Choosing Stones, Moving Mountains: Performance Excellence, Primary Prevention, and Culture Change in a State Health Department.

A new health official of any size jurisdiction, anywhere, will face a mountain or two. Some will be obvious, others much less so. “The People” rightly expect us to have an approach to moving them, particularly the more obvious ones that fortunately are often also the most pressing and important ones. The scenario of being a new state health commissioner, appointed by a new governor, amid 20 years of languishing state health rankings was ours. Yet, many face similar mountains. How to move them, what stones first, why, and then how? For me, even with years of populationand individual-level practice experience in military and civilian settings, including a decade as a multijurisdictional health department director, assessing organizational performance, embracing a broad mission, and leading public health systems change were daunting. The temptation to disassemble health indicators and attack current public health crises was attractive but lacking the broader scope of change that was required. Obvious stones, yes, and the challenge became choosing and giving deliberate attention to approaches that would result in sustainable internal performance and culture change that would create capacity to move more stones faster for a wide range of public health stakeholders.