The new issue of Frontiers in Public Health Services and Systems Research (PHSSR), an online journal that looks at early research on issues related to public health services and delivery, focuses on quality improvement in practice-based research networks.

This issue’s commentary, from the journal’s editor, Glen Mays, PhD, MPH, is about a series of studies sponsored by the Robert Wood Johnson Foundation that  look at how public health decision-makers are responding to accreditation, quality improvement, and public reporting initiatives during  ongoing fiscal problems. Mays is co-principal Investigator of the National Coordinating Center on PHSSR, Director of the Public Health Practice-Based Research Networks and the F. Douglas Scutchfield Endowed Professor at the University of Kentucky College of Public Health. Mays says that, overall, the current evidence shows that “these initiatives represent promising strategies for strengthening evidence-based decision-making and expanding the delivery of evidence-tested programs and policies in local public health settings.” 

Mays  adds that continued comparative research and evaluation activities are needed to provide more definitive evidence about which combination of strategies work best, for which population groups, in which community and organizational settings, and why.

The Public Health Accreditation Board (PHAB) recently celebrated the one year anniversary of the launch of national public health accreditation.

Over 100 health departments have engaged with the Public Health Accreditation Board on their accreditation journey, according to PHAB CEO Kaye Bender in an email exchange with NewPublicHealth, and more health departments enter the system each week. “One year post launch of voluntary national public health department accreditation, PHAB is excited about the progression of health departments through the process,” Bender wrote. “The first site visits began last month, and more are scheduled. We expect to announce the first accredited health departments in early 2013!”

At the recent APHA 2012 conference, representatives from California’s state and local health departments led a session offering their peers a first look at the accreditation process underway in California. As PHAB states, “the goal of national public health accreditation program is to improve and protect the health of the public by advancing the quality and performance of all health departments in the country – state, local, territorial and tribal.” All of the California representatives made a case for why accreditation is a priority for their respective departments.

“Accreditation equals opportunity,” said Dr. Ron Chapman, California Department of Public Health director. “Quality improvement is about problem solving. Infuse quality into what you do every day and you will see transformation.”

>>Watch a VIDEO with Ron Chapman about new opportunities to transform public health by making quality improvement a way of life.

Dr. Alonzo Plough, Emergency Preparedness and Response Program director for the Los Angeles County Public Health Department, said accreditation’s quality improvement standards align well with the “triple aim” goals of: improving patients’ experience of care, improving the health of populations and reducing the cost of health care.

Plumas County Public Health Agency director, Mimi Hall, talked about how building relationships with local hospitals and community and business leaders can help meet public health goals.

“We have to redefine the role of public health and work with outside organizations to get the best benefit for the community,” said Hall. “Accreditation pulls it all together.”

Several sessions at this year’s American Public Health Association meeting include brass-tacks guidelines for initiating and furthering partnerships between public health and hospitals to improve community health. In a session yesterday, Michael Bilton, who co-founded and leads the Association for Community Health Improvement of the American Hospital Association, spoke about the value of partnerships between public health and hospitals, since both have requirements to complete similar community needs assessments.

Health departments seeking public health accreditation must complete a community needs assessment, and non-profit hospitals must complete community benefits reports every three years under the Affordable Care Act.

Bilton pointed out that for many communities, the collaboration won’t be one that starts from scratch. San Francisco has had a community benefit requirement for non-profit hospitals since 1994, “which promoted a sense of collaboration in many communities,” Bilton told the audience at the APHA session.

Bilton says the collaboration also aligns with the National Prevention Strategy, released by the Surgeon General last year, which is promoting partnerships across federal agencies to improve community health.

>>Read an interview series on the National Prevention Strategy on NewPublicHealth.

Bilton says the Strategy specifically points to community needs assessments as a way to identify and begin working on many of the priorities in the Strategy. “And those priorities have already been identified by many hospitals,” says Bilton. The joined forces of hospitals and public health departments also help achieve the “triple aim” of additional goals stressed in the Affordable Care Act including improving improving care, improving health care quality and reducing costs. These collaborations underscore the notion that helping to manage population health is the role of hospitals as well, said Bilton.

