Strengthening systems, improving the public’s health The NPHPS is a partnership effort – with national public health organizations - to improve the practice of public health and the performance of public health systems through the establishment and implementation of standards. Currently, there are program standards in some public health related areas (e.g., laboratory standards) but no national standards for overall public health systems like there are in other sectors (e.g., hospital standards through JCAHO, law enforcement agency standards through CALEA). So this is a much-needed and ground-breaking effort.

NPHPSP: Strengthening Systems, Improving the Public’s Health Laura B. Landrum APHA Annual Meeting Washington D.C. November 5, 2007

Program Vision and Goals To improve the quality of public health practice and performance of public health systems by: Providing performance standards for public health systems and encouraging their widespread use; Engaging and leveraging national, state, and local partnerships to build a stronger foundation for public health preparedness; Promoting continuous quality improvement of public health systems; and Strengthening the science base for public health practice improvement. The NPHPSP will: Provide performance standards for public health systems. Up until this point, there had been no standards for public health practice, like there are in other sectors (managed care, hospitals, law enforcement). Through the use of standards, we will engage and leverage partnerships to create a stronger foundation for public health preparedness. By setting optimal standards, we promote continuous quality improvement of public health systems --– the standards will give systems benchmarks to strive for. And lastly, the NPHPSP gathers data on what state and local public health systems and governing bodies look like, in comparison to the standards. This will provide us with a much stronger science base for public health practice improvement and a stronger understanding of our state and local public health infrastructure. This data can be ultimately used for making policy decisions, allocating resources, and establishing new benchmarks for public health improvement. So, for the first time, we’ll be able to answer questions such as “What are the activities, competencies and capacities of public health systems across the nation?” and how do they differ from state to state? We’ll be able to use this information to identify best practices, improve coordination, and lobby for policy changes or an increased emphasis on low-scoring areas.

NPHPSP Assessment Instruments Partners State public health system Local public health system Local public health governance Partners CDC APHA ASTHO NACCHO NALBOH NNPHI PHF

History of the NPHPSP Key Dates Began in 1998 Version 1 instruments released in 2002 2002-2007 – Version 1 instruments used in more than 30 states Development of Version 2 instruments – 2005-2007 Comprehensive Development of Instruments Practice-driven development by CDC and ASTHO, NACCHO and NALBOH Work Groups Field testing Validation studies

Four Concepts Applied in NPHPSP 1. Based on the ten Essential Public Health Services 2. Focus on the overall public health system 3. Describe an optimal level of performance To truly understand the value and uniqueness of the NPHPS, it is important to realize that there are four concepts that underpin the instruments and standards: 1. The instruments are based on and built around the Ten Essential Public Health Services 2. The standards focus on the overall public health system, as opposed to a single organization or entity; 3. The performance standards describe an optimal level of performance; and The standards are intended to support and stimulate a process of quality improvement The next few slides describe each of the concepts in a little more detail. 4. Support a process of quality improvement

Essential Public Health Services Developed by the Core Public Health Functions Steering Committee (1994) Included reps from national organizations and federal agencies Charge: To provide a description and definition of public health Developed the “Public Health in America” statement

The Essential Public Health Services Monitor health status Diagnose and investigate health problems Inform, educate and empower people Mobilize communities to address health problems Develop policies and plans Enforce laws and regulations Link people to needed health services Assure a competent workforce - public health and personal care Evaluate health services Conduct research for new innovations The ten essential services are shown here on the screen and include: Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems These are the foundation of any public health activity. For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

Focus on the “System” More than just the public health agency “Public health system” All public, private, and voluntary entities that contribute to public health in a given area. A network of entities with differing roles, relationships, and interactions. The second concept addresses the fact that the NPHPS focuses on the overall “public health system.” This assures that the contributions of all entities are recognized in assessing the provision of public health services. Clearly, the governmental public health agency – either at the state or local level – is a major player in the public health system, but agencies cannot provide the full spectrum of essential public health services alone. Hospitals, public safety, voluntary health organizations, mental health centers, schools, civic groups, faith institutions and others all contribute to accomplishing the actions necessary to achieve public health. When we talk about public health systems, a definition we commonly use is: “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” Another way of looking at it is to say that a public health system is a network of entities with differing roles, relationships, and interactions. All of these entities contribute to the health and well-being of the community. All entities contribute to the health and well-being of the community.

