Using the NPHPSP for Performance Improvement Stacy Baker, MSEd Director of Performance Improvement Public Health Foundation Session 3298.0, Nov. 5, 2007, 2:30 – 4:00 PM

Let’s Focus on Results Learning Results of the Assessment Achieving Results ─ Next Steps for Performance Improvement

NPHPSP Reports for “Version 2” Jurisdiction Name Date Obtain User ID Enter data online Generate report www.nphpsp-results.org

Obtain User ID www.nphpsp-results.org

Enter Data Online

Generate Report www.nphpsp-results.org Visit “Report Center Check Status of modules Name Generate report (RTF) Download raw data (CSV) www.nphpsp-results.org

NPHPSP Reports for “Version 2” Jurisdiction Name Date Types of Reports State PH System Local PH System Local Governance Aggregate reports for statewide users All locals or boards in state State-local comparison www.nphpsp-results.org

NPHPSP Reports for “Version 2” Performance Assessment Instrument Results All reports answer three questions: I. How well did the (public health system/board) perform the ten Essential Public Health Services (EPHS)? II. How well did the (public health system/board) perform on specific areas of each Essential Service? III. Overall, how well is the (public health system/board) achieving optimal activity levels?

NPHPSP Reports (Example) I. How well did the board perform the ten EPHS? Figure 3: Rank ordered performance scores for each Essential Service, by level of activity

NPHPSP Reports (Example) II NPHPSP Reports (Example) II. How well did the board perform on specific areas? Figure 4: Performance scores for questions within each model standard/ Essential Service Users receive one bar chart for each Essential Service/model standard. For the governance report, each bar represents a stem question. For the state and local assessments, each bar represents a model standard within the EPHS.

NPHPSP Reports (Example) III NPHPSP Reports (Example) III. Overall, how well is the board achieving optimal activity levels? Figure 6: Percentage of all questions scored in each level of activity

NPHPSP Reports – Optional Modules Optional Priority Rating Results: What are potential areas for attention, based on the priority ratings and performance scores? Optional Agency Contribution Results (State or Local): How much does the (Local Health Department/State Public Health Agency) contribute to the system’s performance, as perceived by assessment participants? Jurisdiction Name Date

Priority Rating vs. Performance Quadrant I ─ May need increased attention Quadrant II ─ May be important to maintain efforts Quadrant III ─ May shift or reduce some resources or attention to focus on higher priority activities Quadrant IV ─ May need little or no attention at this time Perceived Priority (1-10) High I High Priority Low Performance II High Performance Low IV Low Priority III Current Level of Performance (1 – 100) Source: NPHPSP User Guide

Priority Rating Results (Example) Quadrant I (High Priority/Low Performance) ─ May need increased attention Quadrant II (High Priority/High Performance) ─ May be important to maintain efforts Quadrant III (Low Priority/High Performance) ─ May shift or reduce some resources or attention to focus on higher priority activities Quadrant IV (Low Priority/Low Performance) ─ May need little or no attention at this time Figure 8: Scatter plot of Essential Service scores and priority ratings

Priority Rating Results (Example) Table 4: Model Standard by priority and performance score, with areas for attention Essential Service Priority Rating Performance Score (Level of Activity) Quadrant I (High Priority/Low Performance) These important activities may need increased attention. 5.2 Public Health Policy Development 9 25 (Minimal) 5.3 Community Health Improvement Process 10 Quadrant II (High Priority/High Performance) These activities are being done well, and it is important to maintain efforts. 1.3 Maintenance of Population Health Registries 100 (Optimal) 6.3 Enforce Laws, Regulations and Ordinances Quadrant III (Low Priority/High Performance) These activities are being done well, but the system can shift or reduce some resources or attention to focus on higher priority activities. 3.1 Health Education and Promotion 7 3.3 Risk Communication 6 Quadrant IV (Low Priority/Low Performance) These activities could be improved, but are of low priority. They may need little or no attention at this time. 8.1 Workforce Assessment, Planning, & Development 4 8.2 Public Health Workforce Standards

Building Systems to Achieve Health How can we “find the gold” among the standards & results? Which could be drivers of our health outcomes? What’s the shortest path… FROM THIS TO THIS ?

Coordination with MAPP Use of NPHPSP within MAPP Provides the context of health and priorities needed to interpret system results Anchors system changes to strategic and measurable health improvement www.naccho.org/MAPP

5 Steps for Performance Improvement Organize participation for performance improvement. Prioritize areas for action. Explore “root causes” of performance. Regularly monitor and report progress. Develop and implement improvement plans. Source: NPHPSP User Guide

Thinking about System Improvement Every system is perfectly designed to achieve exactly the results it gets! ─Deming

Thinking about System Improvement What kind of system do you need to achieve the results important to your state or community?

Why isn’t this done (or solved!) already? The case for pausing to examine “root causes” of public health performance issues

Source: NPHPSP Users’ Guide, 2006 Why isn’t this done (or solved!) already? Two Jurisdictions: Same Performance, Different Reasons Low Score on “Essential Public Health Service 10” (Research for New Insights and Solutions to Health Problems) Jurisdiction A Jurisdiction B Reasons for Low Score No university or research institution nearby Don’t know how to link with research institutions, despite leader-ship interest No leadership support for research with local universities No incentives for organizations or staff to identify innovations Source: NPHPSP Users’ Guide, 2006

Source: NPHPSP Users’ Guide, 2006 Why isn’t this done (or solved!) already? Two Jurisdictions: Same Performance, Different Reasons Low Score on “Essential Public Health Service 10” (Research for New Insights and Solutions to Health Problems) Jurisdiction A Jurisdiction B Potential Improvement Actions Identify out-of-town research partners Access sample academic-practice linkage agreements Meet with leaders to show benefits to local priorities Recognition and grant incentives for innovative solutions FROM USERS’ GUIDE Source: NPHPSP Users’ Guide, 2006

Successful Improvement Efforts Analyze and Address “Root Causes” Why can’t we make progress on ______________? Is it because of: Methods / procedures Motivation / incentives Materials / equipment People (personnel, partners, providers, or patients) Information / feedback Environment Policy One of the key concepts in QI is to examine and address root causes of problems Value systems thinking Pause to consider what is causing a problem in the first place Before deciding what the solution will be We simply don’t do this enough in public health. Fill in the blank: Why can’t we make progress on _____________? (speeding up purchase orders, obesity, having a regular state health profile) There are tools to examine these, as well as prioritize places to delve deeper. What if you filled in the blank with “spreading QI practices?”

What it Takes to Improve 2005 Study: Characteristics of Public Health Systems Engaged in Performance Improvement After NPHPSP Assessment Leadership support Ability to find, use, or hire expertise Partnerships/involvement of community Small steps toward system improvements Experience with multiple, related efforts MAPP, accreditation program Regular PI meetings with feedback Data from PHF interviews in 2005 with NPHPSP users believed to engage in performance improvement efforts. Source: Public Health Foundation, 2005.

NPHPSP Improvement Resources User Guide Post-Assessment Toolkit Monthly User Calls MAPP Clearinghouse Personalized technical assistance Searchable Online Resource Center www.cdc.gov/od/ocphp/nphpsp

Tips Start with a vision for what’s next after assessment Get started – action trumps nice write-ups Set priorities – and put aside the rest Ask why the system is this way Find something to measure Do we need to do it? Or do it well? How do we know if it’s getting better? Plan-Do-Check-Act

“When you come to a fork in the road, take it." ―Yogi Berra