APHA Midyear Meeting 2012: Assuring Quality When Asked to "Do More with Nothing"

Jun 28, 2012, 12:30 PM, Posted by NewPublicHealth

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.”

This commentary originally appeared on the RWJF New Public Health blog.