Community Centers Employers Transit Elected Officials Doctors EMS Schools Community Centers Employers Transit Elected Officials Doctors EMS Law Enforcement Nursing Homes Fire Corrections Mental Health Faith Instit. Civic Groups Non-Profit Organizations Neighborhood Orgs. Laboratories Home Health CHCs Hospitals Tribal Health Drug Treatment Public Health Agency

A system of partnerships that includes, but is not limited to . . . Churches Justice &Law Enforcement Community Services Environmental Health Healthcare Providers Philanthropy Transportation Business Media Schools Mental Coalitions Federal DHHS State Health Department Local Health Departments Tribal Health

Our goal is an integrated system of partnerships Churches Justice &Law Enforcement Community Services Environmental Health Healthcare Providers Philanthropy Transportation Business Media Schools Mental Coalitions Federal DHHS State Health Department Local Health Departments Tribal Health

Stimulate Quality Improvement Standards should result in identification of areas for improvement Link results to an improvement process NPHPSP Local Instrument - used within the MAPP planning process Plan Do Study Act Finally, the NPHPS are intended to promote and stimulate quality improvement. The major outcome of responding to the performance standards instrument should be the identification of strengths and weaknesses within the state or local public health system. This information should be used to determine areas and methods for improvement. Ideally, this information should feed into a health improvement process and should result in planning and action around identified priority areas. The development of the local public health system instrument, in particular, has already been linked to a recently-developed community health improvement process, called MAPP.

NPHPSP State Instrument Use (Thru August 2007, n = 22 states) WA OR NV CA ID MT AK UT AZ WY CO NM ND SD NE KS TX OK LA AR MO IA MN MS OH WI IN IL MI ME KY NY PA WV VA NC GA TN AL FL SC VT NJ DE MD NH MA RI CT NH MA RI CT Completed (Blue): States that completed implementation of the state instrument HI *Also includes sites using field test versions of the NPHPSP State Public Health System Performance Assessment.

NPHPSP Local Instrument Use (Thru August 2007) WA OR NV CA ID MT AK UT AZ WY CO NM ND SD NE KS TX OK LA AR MO IA MN MS OH WI IN IL MI ME KY NY PA WV VA NC GA TN AL FL SC VT NJ DE MD NH MA RI CT Significant Use (Dark Blue): Completion range = 67% or greater of local health departments completed use of the local instrument (Total number of significant use states = 6) Moderate Use (Blue): Completion range = 33% - 66% of local health departments completed use of the local instrument (Total number of moderate use states = 4) Limited Use (Light Blue): Completion range = 1% – 32% of local health departments completed use of the local instrument (Total number of limited use states = 12) NOTE: Completion rate for Maine (1/1 = 100%) HI Moderate Use (33% - 66%) Significant Use (67% or greater) Limited Use (1% - 32%) *Also includes sites using field test versions of the NPHPSP Local Public Health System Performance Assessment.

NPHPSP Governance Instrument Use (Thru August 2007) WA OR NV CA ID MT AK UT AZ WY CO NM ND SD NE KS TX OK LA AR MO IA MN MS OH WI IN IL MI ME KY NY PA WV VA NC GA TN AL FL SC VT NH MA RI CT NJ DE MD Significant Use (Dark Blue): Completion range = 67% or greater of local health departments completed use of the local instrument (Total number of significant use states = 1) Note: New Jersey is the only state showing significant use of the governance instrument. Moderate Use (Blue): Completion range: 33% - 66% of local boards of health completed use of the governance instrument (Total number of moderate use states = 0 Note: There are no states showing moderate use of the governance instrument. Limited Use (Light Blue): Completion range = 1% - 32% of local boards of health completed use of the governance instrument (Total number of limited use states = 8) (Total number of field test states = 4) HI No Boards of Health Moderate Use (33% - 66%) Significant Use (67% or greater) Limited Use (1% - 32%) *Also includes sites using field test versions of the NPHPSP Local Public Health Governance Performance Assessment.

