Southern Nevada Health District board's makeup is at the root of SNHD's problems, say experts

Former county manager, current elected officials call for board overhaul

LAS VEGAS — Current troubles at the Southern Nevada Health District didn’t emerge out of the blue, say long-time observers.

Those problems have a common root, they argue, that goes back many years.

It’s the organization’s governance structure.

Thom Reilly, who ran Clark County for five years as its county manager, sees the parallels between the district’s troubles then and its troubles now.

It was July 2001 when Reilly — currently director of San Diego State University’s School of Social Work — began his five-year stint as Clark County manager.

Just days earlier, then-Nevada governor Kenny Guinn had designated the Clark County Commission as the sole air-quality agency for Southern Nevada.

For the preceding 10 years, the problem-ridden health district had been Southern Nevada’s lead agency on air-pollution matters. For the previous year it had been at the center of discussions between local governments regarding establishment of a new regional air-quality-control entity.

With the governor’s action, however, it had been unceremoniously sidelined — eliciting a wide range of expressions of concern and discomfort from other local municipalities.

Most emphatic was the explosion from the then-Las Vegas mayor. “Outrageous!” said Oscar Goodman.

Behind Guinn’s move were two separate recognitions:

First, because Southern Nevada had repeatedly failed to meet federal air-quality standards, the entire state was risking the loss of federal highway funding dollars, as an Environmental Protection Agency sanction.

Second, significant internal problems within the health district were widely known to be hampering its performance on air-quality matters. Those troubles had been documented by an extensive, state-funded enquiry authorized by the 1999 Nevada Legislature.

The district’s internal problems included “alleged corruption, mismanagement, favoritism and employee morale” troubles, as then-state senator Dina Titus told a Senate committee in 2001.

Name changed, but the same problems persist

Today, 11 years later, the district has a new name, but the problems reported there remain virtually identical.

No longer known as the Clark County Health District, after a name-change in 2005, the Southern Nevada Health District again faces allegations of corruption, mismanagement, favoritism and employee-morale problems.

Nearly all of these problems, in the view of Thom Reilly, arise from a basic incoherence built into the health district’s governing board, the Board of Health.

“I think the health district has too big of a board, [with] too much of a mixture of elected versus appointed members,” he told Nevada Journal.

Not only does the board have 14 members, each of whom serves a mere two-year term, but six of the 14 members are not elected and therefore not accountable to voters.

Additionally, all 14 members have an alternate member, who also serves a two-year term. That means a quorum can be made up by as few as eight out of 28 eligible individuals.

“I don’t know why that ever evolved — if you don’t show up, you could bring somebody else in. Nowhere else does that exist,” said Reilly.

“You can’t do that at the RTC, you can’t do that anywhere else. That needs to be eliminated.”

With 14 members and 14 alternates always coming and going, a dozen of the 28 not elected and all 28 serving only two-year terms, “there’s little continuity of issues,” he said.

“I mean, when you have county commissioners and city councilmen substituting people when they can’t make it, so they have a seat at the table, you have different people. And unless they’re in intense communication with you, they’re not having continuity on the issues.”

The upshot, argues Reilly, is that the membership structure of the Board of Health operates to dilute its members’ understanding of the issues.

In order to “understand the issues … understand the dynamics of what’s happening at a board meeting, [and] who the players are, you need the same people there,” he said.

Staffers take over

The clear implication of the Reilly critique is that the structure of the Board of Health increases the likelihood of board members being uninformed and inattentive — thus decreasing clarity of direction and leadership from the board, and encouraging staff to step into the breach.

Some members on the current Board of Health agree with Reilly. One told Nevada Journal of initially wondering whether the dysfunction at the health district stemmed entirely from the then-chief health officer, Dr. Lawrence Sands, or if “the entire organization and governance structure is dysfunctional and the only way anyone can cope with it is to act in a dysfunctional manner.”

Today, that board member says, “I think that the governance structure is unworkable, and that no one could be functional in his position.”

One case in point that Reilly spotlights is the Board of Health’s 2010 approval of 5.5 percent pay raises for district staff at the same time that everyone else in Southern Nevada was struggling.

“It’s amazing that it didn’t dawn on any of the elected officials to ask about that, that there are collective bargaining agreements. But the fact that you have so many people in there, that it’s such a large board, and the fact that you can have alternates,” all operate together to undermine good decision-making, Reilly said.

Reilly also believes the district suffers from the absence of a general administrative officer — like those in place at the county, the Regional Transportation Commission, the Southern Nevada Water Authority and the county Regional Flood Control District.

Under the present model, the chief health officer also bears responsibility for all administration.

“Although there have been very successful MD-administrators,” he said, “I just think it’s a challenge recruiting someone” qualified to be chief health officer for the district, now that state law requires that candidate to also have 10 years of administrative background.

