Sharing Public Health Resources and Services Gianfranco Pezzino Patrick Libbey Co-Directors, Center for Sharing Public Health Services

Outline  Frame the issue of cross-jurisdictional sharing (CJS)  Introduce the Center for Sharing Public Health Services

3 “Handshake” MOU Information sharing Equipment sharing Coordination Service provision agreements Mutual aid agreements Purchase of staff time Joint projects addressing all jurisdictions involved Shared capacity Inter-local agreements New entity formed by merging existing LHDs Consolidation of 1 or more LHD into existing LHD Informal and Customary Arrangements Service Related Arrangement Shared Functions with Joint Oversight Regionalization Cross-Jurisdictional Sharing Spectrum

Two Critical Questions  Who makes the decision to enter a CJS arrangement? 4  What are the drivers behind deciding to engage in CJS?

Drivers National Public Health Standards Increasing burden of chronic disease Emergency Preparedness Lean fiscal environments Health care reform CJS Agreements

Survey Findings Insights from Implementers of Shared Services  Most common goal - cost savings  Most participants - achieved goals  Most common measurement of progress - cost savings  Most positive result - improved service  Most negative result - “people issues”  CJS most often initiated - by agency leaders  Most common driver - cost or service variables  Most significant lesson learned from implementing CJS - “Change Management Is Key”  Biggest mistake - insufficient change management  Thing most organizations did well - project management  Greatest challenges - “people issues”; overcome with - improved communication Source: Success Factors for Implementing Shared Services in Government. IBM Center for the Business of Government, 2008

Survey Findings Insights from Implementers of Shared Services  Most common goal - cost savings  Most participants - achieved goals  Most common measurement of progress - cost savings  Most positive result - improved service  Most negative result - “people issues”  CJS most often initiated - by agency leaders  Most common driver - cost or service variables  Most significant lesson learned from implementing CJS - “Change Management Is Key”  Biggest mistake - insufficient change management  Thing most organizations did well - project management  Greatest challenges - “people issues”; overcome with - improved communication Source: Success Factors for Implementing Shared Services in Government. IBM Center for the Business of Government, 2008

Survey Findings Insights from Implementers of Shared Services  Most common goal - cost savings  Most participants - achieved goals  Most common measurement of progress - cost savings  Most positive result - improved service  Most negative result - “people issues”  CJS most often initiated - by agency leaders  Most common driver - cost or service variables  Most significant lesson learned from implementing CJS - “Change Management Is Key”  Biggest mistake - insufficient change management  Thing most organizations did well - project management  Greatest challenges - “people issues”; overcome with - improved communication Source: Success Factors for Implementing Shared Services in Government. IBM Center for the Business of Government, 2008

Greater efficiency Enhanced capacity

Who Are We?  The Center for Sharing Public Health Services (DOB: May 2012) is a national initiative managed by the Kansas Health Institute with support from the Robert Wood Johnson Foundation. 10

Center’s Goal  Increase the ability of public health agencies to improve the health of communities by helping explore, inform, track and share learning about regional and shared approaches to delivering public health services. 11

Target Audiences  Policymakers  Public health practitioners  Professional organizations representing these groups 12

Center’s Role  Support exploration approaches to share public health functions and services  Technical Assistance (TA)  Decision-making tools  Share knowledge  Document examples  Translate evidence  Support a learning community 13

The Learning Community  Policymakers  ICMA  NACo  USCM  NGA  NCSL  Learning community  16 local projects  Both groups will  Learn  Share  Explore 14  Public Health Officials  ASTHO  NACCHO  NALBOH  CDC

The Learning Community  Policymakers  ICMA  NACo  USCM  NGA  NCSL  Learning community  16 local projects  Both groups will  Learn  Share  Explore 15  Public Health Officials  ASTHO  NACCHO  NALBOH  CDC

Shared Services Learning Community sites 14 states 2-year grants

Teams at Learning Sites  Teams funded are:  Working with two or more PH agencies  Made up of PH officials and policymakers  Exploring, implementing or improving CJS  Committed to  achieving greater efficiency  enhancing public health capacity  collaborating 17

Range of Site Activities  Begin exploration  Identify specific goals  Develop a feasibility study  Learn about various sharing models  Review implications of shared capacity 18

Range of Site Activities  Select sharing model  Develop strategic plan  Prepare for implementation  Begin implementation 19

Key Points: CJS, QI, Accreditation 1.QI and PM tools can support successful CJS efforts 2.CJS can provide QI and PM documentation for accreditation 3.CJS may increase accreditation readiness  Some jurisdictions can achieve standards jointly, but not independently