Bilton advised public health officials anxious to collaborate with hospitals on community benefit requirements to do several things including:

• Become acquainted with hospital regulations
• Approach hospitals as early as possible in your process
• Find out who is leading the assessment
• Ask hospitals about their assessment  process and goals
• Offer to help hospitals with with data, communications,  facilitation or staff expertise, as appropriate  
• Balance short term needs such as fulfilling IRS or accreditation requirements with longer term opportunities—sustained health improvement collaboration.

>>Bonus Link: Read a NewPublicHealth interview with Laurie Cammisa from Children's Hospital Boston on community benefit collaboration. 

The Office for State, Tribal, Local and Territorial Support (OSTLTS) at the Centers for Disease Control and Prevention (CDC), was launched in 2009 as a central office dedicated to advancing public health at the state and local levels and identifying both gaps and opportunities for collaboration. Judith Monroe, the office's director, spoke to us last year about challenges facing health departments in a tough time. Recently, at the ASTHO Annual Meeting, we had a chance to catch up with Dr. Monroe to hear what she and her office have been up to since we last spoke in the summer of 2011.

>>Read our earlier Q&A with Dr. Monroe.

NewPublicHealth: The focus of the ASTHO annual meeting this year is on the intersection of health care and public health. What efforts is CDC engaged in right now in that intersection?

Dr. Monroe: We’ve been involved in a number of areas. The IOM report on the integration of primary care and public health, was co-funded by the Health Resources and Services Administration and CDC. And CDC had a seat at the table when ASTHO and the IOM came together to develop the strategic map for the integration. We’re excited about that and we continue to be on those calls.

We have an office here at CDC recently created called the Office of Prevention Through Healthcare that is looking at this intersection and where the gains might be, working with the Centers for Medicare and Medicaid Services very closely. And, in addition, our office—the Office of State, Tribal, Local and Territorial Support—has forged a relationship with all of the primary care residency programs across the nation. That’s dear to my heart because I was a residency program director in family medicine for a number of years. We’ve had a number of educational venues taking the science from CDC and packaging it in a way that the residency programs can use. We’re looking toward some quality improvement projects with the residency programs as well as “playing matchmaker” in many ways, between health departments and residency programs. And, I am the point person here at CDC for our relationships between the American Academy of Family Physicians and the American College of Physicians so we have a lot going on. Those are the biggies, but there are many daily activities taking place as well.

NPH: Thank you for that overview. Since you’ve been at OSTLTS, what are some successes that you’d point to?

A highlight of last week's Public Health Systems Research Interest Group meeting, which followed the AcademyHealth Annual Research Meeting, was a “Critical Opportunities” reception during which several presenters pitched their ideas for a law that could be used to improve or solve critical public health issues. The presenters were timed, given only five minutes to share the background of the issue to be addressed, their idea for the law, evidence that it could work and the feasibility of implementing the change. Attendees were encouraged to vote on their favorite to see which Critical Opportunity ranked highest--see below for the results!

This was the second such event since this year’s debut of Critical Opportunities for Public Health Law, an initiative of the Public Health Law Research Program (PHLR), a Robert Wood Johnson Foundation program at Temple University. The goal is to make the case for laws that can improve current critical public health needs by:

• Identifying important ways to use law to improve the public’s health
• Enhancing public and professional recognition of law as a vital force for better public health
• Guiding public health law research

NewPublicHealth caught up with two of the invited presenters, who also accrued the most votes on their topics--Tamar Klaiman, assistant professor at the Jefferson School of Population Health in Philadelphia, and Georgia Heise, DrPh, director of the Three Rivers District Health Department in Kentucky, and recently elected vice president of the National Association of County and City Health Officials.

NewPublicHealth: What did you both present on?

Tamar Klaiman: The policy that I addressed is about requiring physicians to offer new parents TDAP (pertussis) vaccines because infants who are [less than] six months of age are at the highest risk of mortality from pertussis, and so parents can protect their children by being vaccinated. Around 80 percent of pertussis cases in infants, when they can track where the pertussis came from, come from parents. The policy that I talked about is having providers offer pertussis vaccine to new parents prior to leaving the hospital or birth center with the newborn.

NPH: Why would that be valuable?

Tamar Klaiman: Newborns are not fully protected against pertussis until after their 6-month booster so vaccinating parents offers the best protection. So it’s a very low risk, high reward policy.

NPH: Are there states that are already implementing this law?