NPHPSP Use in the Field (What the evaluation data* tell us) Reasons for Using NPHPSP – State and Local Establish a baseline measure of performance Wanted a national developed & recognized assessment tool to help improve performance NPHPSP the best tool available for improving public health system effectiveness Was part of the MAPP process (local users only) *State evaluation data gathered through ASTHO survey 10/05-1/06 – 80% response rate (9 respondents reporting completion of State NPHPSP). Local evaluation data gathered through NACCHO survey to known NPHPSP and MAPP users in 01/06 – 05/06; 212 total respondents (149 respondents reporting completion of Local NPHPSP).

NPHPSP Outcomes Achieved Percentage of respondents indicating achievement of these outcomes was partial/medium or high

Impact of NPHPSP Use on the State / Local Public Health System Percentage of respondents indicating moderate to major effect

Strategic Linkages Healthy People 2010 Objective 23-11 Institute of Medicine reports Turning Point Performance Management Collaborative MAPP Operational Definition of a Local Health Department Accreditation

NPHPS Version 2.0 Launched Streamlined and shortened!! New options, new reports Updated content areas Preparedness Informatics Communications and health marketing Partnerships Workforce Public health law Laboratory issues Social Justice State / local public health agency roles

See www.phf.org/infrastructure Turning Point’s Performance Management Model Four components of a performance management system So if performance improvement is positive changes in capacity, processes and outcomes across the entire system, then Performance Management is HOW improvement can be done. See www.phf.org/infrastructure

Using Results for Performance Improvement Changing Laws Illinois New Hampshire Planning Colorado Texas New Partnerships Access to care Workforce Epidemiologic Capacity Here are some examples of the types of action that NPHPS use has spawned. So, using the results of your assessment can: help shape policy help address funding issues/possibilities help to build stronger PH infrastructure build partnerships show where your system capacity currently is and where you need to go NPHPSP in laws in states: IL – State Health Improvement Plan Act NH – new state legislation appointing an Advisory Council to oversee and implement changes to better meet the NPHSP NPHSP in regulations: OH - Ohio has language - in rule, not law - which authorizes the Director of Health to require, at his or her discretion, that local health departments use the NPHPSP local tool as frequently as every other year in order to qualify for a state subsidy (NPHPS use is one component of a larger performance measurement program) NJ – administrative rule outlines use of NPHPS for locals and governing bodies as part of a larger performance measurement statewide program

Illinois State Health Improvement Plan Act (PA 94-0975) Create priorities for improving health and the public health system in Illinois Create specific priorities to address health disparities: age, race, ethnicity, gender, socio-economic status, geographic Conduct a systems assessment and health status assessment using national benchmarks (HP2010 and NPHPS) Director of IDPH appoints a Planning Team representing a broad array of stakeholders Hold 3 public hearings SBOH delivers plan to governor every four years

Illinois SHIP Process: A State MAPP SHIP MILESTONES Illinois SHIP Process: A State MAPP

Illinois Public Health System Assessment Created new “action” categories from major findings Collect Data and Use Information Effectively Garner, Leverage and Manage Resources for a More Proactive Public Health System Integrate State and Local Action Continuously Improve the Quality of the Public Health System Infuse Cultural Competency throughout the System Invest in the Public Health and Personal Health Care Workforce

For More Information Online Toolkit at: www.cdc.gov/od/ocphp/nphpsp State, Local, and Governance Instruments (Version 2) User Guide Sample letters, agendas, and reports from users Performance improvement resources and links And much more! Contact 1-800-747-7649 or email: phpsp@cdc.gov Going through the assessment process and evaluation provides some terrific benefits for the system partners and, by extension, the communities that they serve. Obviously, it improves communication among stakeholders Brings partners to the table to discuss issues, needs and activities, and promotes collaboration among the system members Provides a systems view of public health services delivery Provides a benchmark for improvement And finally Provides information for policy development, program evaluation and grant-writing