Utah Health Department 'strongly influenced' by feds instead of state lawmakers, state audit says

After more than a year of tension between state lawmakers and public health officials prompted by pandemic-related health orders, a new audit urges the Utah Department of Health to prioritize the Utah Legislature's demands.

The audit of the Utah Department of Health, based in Salt Lake City, found the agency appears "strongly influenced" by the federal government over the Utah Legislature and has been slow to implement recommendations made by state lawmakers.

"We have heard it described that (the Department of Health) is an 'agency of no,'" auditors wrote in a pair of reports released Monday during a Legislative Audit Subcommittee meeting at the state Capitol.

"Our review of bills affecting the department, as well as our observations of audit recommendation implementation efforts, supports the idea that (the department) has not proactively sought opportunities to innovate within the boundaries of federal oversight and respond more fully to legislative direction," the report states.

The Office of the Legislative Auditor General, which works under legislative leadership, performed the audits at the request of the Utah Legislature.

Relationship with Legislature

Auditors believe the agency's stronger relationship with the federal government is due to financial incentives of federal funding, which comes with federally mandated rules. The report contends that the Utah Department of Health "may have allowed this process to hinder the department's pursuit of new ideas and innovations."

That's despite the Utah Legislature appropriating more than $600 million for the health department in this year's general fund, according to auditors. State lawmakers also allocate federal funding to the department.

The health department has implemented two-thirds of the recommendations made in previous legislative audits, the report states — warning of a "potential risk" of inadequate funding if all recommendations aren't met.

The report calls for health department leadership "to balance stakeholder needs and appropriately emphasize legislative priorities," with auditors saying they believe employees will follow that example.

The auditors also noted that the health department hasn't proposed much legislation within the past few years, and the Legislature has been responsible for two-thirds of the bills passed that affect the public health agency.

According to the report, the Utah Department of Health should "develop and take the lead in proposing new public health policy innovations for the Legislature to consider, as (the department) has the expertise and experience to be a leader in health innovation."

Auditors said they believe the merger between the Utah Department of Health and Department of Human Services — which was put into action during the 2020 Legislature — will give a "framework" to create a department that the Legislature, governor's office, local governments and federal government "can rely on to be the public health authority of the state."

The audit did not delve into the pandemic and its ensuing health orders, which prompted the 2021 Utah Legislature to pass an "endgame" bill that placed emergency health orders into the hands of local elected bodies and state lawmakers.

Local health department collaboration encouraged

Auditors said the department also sometimes applies for grants to address issues already being addressed by other agencies or for issues that are "relatively less prominent" in Utah, which can lead to diminishing returns. Auditors called for the health department to be more "strategically driven" in applying for federal grants.

The report urged the state health department to work more closely with local health departments in "identifying the most pressing needs of the state." The state health department and local health departments should increase transparency with each other to better use funds, auditors said.

For example, coronavirus funding for local health departments increased by $43 million compared to what the Utah Department of Health originally proposed after discussions between state and local health officials.

"While we acknowledge that ultimately the committee's reviews and negotiations were effective in shifting the funding allocation strategy to align with need, it is concerning that the initial proposal was devised without substantial local input or significant local funding," auditors wrote.

More innovation needed?

Auditors also expressed concern about what they described as a culture that doesn't foster innovation, and noted that "employees stated that new ideas and processes may be accepted but are not encouraged, and there is a lack of will to implement innovation."

Several years ago, the department created an Office of Organizational Development and Performance Improvement, but that has faced "significant hurdles" inspiring innovation, auditors wrote. The department was also awarded almost $3 million to create and implement the Utah Health Innovation plan, which was "never fully implemented," according to the report.

"Our survey to (department) employees also identified that new ideas or processes may be embraced but are not encouraged, and there is a lack of will to implement innovation," auditors said.

With the concern that the new merged agency "is not sufficient" to solve all the issues, auditors also recommend the creation of an "innovation center" to "foster a culture of innovation" and help the state improve its public health efforts.

The auditors pointed to centers created in Idaho, Oregon and Washington that aim to promote initiatives to improve health in their states.

Auditors believe such a center in Utah should:

  • Identify opportunities for information that "will help shape the future of health care in the state."
  • Use accurate data to find strategies for health care transformation and health information infrastructure.
  • Build a "cohesive policy agenda"; recommend strategies to reduce health care costs.
  • Promote improved health care practices.
  • "Support efforts to provide a workforce that is sufficient in numbers and training" to meet the demands of the health care system.

Auditors said they did find "several encouraging aspects" of the health department's culture, including a dedicated workforce, a willingness to follow department leadership and general job satisfaction.

Social service agencies' performance

A second audit report found that the state's social services departments — which includes offices in the Utah Department of Health and Utah Department of Workforce Services — have "no required legislative performance measures" in base budget bills, giving the Legislature limited oversight of them.

Many social services performance measures reported in 2020 were "consistently below target and point to deteriorating performance," auditors said.

The report's recommendations include that the agencies, along with fiscal analyst and the governor's office, address "oversight gaps" in large programs, and that they ensure that the information system used can report multi-year trends for base budget bill measures.

In a letter responding to the Utah Department of Health's audit, its executive director Nate Checketts noted that over the years the department has "simultaneously implemented multiple advancements in its services to Utahns during very difficult circumstances."

"The department, the state and its residents can rightly feel proud about many aspects of the overall health of our state and steps we collectively are taking to make it better," Checketts wrote.

But he acknowledged that the department can improve in certain areas, including in culture, innovation and processes. He said the agency will "begin addressing these recommendations immediately."

In a joint response to the social services audit, Checketts and Tracy Gruber, executive director of the Department of Human Services, called the development of "comprehensive strategic plans and meaningful performance measures" essential to the new joint department.

They said the department will include a Center for Strategic Performance Management with divisions focused on quality and improvement and data.