Tamar Klaiman: None as far as I know.

NPH: Georgia, what’s your critical opportunity?

Georgia Heise: I talked about voluntary public health department accreditation for local health departments. Accreditation encompasses a myriad of standards that cover the mission of public health and what health departments should be doing. This would standardize public health across the nation and force into place a lot of preventive measures and assessments and best practices that the health department would be doing things that would actually make a difference in population health.

NPH: Why is this a critical opportunity?

Georgia Heise: I think that across the United States we operate on a medical model, which means we don’t really put enough funding into anything that would teach people how to be healthy or keep them healthy. We put a lot of money into taking care of somebody once they’re sick or dying. We need to push in the opposite direction and focus on keeping people healthy, and these accreditation standards are a framework for health departments to start that. There’s now an opportunity for health departments to become accredited at the national level. It’s in place and ready to go, however, not all the health departments have opted in yet.

Results of the Critical Opportunities Vote at AcademyHealth

About 100 people texted their votes for the presentations at the Interest Group meeting. The results were as follows:

• Requiring physicans to vaccinate parents of newborns against pertussis (whooping cough) to better protect young babies: 50 percent of votes
• A law requiring that states health departments be accredited and that funding be provided to go through the accreditation process: 24 percent of votes
• Establishing comprehensive laws to deal with designer drugs such as synthetic marijuana that would be broad enough to encompass new drugs as they are introduced: 18 percent of votes
• Creating standards for public health department contracts with private entities: 9 percent of votes

>>Watch YouTube videos of Critical Opportunities presentations at the Public Health Law Research Program meeting earlier this year.

Public has heard the mantra of “do more with less” so often it’s become somewhat cliché. This year, in some circumstances, said Laura Gerald, MD, MPH, State Health Officer of the North Carolina Department of Health and Human Services, public health has been “challenged to do more with nothing.” But as Charlotte, N.C., welcomed the American Public Health Association (APHA) Midyear Meeting into town this week, June 26 through 28, public health officials from across the country came together to share strategies on not just getting by but ensuring even better quality in public health, to help create healthier communities and a healthier nation.

It is no mistake that North Carolina was chosen as the destination for the meeting. Frances Phillips, RN, MHA, Deputy Secretary for Public Health for the state of Maryland, thanked the host state: “North Carolina—we have watched you, we have emulated you. You have really been the state to beat.” (APHA’s Georges Benjamin also noted the organization’s solidarity with North Carolina counties that did not support the state’s recent gay marriage ban, as “public health is fundamentally about human rights.”) Among other accomplishments, North Carolina was the first state to mandate accreditation at a local level. Other innovations have included:

• Creation of the NC Center for Public Health Quality through a public-private partnership between the North Carolina Foundation and the and the North Carolina Division of Public Health. The Center collaborates with state and local public health agencies to provide training in quality improvement (QI) methods and tools, and leads QI efforts for local public health and sister agencies. This, said Gerald, “provides a good infrastructure for continuous improvement.”
• Development of QI 101 training, an interactive learning program designed to help health departments improve the quality of their programs and services. After going through the training, one division increased immunization rates by 21 percent among children age 2 and younger, and reduced clinic wait times by 40 percent, from a starting point of 2.5 hours down to 1.5 hours, resulting in a savings of $200/visit in indirect costs.
• Implementation of a statewide tobacco ban—“no small feat in a state that’s a proud producer of tobacco,” said Gerald.

Gerald said tobacco efforts have been the prime focus of budget constraints, and a push to deliver quality efforts with little to no funding. Last year, the division had $18 million for tobacco prevention and cessation programs. This year, said Gerald, those funds are just about gone–they’ve been cut to $2.7 million to invest in tobacco cessation alone, with nothing allocated for tobacco prevention.

Kaye Bender, PhD, RN, FAAN, executive director of the Public Health Accreditation Board (PHAB), said about the current economic constraints, “Many have chosen this opportunity to see a light at the end of this tunnel and see it’s not an oncoming train.”

“We need to work smarter, and restructure, reform and clean up closet. We can use QI and a performance management model to take a look at how we’re working and how to survive and thrive in this crisis.”

Paul Kuehnert, recently named Public Health Team director at the Robert Wood Johnson Foundation and former executive director for Health for Kane County, Ill., told the story of one county’s efforts to use the downturn as a catalyst for rethinking public health delivery for better quality and results.