“You can cast a wider net” for candidates, said Reilly, if you separate “out the duties of the health officer, vis-à-vis the person that is charged with being a good administrator.

“And you wouldn’t have to add positions. You’d just restructure the positions that are there [now].”

The unique nature of the health district makes the chief health officer’s position more challenging than people realize, Reilly suggests.

“When you have a physician on a political board, it’s challenging enough. And then when you have multiple local governments, it can be even more challenging,” Reilly said.

Reforms proposed at state legislature

In 2005, Clark County had sought to add a chief administrative officer position to the health district’s governing structure. The proposal was included in amendments suggested to a bill, AB 380, being offered by then-assemblyman David Parks and co-sponsored by then-assemblywoman Chris Giunchigliani.

Parks testified that he had discovered growing concerns across Southern Nevada about the operation of the health district, and a growing desire that the district operate more like either the Regional Flood Control District or the Regional Transportation Commission (RTC), which — with much smaller boards, augmented by advisory committees — were seen as models of efficiency.

AB 380, therefore, would have reduced board membership to merely eight elected members, with no alternates. Two board members were to be named by the Clark County Commission, two by the City of Las Vegas, and one each by the city councils of Henderson, North Las Vegas, Boulder City and Mesquite.

As an alternative to the existing contingent of board-selected at-large members, the bill would have established advisory committees, following the successful model in use, Parks told Nevada Journal, in Los Angeles, San Diego and Maricopa County, Ariz.

A health advisory committee would have been composed of eight medical and health-related professionals, each one named by a Board of Health member. A larger citizen advisory committee would have been similarly appointed, but have additional members named by the county commission and the cities.

Parks said that he hoped that the advisory-committee approach would improve “how the health district functions relative to the community as a whole.”

While “there’s a lot of nonprofit organizations that do a lot of great work,” he told Nevada Journal, his “experience has been that the health district looks at themselves as being in competition with nonprofits — rather than being the agency to help support and further its mission through the use of nonprofit organizations.”

A similar observation about the district was recently leveled by Dr. Michael J. Silvers, the subject of an earlier Nevada Journal story: “What I found,” he said, “was that they are highly territorial, if that’s a fair way to put it. They do not welcome people getting involved in public health and healthcare initiatives in any shape or form as far as I can see — unless they are basically controlling it.”

The amendment to AB 380 offered by Clark County in the 2005 legislative session proposed:

  • Funding of the district through a tax levy not to exceed 3.25 cents — later amended to 3.5 cents — per $100 of taxable property,
  • Deposit of those proceeds and other funds received by the district into a designated fund in the county treasury,
  • Submission of a budget to the board of county commissioners,
  • Employment of a general manager to administer and operate the district, and
  • A provision that the district board define the powers, duties, and functions of both the district health officer and the general manager.

Given the recent lawsuits and counter-lawsuits between Clark County and the health district over the 3.5 cents funding stream, Nevada Journal asked Reilly why the county had proposed it.

“As I recall,” he said, “we either wanted to make it a county department to give us total control, or we were willing to give them a dedicated funding stream so they controlled their own destiny.

“There would be more accountability with either of those options,” he said in an e-mail. “I guarantee [Dr. Lawrence] Sands would not have been giving the generous employee increases to health district employees (during the recession) if he had a set funding stream .....with no ability to go to the County for additional funding.”

Reilly says he still feels “strongly that moving the health district's governance structure towards a general-manger position is a more effective and efficient model,” and adds that he is “not convinced having an MD as the CEO is necessary or always desirable.”

Although AB 380 eventually passed both legislative chambers, none of the governance reforms sought by Parks and Clark County were included.

District insiders were opposed

The provisions were opposed by both Sands — at the time director of the community health services division — and Dr. Donald Kwalick, then chief health officer. Kwalick also presented Las Vegas city councilman and mayor pro-tem Gary Reese, board-of-health chairman at the time, to testify against the proposals.

“The Clark County District Board of Health is a well-functioning board that effectively sets policy for protecting and promoting the health of Clark County residents and visitors,” asserted Reese.

Moreover, “[i]n regard to the citizen and health advisory committees,” he told legislators, “this component of citizen and health professional involvement is already built into the current structure of the board.

“Changing the composition of the board,” he contended, “would only serve to eliminate the direct input of citizens and health professionals, and add permanent administrative layers.”

Some of the testimony against the proposed governance changes was disingenuous. Northern Nevada lawmakers, for example, were allowed to believe that four Southern Nevada cities each had two board-of-health seats, one of which would be lost under the Parks plan. The reality was that those cities actually already had only one seat, which was occupied either by the appointed member or the alternate — whoever showed up.