Change Management QI and PH Practice Assess willingness to changeQI approach: Identify issues Brain storming Affinity diagram Develop strategy for changePDSA = PLAN Use of QI tools (workflow analysis, affinity diagrams, etc.) Implement changePDSA = Do Evaluate experiencePDSA = Study Phased approachPDSA = Act QI approach: start on small scale, assess and expand

The Uncomfortable Questions  We have about 2,700 LHDs in the U.S.  Do we need 2,700?  Can we afford 2,700?  Can we imagine a day when all of them would meet accreditation standards?  Is it politically feasible to change the current LHD structure? 22 Adapted from: Gene W. Matthews, JD

Moving Forward Let’s look at things differently Let’s brainstorm possibilities Let’s explore options and alternatives Then, let’s SHARE 23

(855) The Center for Sharing Public Health Services is a national initiative managed by the Kansas Health Institute with support from the Robert Wood Johnson Foundation. 24

 Steven J. Ward, MA, MPH  Assistant Director of Public Health  City of Worcester  Division of Public Health

Central Massachusetts

 City Manager Task Force and State Department of Public Health (PHDIG) encourage regional shared service model  Develop and sustain a high quality cost effective and labor-efficient regional public health district  Using Constant Quality Improvement methods  Share lessons learned with National Partners and Massachusetts PHDIG communities as to Cross Jurisdictional Best Practices

Quality Improvement Plan AIM:  Standardize the practice of Environmental Health throughout the 5 CMRPHA communities Why It Is Important:  Standardization leads to a uniform approach to regulatory programs and enforcement strategies and efficient use of staff time.  Field staff will have more time for Community Health and Emergency Preparedness programs

 Time-motion study to support Environmental Health Standardization  Workforce development  Filed staff and BOH Credentials

 Assure consistent training of all staff  Assess current academic credentials of field staff and develop plan to address acquisition of needed academic credentials  Creation of Center for Public Health Practice for producing field ready Environmental Health interns and to deliver IDP academic content to staff

Planned Improvement Activities  Institutionalize standardized practices  Improve efficiency of staff time  Utilize time-motion and direct observation analysis to ensure appropriate allocation of personnel and staff

Review program in December of 2013 for ongoing QI

Northwoods Shared Services Project

Starting Out 2003 influx of funding created public health preparedness consortia Northwoods Consortium – 21 jurisdictions – Epidemiology/outcomes-based approach – Accreditation July 2011 elimination of consortia funding August 2011Northwoods Collaborative – 9 jurisdictions (now 10)

Why not 21 of 21? Possible barriers to joining collaborative: Budget cuts/retain staff Agency size allows for dedicated staff Extra funding helps shore up other efforts (accreditation) Distance/relate more to other regions

Northwoods Collaborative Memorandum of understanding – Preparedness – “Other services” Mutual aid agreement Public Health Infrastructure Improvement Project (accreditation)

Shared Services Learning Community Grant Application to Robert Wood Johnson Foundation Natural fit for collaborative and region Accreditation Shrinking resources Examine and improve on what we are doing Increase policymaker involvement Local team approach/identity

Sharing Arrangements Fall 2012 Type of Sharing ArrangementNumber of Agencies Memorandum of Understanding (MOU)16 Joint Projects13 Informal agreement or coordination10 Mutual Aid Agreement8 Services5 Capacity5 Staff time3 Equipment1 Merger1

Key Questions What criteria should health departments use to evaluate the effectiveness of sharing arrangements? When is cross-jurisdictional sharing cost- effective? How can sharing arrangements contribute to an increase in quality and capacity in public health department services, functions, and accreditation efforts?

Northwoods Shared Services Project

Resources & Expectations Pressure to provide effective and efficient services Wisconsin at bottom in funding public health Affordable Care Act Accreditation Performance management

Current Course Public Health Accreditation Board (PHAB) self- assessment Performance management – Strategic planning – Performance monitoring and measurement – Quality improvement – Community Health Assessment (CHA)/Community Health Improvement Plan & Process (CHIPP)

Infrastructure Road Blocks Lots of will! Capacity deficit

Policymakers – aligning paths Support for reallocating resources Essential Services as framework for internal capacity What are we getting from tax levy support? Customer satisfaction Focus on efficiency, effectiveness, and spending

Lessons Learned Money isn’t everything Build capacity from within Need access to people resources you can draw on quickly Conserving policymaker time while keeping them involved

Evaluate to Improve Sharing Arrangements What types of services and functions are being shared? What are inputs, benefits, costs? What criteria should be used for entering into a shared services arrangement?

What we hope to accomplish Increased understanding among policymakers – 10 Essential Services/national accreditation – Infrastructure necessary to support public health Cross-jurisdictional sharing criteria How sharing can increase capacity and infrastructure