“The problem we were facing is the problem everyone’s been facing,” said Kuehnert. “We had lost $1 million in revenue, a little more than 10 percent of our budget, over a couple of years. We were in violation of county policy that requires at least 3 months of income in cash reserves, and knowing we had to deal with things like TB outbreaks, having such low cash reserves was very concerning.”

“We’re being nibbled to death by ducks,” Kuehnert said. “Are we going to let that go on or take a different approach?”

They decided to take a different approach. The county transferred direct client services (and funds) to three federally-qualified health centers, reduced their workforce by 50 percent and completely reorganized the department using PHAB accreditation standards as framework.

“We rewrote each and every job description, and created a totally new set of positions that were population-focused,” said Kuehnert. Positions were given a renewed focus on essential services, emergency preparedness and quality improvement.

Results so far:

• The department turned around its financial stability, adding $1 million net dollars to its budget, and in 2012 was able to add back two additional staff positions
• The new structure allowed for a new community assessment planning process, including partnership with hospitals that serve the county, local United Ways and mental health boards, to jointly fund a comprehensive community assessment. A priority for all partners will be promoting healthy towns, cities and neighborhoods, and promoting social, economic and educational environments that support health, which will mean working across sectors.
• Staff reported a shift in their interest in QI, as it has become a part of all job descriptions.
• Vaccine accountability increased from 92 percent to 100 percent.
• Kane County’s application for national public health accreditation was accepted in May 2012.

“Public health has to be at the table as we debate and solve this problem of the great reset,” said Gene Matthews, JD, senior fellow at the North Carolina Institute for Public Health. “We need to do it better.”

>>Get more updates from the meeting on APHA's Midyear Meeting Blog.

>>Follow our continued coverage of the APHA Midyear Meeting.

Across the nation, health departments are exploring ways to share services, resources and functions across multiple public health agencies and jurisdictions. Often motivated by the need to do more with fewer resources, many health departments and elected officials are approaching cross-jurisdictional sharing as a way to improve efficiency as well as strategy to improve the quality of the services provided and, hopefully, the health of the affected communities and residents.

With support from the Robert Wood Johnson Foundation, the Kansas Health Institute (KHI) has been selected to form the Center for Sharing Public Health Services to assist public health agencies across the country that are considering or implementing cross-jurisdictional sharing. The team will include a national learning community of up to 18 competitively selected and funded sites. The Foundation has issued a call for proposals from health departments considering or working on shared relationships to join the new project. The members of the new learning community will help identify successful, innovative regional and shared approaches to help improve the quality, efficiency and impact of public health services.

Patrick Libbey, former executive director of the National Association of County and City Health Officials and a national expert on the issue of cross-jurisdictional sharing, will serve with Gianfranco Pezzino, MD, MPH, KHI senior fellow, as co-director of the project. Libbey also co-authored the first major environmental scan on the state of cross-jurisdictional sharing arrangements among U.S. public health agencies. NewPublicHealth spoke with Patrick Libbey about the new project.

NPH: What are some of the key reasons that health departments are exploring or entering into shared service arrangements?

Patrick Libbey: There are several reasons but the key ones are to improve their service capabilities and capacities and to be able to do things together that individually they might not have been able to do. This has been accelerated in some respects by the emergence of performance standards, notably, voluntary national accreditation of public health departments.

There is an increasing concern about being as efficient as possible in costs and other resources. And given the economy and the effect on local and state budgets, there’s an increased attention on how can we do well at lesser costs or at least without increasing costs. In public administration circles of all kinds, regionalization and shared services is one method being looked at and increasingly being used as a means of being more effective and efficient. Examples of different public sectors that have looked at or implemented shared services include schools, traditional government service areas such as fire and police, library services and parks and recreation. It’s not a question that’s emerging exclusively in public health.

NPH: What types of sharing relationships currently exist between local health departments, and how common are they?

