Category Archives: Accreditation
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?
It's been an exciting year for us at NewPublicHealth! We launched in March, and nine months, nine conferences and 568 posts later, we are ready to ring in the new year.
Here's a glimpse into the inaugural year of NewPublicHealth, and the top posts by popularity.
- Power of Health IT for Public Health: A NewPublicHealth Q&A With Farzad Mostashari. This piece was a conversation with the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services (HHS), about the evolving public health informatics field.
- Dr. Douglas Jutte: My Patient's Most Pressing Health Concern Was a Broken Carburetor. Dr. Jutte provided a personal commentary on how unmet social needs—like access to nutritious food, transportation assistance and housing assistance—were sometimes the most critical in treating his patients. (Also check out a round-up of reader responses to this post.)
- Public Health and the Community Benefit: A NewPublicHealth Q&A With Abbey Cofsky. The Patient Protection and Affordable Care Act requires that non-profit hospitals, starting in 2012, perform a community health needs assessment, and that the assessment serve as the foundation of an implementation plan to address identified needs. NewPublicHealth spoke with Abbey Cofsky, program officer at the Robert Wood Johnson Foundation, about the public health opportunities this provision offers.
- The National Prevention Strategy: A NewPublicHealth Q&A With Surgeon General Regina Benjamin. Upon its launch, we spoke with the Surgeon General about the nation's plan for increasing the number of Americans who are healthy at every stage of life.
- Teen Birthrates Down in U.S. But Still Lag Behind Other Developed Nations. This article looked at the April Vital Signs report from the Centers for Disease Control and Prevention on the latest stats on teen childbirth, such as, "Girls born to teen mothers are about 30% more likely to become teen mothers themselves."
- Health Literacy: Reducing the Burden of a Complex Healthcare System. During Health Literacy Month, NewPublicHealth caught up with Linda Harris of the HHS Office of Disease Prevention and Health Promotion and Cindy Brach of the Agency for Healthcare Research and Quality about federal efforts to improve health literacy and to reduce the burden of a complex healthcare system.
- The County Health Rankings 2011: Mobilizing Action to Improve Health. NewPublicHealth's very first post announced the second annual County Health Rankings, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute that provides a standard way for counties to see where they are doing well and where they are not so they can make changes to improve health.
- What to Expect at the Health Data Initiative Forum: A Q&A With Todd Park. The Forum, presented by HHS and the Institute of Medicine, convened more than 500 people to showcase how health data can provide a rich seeding ground for new tools to support more informed decision-making by consumers, healthcare systems and community officials. NewPublicHealth spoke with Todd Park, Chief Technology Officer at HHS, to get his take on health innovation.
- HHS Leading Health Indicators: Health By Some New Numbers. NewPublicHealth was on the ground at the APHA Annual Meeting covering top news, including the announcement of the latest Leading Health Indicators from HHS, a set of the top national high-priority health issues and actions that can be taken to address them.
- Housing Policy is Health Policy: A NewPublicHealth Q&A With HUD's Raphael Bostic. Raphael Bostic of the U.S. Department of Housing and Urban Development (HUD) spoke with NewPublicHealth about the role of housing in health, and new collaborations across sectors that recognize that providing healthier, more affordable housing can lead to significant health outcomes.
Runners up included Q&As with CDC Director Thomas Frieden and Virginia Comonwealth University researcher Steven Woolf; a post on public health mobile phone apps and a commentary on the popular movie Contagion.
These were just a handful of the conversations that captured our readers' interests this year. Keep reading in 2012 for the latest in public health and new ways to prevent disease and health crises where they begin—in our communities.
Thanks for reading and for your always insightful comments. Have a happy, healthy New Year and we'll see you in 2012!
NewPublicHealth spoke with Yvette Roubideaux, MD, MPH, director of the Indian Health Service (IHS) and a member of the Rosebud Sioux tribe, about innovative efforts to improve the health of Native Americans.
NewPublicHealth: What is significant to you about the observance of Native American Heritage Month?
Dr. Roubideaux: Each year it’s a celebration of the richness and the strength of Native American cultures. It’s a great opportunity to be reminded of the great cultures and traditions of American Indians and Alaska Natives and how that relates to overall health and well-being.
NPH: For 2012, what are some of the key projects and issues that are on the front burner with regard to Native American health in the U.S.?
Dr. Roubideaux: Well certainly one of the biggest issues relates to the disparities that this population experiences compared to the U.S. general population and the significant burden of disease that’s causing lots of illness for the population, including chronic diseases and obesity. Trying to narrow that gap in disparities, trying to improve access to care are major efforts of what we’re doing with the Indian Health Service. For example, the mortality rates on diabetes are almost three times the U.S. population rates. We know that obesity is higher in American Indians and American Indian children. We know that, for example, alcohol-related mortality is almost six times greater in American Indians and Alaska Natives.
NPH: In what ways might Native Americans approach health and well-being differently than other Americans?