But the issue of city representation on the health district board was clearly seen as a telling issue, and Reese bore down hard on it:

I would also like to make a point regarding the diminished representation of the cities. I make this point as the elected representative from the largest city, which had retained both positions on the board. I am opposed to limiting representation from the cities of Boulder City, Henderson, Mesquite, and North Las Vegas. Public health matters are not quantifiable. You cannot measure whether one community would be more effective than another, and therefore, it would not be good to limit the oversight provided by the other members of our board.

None of the testimony before lawmakers dealt with the management and operational problems that had been explicitly identified in the Legislature’s report five years earlier.

“The Clark County Health District Board of Health is not broken,” said Reese, “and not only does it work, it works well.”

Post-mortem on the 2005 reforms

County Commissioner Chris Giunchigliani, who supported the 2005 Parks bill as an assembly member, told Nevada Journal that she also “researched other areas for his 2007 bill on consolidation.” She also offered a more sweeping amendment that would have moved the health district entirely back under the county’s authority.

Today, she says, “I know the cities probably don't want it back under the county.” But at a minimum, she argues, the district’s Environmental Health division should be “co-located in the jurisdictions to be close to business licensing and building permits.” The district could still operate a small centralized presence, she wrote in an e-mail.

“The Board should only be elected members — at least we are accountable to the public. An appointee isn't,” said Giunchigliani. The more appropriate role for appointees, she suggested, would be in assessing fees and fines and writing regulations.

As for Reilly, he sees multiple reasons why the issue of city representation posed such a large obstacle to district governance reform in 2005.

One factor he highlighted facing the cities is the already-disproportionate relative power of Clark County. That power stems from a 1983 state law requiring:

… that certain areas that were already established as incorporated towns can’t be annexed. So in other jurisdictions, over time, those areas were just annexed by the city … and the county would have been more of a regional body — not have a dual hat as a municipal and a regional [entity, as Clark County now does].

The county’s always been a little strange, because it serves its regional functions, which all counties do, but unlike other areas, because of that law that prohibits the annexation of some of the core areas that truly are [of the] city — you know, Paradise, the Strip, the airport — the county has another hat and it acts like a city. So it does municipal services: you know, garbage pickup and all those municipal building inspections, …

The fact that the county is also a city, I think, leads to some of that concern within the other municipalities — of, “Hey, which hat are you going to use? One day you’re a city, one day you’re a county.” (laughs) It leads to a reluctance….

A second factor Reilly identifies was the still-recent transfer, four years earlier, of air-quality powers from the health district to the county. That had happened, he notes, to the “consternation” of the cities, leaving them “a little raw about that.” And while the transfer “turned out very well … I think that was also playing a part at that time, too.”

Yet another factor, he speculates, was the legacy of Otto Ravenholt, still alive at the time, who had been both an MD and “a very effective administrator.” Because Ravenholt had been able to make the existing health-district structure work — despite the flaws in it that he himself had identified — legislators could conclude that the governance issues weren’t significant.

Finally, said Reilly, the proposal to replace at-large, non-elected board members with advisory councils too easily can become personalized.

“You have individuals who serve in good faith, like appointed individuals, who get offended and feel, ‘Hey look, I do my job really well, and I’m diligent and dedicated and show up…’ So that personalizes the issue.”

Reilly: The time is ripe

Notwithstanding the various factors involved in the 2005 defeat for health-district governance reform, Reilly believes that today is different.

“There are two issues that have surfaced, and I think that those two can now become the rallying point to actually bring some reform, in a different type of governing structure,” he said.

One issue is “the fact that during the recession, when everyone else is struggling, [Sands] is giving 5 percent [pay] increases. It’s amazing that it didn’t dawn on any of the elected officials [on the board of health] to ask about that, that there are collective bargaining agreements.

“But the fact that you have so many people in there, that it’s such a large board, and the fact that you can have alternates,” all operate to produce an ultimately feckless governing board.

The other issue revealing serious dysfunction at the district, suggested Reilly, was Sands’ decision to not even consult with his governing board, but to instead just close the Ravenholt Center, attempting — in many observers’ eyes — a fait accompli in district management’s ongoing battle to get the new building it wanted.

Said Reilly, “I think if the county tried again to just make it that regional structure … with a seven-member board, like the RTC, like Flood Control, with a general manager — I think that would probably have a lot better chance of getting passed, in light of what occurred.

“And then you can get the cities on board,” he said, since — on any governing entity that takes the RTC or regional Flood Control as the model — they would thus keep their current balance-of-power with the county.

Steven Miller is the managing editor of Nevada Journal, a publication of the Nevada Policy Research Institute. For more in-depth reporting, visit http://nevadajournal.com/ and http://npri.org/.

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