Patrick Libbey: In every state we interviewed we saw evidence of shared arrangements. We need to think of shared services as a spectrum or a range of options. It can be as informal as almost a handshake agreement to share resources and equipment. In many places we saw service agreements, where a department might purchase a service they didn’t provide—more of a transactional arrangement. Particularly in the last decade there has been an emphasis on preparedness, and that has led to mutual aid agreements. We see arrangements where an official for one department on, say, Women, Infants and Children, might direct that service for a neighboring department but still remain on the full-time payroll of their own department

More complex arrangements include ones on a multi-jurisdictional basis, such as working jointly on community health assessments or joint epidemiology efforts covering all the participating jurisdictions. The most complex arrangements are where local health departments merge—in essence creating a new entity comprised of two or more former local health departments—or consolidate, where two or more departments are combined into an existing department.

NPH: What are good examples of shared relationships in place right now?

Patrick Libbey: There are lots of examples across the country. Several come to mind immediately. There are five relatively small health departments in the Colorado Rockies. They had environmental health services needs and only one of the five had the capacity to do it, so they worked out a way to share that capacity. They got needs met that they could not have met individually and as a result they are able to sustain the necessary expertise at the local level. From that, they then worked further to develop a joint community health assessment process, but will create individual improvement plans.

We tend to think smaller parties are the ones that need to share, but another example is a joint effort of the eight local health departments serving the greater Chicago metropolitan area including the Cook County and City of Chicago Health Departments. They do some of their planning and development work together, because in a sense, they share a population. People may live in one place but work in the other. So for public health emergencies, they have worked out arrangements for a single media communications process. It reduces confusion and gets out a clear message.

More recently, on a large scale, has been the merger of the Akron, Ohio, Health Department with the Summit County Health Department. This example gives you some idea of the complexities involved in a sharing effort at this scope. The merger came about as the result of a very thoughtful planning process beginning in mid-2009 including a thorough feasibility study, cost projections, political considerations and key partner and community involvement. Time was taken to ensure an orderly transition and to make sure necessary administrative and other operational details were carefully addressed before the merger was actually implemented. The newly merged Summit County Health Department began serving the population of Akron in 2011.

NPH: Have the relationships always been based on a need that emerged?

Patrick Libbey: What we saw for the most part was opportunistic—there was a funding opportunity or there was a need of service issue. We didn’t see as much proactive efforts, such as let’s get together up front, and agree to jointly fund a service or a capacity that could then be deployed as seen fit by the participating jurisdictions. What has been happening has been extremely pragmatic, though that may change over time or change as resources become more flexible. It has been reactive in a positive sense. But it works. That’s the litmus test.

You can demonstrate the benefits in ways that connect to the drivers—increased efficiency, increased cost-efficiency and improved service.

NPH: What factors contribute or detract from the success of these cross-jurisdictional relationships?

Patrick Libbey: There needs to be willingness on the part of both the health officials and the policy-makers. Not necessarily a champion, though that’s nice, but there needs to be openness to consider sharing services or capacities across jurisdictions . There also needs to be clarity up front about the intended purposes of such sharing. Improved public health performance and cost containment are both legitimate policy goals based often coming from different roles and perspectives. There’s some risk of conflict or perceived contradiction if the purposes of all the parties involved aren’t clear and attended to from the outset. There can be ways to get to a win-win opportunity but only when all the intended purposes are on the table.

Policy-makers need to know that their obligation to their constituency is met and potentially improved as a result of the service sharing and they need to have a say and an oversight in that. And health officials need to be in a position of assuring the public health needs of their respective jurisdictions are being met or improved. For the policy-makers, their obligation as an elected official is to their jurisdiction and their constituency. In that framework, they can’t willingly contribute to what may a greater good if it is seen as coming at a cost to the good of their jurisdiction. That’s not a turf issue, that’s a civic and an ethical issue.

Candidly, financial resources do make a difference. There’s a cost to putting shared arrangements together effectively. That cost sometimes is a direct expense in planning and implementing a shared arrangement and in other times it’s a lost opportunity expense, what else might have been done with the resources committed to developing the shared service relationship. It will cost something to take the time and energy to make this happen. Funding incentives have been helpful.

Long-term working relationships, history, the sense of local control and cultural factors—those are some of the other factors that are important to the success of a sharing arrangement.

NewPublicHealth: What will the Center’s goals be?