Dr. Roubideaux: Well, I think that there’s a general understanding among American Indian and Alaska Natives that the culture and their traditions promote health, and so a lot of the prevention efforts and community-based health initiatives are really starting to focus more on what we can learn from our traditions. How can we learn to be healthy and live in balance and seek wellness? It comes from the fact that for American Indians and Alaska Natives, there’s a recognition that over a hundred years ago we didn’t have the illnesses that we have now, we didn’t have diabetes, we didn’t have obesity, and so they must have been doing something right and what can we take from the lessons of our ancestors and our traditions to be healthier. And, of course, it’s eating healthy and making healthy food choices, more physical activityand living a life in balance—in balance in general and in balance with nature.
Many programs are focused on returning to traditional ways. Some of those are reintroducing gardening and growing traditional plants and some are returning to traditional games and physical activity that the tribes did. Some tribes, they were runners, and so they’re doing more runs, and lacrosse is a traditional Native game and they’re reviving that for the kids. Many tribes are looking at their past to find answers to the health problems that are plaguing them today. Healthy eating practices of Indian people included eating very lean meats, berries and greens—foods from nature. And they had to have enough food for the whole group so they didn’t over-indulge and had to prepare for famines, and so they were very cautious about what they ate.
NPH: How can accreditation benefit tribal public health departments and the communities they serve? What are some of the greatest opportunities and challenges that accreditation presents?
The impact of the economic crisis on budget coffers has prompted a growing number of state and local health department officials to consider cross-jurisdictional sharing as a strategy to cut costs and deliver services more effectively and efficiently. At the 2011 APHA meeting, a packed room of researchers and practitioners from across the country heard from a panel on this emerging topic, which included presentations on the experience of two states with vastly different sociopolitical landscapes: sprawling Colorado with its large rural expanses, and dense Massachusetts with its 351 local boards of health, just over half of which serve 10,000 people or less.
Despite the differences, two major themes dominated the discussion, which was moderated by Pat Libbey, former executive director of the National Association of County and City Health Officials and now a consultant and leading expert on cross-jurisdictional sharing: more information is needed to illuminate which approaches may be most appropriate for specific locales, and proactive stakeholder engagement is critical to gain buy-in for changes that may be seen as potential threats to local control.
"The minute you say regionalization, it’s a top-down approach," said Lisa VanRaemdonck, MPH, MSW, executive director of the Colorado Association of Local Public Health Officials and co-director for the Colorado Public Health Practice-Based Research Network, who shared findings from a recent examination to identify what types of service-sharing among local health agencies are most prevalent in the Centennial state, what the law allows, and why agencies have entered into these agreements and relationships. "Language and finding a careful balance is really important."
VanRaemdonck said the Colorado Public Health Act of 2008 allows the creation of district health departments to do regional work, and many agencies have begun regional approaches to provide services that were not previously available.
Numerous public health leaders across the country credit the Multi-State Learning Collaborative (MLC) for establishing a vision of a quality-improvement (QI) culture in the field and helping pave the way for the launch this year of national, voluntary public health department accreditation by the Public Health Accreditation Board. The group presented progress on the project this week at the APHA 2011 Annual Meeting.
>>Follow the rest of our APHA 2011 coverage.
Between 2005 and 2011, the project – funded by the Robert Wood Johnson Foundation and managed by the National Network of Public Health Institutes (NNPHI) – brought together teams of public health departments in 16 states, along with other stakeholders such as institutes, health care providers, and universities to prepare for accreditation and apply QI to important public health goals, such as increasing immunization rates, and implementing procedures to communicate with community members in health emergencies.
This year’s APHA meeting is the first one since the launch of the Public Health Accreditation Board’s (PHAB) national, voluntary accreditation program for state, local and tribal health departments. At past APHA meetings, attendees have gotten previews on the accreditation standards and rollout plans. This year, it’s finally time to learn how health departments are starting to get organized and ready to apply for accreditation—and what PHAB has been hearing as the program gets underway. Several state health department representatives shared their accreditation plans and activities to date at a session here this morning.
Jack Wilson, from the New York State Department of Health, told attendees that his department is using a strategic planning tool traditionally used in the private sector to align its specific strategies (enforce public health laws, maintain a competent workforce, promote tools to improve health, etc.) to PHAB’s domains. The health department recognizes that it has many disparate programs and initiatives that would benefit from being aligned with larger strategic goals. Despite progress, though, Wilson said that the strategic planning process is time-intensive and can be derailed by unexpected events like this summer’s Hurricane Irene damage in upstate New York.
“The Kentucky accreditation train has departed!” said Rona Stapleton from the Kentucky Department of Public Health(KDPH), sharing that her department plans to apply in 2014. In spring 2010, with help from ASTHO staff and an ASTHO grant, KDPH began developing a plan to sell the idea of accreditation internally; pull together a readiness team; and design a logic model for meeting accreditation goals. Stapelton said she and her colleagues reached out to ASTHO, NNPHI and others who could share best practices so that the department could take advantage of work that had already been done.