similar work in advance as reference material.
• Prior to the mapping activities, conduct a series of key informant interviews to ensure the right people are in the room, gain an understanding and awareness of organizational and interpersonal dynamics that may impact the process, and identify opportunities to establish bidirectional communications between state and local staff.
• Plan for ongoing technical assistance follow-up to ensure understanding of the initiative and support implementation.
• Ensure logistics can accommodate the process, such as proper room size and technological support.

In Conclusion

Given the challenges identified in this pilot learning community, states would likely benefit from change management prior to beginning BPI activities. Having intentional conversations up front can prevent these common challenges, as outlined previously. Overall, all state participants agreed that the learning community was valuable to their work, increased their organization’s knowledge and capacity, strengthened their relationships within their agency, and they intend to continue working on their improvement plans.

One state team shared, “A major success from this mapping workshop was understanding the significance of engaging and listening to colleagues from diverse departments. The workshop facilitated a clearer understanding of civil service and HR operations, emphasizing the hurdles faced by hiring managers.” While business process mapping and implementation plan development can be laborious, the results are well worth the effort.