Patrick Libbey: The project will assist public health officials and policy-makers in how to consider the use of cross-jurisdictional sharing. One of the major features will be the recruitment of 18 sites across the country to serve as learning laboratories in a national learning community. These will include sites who are actively engaged in the development of cross-jurisdictional sharing arrangements, sites engaged in implementing such arrangements, and sites that have arrangements in place but are seeking to improve or expand them. The Center will provide technical assistance and support to these sites. The Center will also provide some technical assistance to other jurisdictions and organizations working on shared services. Beyond the benefit to the 18 sites and others directly receiving technical assistance, the Center will be capturing, synthesizing and sharing the learning from these efforts. This also includes gathering or developing if necessary useable tools for others to use. All the learning and resources will be shared with policy-makers, health departments and others with an interest in public health performance improvement. Put more simply, the overall intent really is to better understand, share and support ways in which cross-jurisdiction service sharing can be used to improve public health performance and efficiency.

>>Read more on sharing arrangements across public health department jurisdictions.

>>View for call for proposals to join the Shared Services Learning Community.

Jo Ivey Boufford, MD, president of the New York Academy of Medicine, was a keynote speaker this week at the National Network of Public Health Institutes (NNPHI) Annual Conference in New Orleans, La.

>>Watch Dr. Boufford in a video series on working together to make communities healthier places to live:

NewPublicHealth spoke with Dr. Boufford about the conference theme, “Leveraging Public Health Institutes for Systems Change.”

NPH: The theme of the conference is leveraging public health institutes for systems change. What systems do you think need changing to improve population health?

Dr. Boufford: I think there are really two major components to a public health system. One of them obviously is the governmental public health infrastructure—the public health agencies at state and local levels that are really charged to assure the health of the public, by detecting illness and promoting health information and trying to change environments so people can live in healthier communities. A lot of reports have shown that that part of the health system has historically been very under-invested in, and it needs to be shorn up. I think the national public health institutes should be strong advocates and partners of the governmental public health agencies in leveraging resources to improve population health.

The other part of the system is the personal health care system, which is and potentially will be undergoing dramatic change with the Accountable Care Act (ACA). There are a number of opportunities to get better population health impact out of the personal health care system, such as looking at the role of community health centers, of medical homes, of accountable care organization models to improve the health of a geographic community or particular population over time. So I would say those are the two big opportunities, and public health institutes in states need to work closely to take full advantage of the opportunities for populations.

NPH: What other key roles do you see public health institutes playing in improving population health?

National Public Health Accreditation launched last fall, and since then 64 local health departments, three tribal health departments and one state department have submitted applications to the National Public Health Accreditation Board (PHAB). Carol Moehrle, chair of PHAB and director of public health for the Idaho North Central District, spoke about the accreditation process and benefits during a keynote speech at the Keeneland Conference. NewPublicHealth caught up with Carol Moehrle during the meeting.

NewPublicHealth: Are you pleased with the number of applicants you’ve seen so far?

Carol Moehrle: We are pleased. We knew we’d have some early adopters. And to have 68 complete their applications with the last seven months, that’s a great start. We’ve got a long way ahead, but we also know we have many applicants in the queue waiting to apply. We’re hearing lots of good energy, and departments beginning the process now can look to the earlier applicants for best practices, so applying will be easier as time goes on.

NPH: What is the process and timetable for accreditation application review?

Lawrence Gostin wrote two of the founding books on public health law and developed some of the most influential public health model policies of our time. NewPublicHealth spoke with Lawrence Gostin, JD, Linda D. and Timothy J. O’Neill Professor of Global Health Law at the Georgetown University Law Center and director of the O’Neill Institute for National and Global Health Law, about his keynote address at this week’s Public Health Law Research (PHLR) Annual Meeting and emerging trends in public health law.

>>NewPublicHealth will be covering the PHLR Annual Meeting all week, including Q&As with some of the top researchers and influencers who are presenting. Follow our coverage here.

NewPublicHealth: What do you plan to speak about at the PHLR meeting?

Lawrence Gostin: I’m going to speak about global health law and global health governance. The idea is to talk about something that’s innovative and exciting and I have a proposal for a Framework Convention on Global Health, which is a global health treaty that the UN Secretary General has endorsed and many countries now are on board. So it’s an exciting, fascinating and vital time for global health. We’re really expanding the horizons beyond America to how we can make sure that all the world’s people have good health, and particularly those who are poor and vulnerable.

NPH: That’s very interesting. What is the treaty about?