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CHAPTER 17

Performance Management in Public Health

Learning Objectives (1 of 2)

To understand the challenges faced by public health practitioners related to performance at the many different levels of the public health system

To appreciate the historical trends that resulted in the development of public health standards and measures

To describe and explain the elements of performance management as developed by Turning Point: performance standards, performance measures, reporting of progress, and quality improvement process

To explain the meaning and use of performance measures and standards

Learning Objectives (2 of 2)

To develop an understanding of the “10 Essential Public Health Services” as a foundation for the National Public Health Performance Standards (NPHPS), the “Operational Definition of a Functional Local Health Department,” and the new Public Health Accreditation Board accreditation program standards

To understand the integration of national public health performance standards into the community assessment process, and why it improves public health infrastructure and capacity

To discuss the development of the Public Health Accreditation Board accreditation program and how it may improve public health performance

Overview

Many public health organizations use performance management efforts to track the work they produce and the results they achieve

Public health leaders and managers face issues related to performance at many different levels of the public health system, including the performance of individuals, programs, agencies, interorganizational collaborations, and the public health enterprise itself

This chapter examines these lessons, as well as various applications using performance standards to improve the performance of public health organizations and systems, including the accreditation of public health agencies

The initial development of a performance management framework for use in public health organizations and systems will be described

Four Quadrants of Performance Management (1 of 2)

Standards: direction-setting practices, performance targets, levels of excellence, accepted expectations

Measures: quantitative assessment of performance

Reporting of progress: studies of trends, comparing actual to desired levels; sharing with others

Four Quadrants of Performance Management (2 of 2)

The quality improvement process uses:

Standards

Measurements

Reporting of change management processes

Revising program strategy

Figure 17.1: The Performance Management Model

Courtesy of Robert Wood Johnson Foundation. Used with permission.

Effective Performance Measurement

Incorporates stakeholder input

Promotes top leadership support

Creates a clear mission statement

Develops long-term goals and objectives

Formulates short-term goals and interim measures

Devises simple, manageable approaches

Provides support and technical assistance

Benefits of Measuring Performance

Clear goals and objectives

Identifies strengths and weaknesses

Opportunities for collaborative approaches

Clearer lines of accountability

Improved quality

Better tracking of progress over time

More effective communication

Better resource allocation and deployment

Strengthened organizational effectiveness

Performance Measurement (1 of 2)

Focuses on what is occurring

Evaluative research (often called program evaluation) provides assessment of the conceptualization, design, implementation, and utility of social interventions of the underlying activities being measured

Performance indicators determine whether or to what extent a performance standard is achieved

Acknowledges critical dimensions of performance, capacities, processes, and outcomes

Processes refer to what is done to, for, with, or by defined individuals or groups to identify and address community or population-wide health problems

Provide useful information concerning the capacity to perform, process performance (including outputs), and ultimate results (impact/outcomes)

Measuring Public Health Performance After 1988

1988 IOM report identified three core functions of public health:

Assessment, policy development, assurance

Based on a variety of field tests and performance studies completed in the early 1990s, a consensus set of 20 practice performance measures was established by leading researchers in the field

Lessons from Twentieth-Century Efforts

Discuss Text Box 17-1 and Exhibit 17.2

Measurement for sake of measurement is not a goal

Easier to measure specific aspects of the public health system than develop consensus about the meaning of the measurements on overall performance

Efforts included outcome measures, but most failed to link capacity and process measures to outcomes

Evolution of Performance Measurement (1 of 2)

Prior to 1990, measures related to capacities and outputs rather than key processes

In the 1990s, many public health organizations were conducting organizational self-assessments, identifying strengths and weaknesses, and channeling information into capacity-building plans

In 1997, increased interest in performance measurement in public health expanded to community-driven and state-level collaboration

Local and state partnerships initiated under Turning Point: Collaborating for a New Century in Public Health, Turning Point

Trends toward strategic effectiveness and evolution of APEX-PH into MAPP

Evolution of Performance Measurement (2 of 2)

The NPHPS framed optimal standards using the “Ten Essential Public Health Services,” framework, and as such constitute a unique resource to examine public health system expectations and measure current performance

See Exhibit 17-4 for examples of performance standards and measures for local and state public health systems used in NPHPS assessments

Performance Measurement And Improvement After 2000

Established national health objectives to address public health infrastructure

See Exhibit 17-4

Turning Point Performance Management National Excellence Collaborative (PMC) studied performance management practices in state public health agencies

Public Health Foundation is refreshing the performance management model

See Figure 17-1

Critical Issues For Success

A useful definition of performance improvement is positive change in the capacity, process, and outcomes of public health organizations and public health systems (public, private and voluntary organizations that collectively contribute to the health of the public)

Quality improvement (QI) is the use of a deliberate and defined improvement process to identify needs and improve population health

Continuous and measurable improvements result in:

Efficiency

Effectiveness

Performance

Accountability

Outcomes

Accreditation of Public Health Agencies (1 of 12)

Inspiration for PHAB accreditation was derived from pioneering state programs

Accreditation must strike a fine balance between minimal and optimal standards

The PHAB accreditation program development has been an intensive iterative process building upon the strong foundations of the previous work

Assessment process:

Pre-application and application phase

Evidence selection and submission

Site visit and accreditation determination

Annual reporting

Reaccreditation

Accreditation of Public Health Agencies (2 of 12)

Voluntary accreditation could lead to interest in credentialing segments of the public health workforce

The most recent IOM Report calls for careful study of the feasibility of creating a national voluntary public health agency accreditation system

This recommendation stems from the fact that public health organizations remain one of the few health-related entities that are not subject to national standards and review from an external accrediting body

Credentialing of both individuals and organizations has become such an accepted means of fostering quality improvement and accountability throughout the health sector that its absence from the public health system is noteworthy

Accreditation of Public Health Agencies (3 of 12)

Following the recommendation of the IOM report, and the well-traveled pathway of successful predecessors like JCAHO, CDC and the Robert Wood Johnson Foundation (RWJF) have joined forces to fund an exploration of public health agency accreditation

CDC and RWJF agreed to fund a joint ASTHO/NACCHO staffed study of accreditation for public health agencies

The Exploring Accreditation Project (EAP) is a year-long endeavor with its Planning Committee lead by APHA and NALBOH as well as NACCHO and ASTHO

Accreditation of Public Health Agencies (4 of 12)

Five states were selected to participate: Illinois, Michigan, Missouri, North Carolina, and Washington

A fundamental intent underlying the project design is for the learning of the MLC to be available to inform the deliberations of the EAP

Typically, the LPHA is the focal interest. Nonetheless, similar emphasis on state health departments, and even federal agencies, is likewise warranted

In Michigan, LPHAs participate in an accreditation program consisting of a self-assessment and an onsite review

Accreditation of Public Health Agencies (5 of 12)

An extensive set of accreditation standards is available in published form addressing requirements for core capacity, cost shared, and categorical services. The onsite review serves to validate and verify self-reported compliance

Although LPHA participation is mandatory, incentives come in the form of linkages to state funding through grants and contracts

An external accreditation commission housed in the Michigan Public Health Institute and based on authority conferred in state statutes coordinates the entire process

Accreditation of Public Health Agencies (6 of 12)

The North Carolina Local Public Health Accreditation Program (NCLPHAP) emphasizes capacity within LPHAs

It has foundations in the Operational Definition of LPHAs as well as standards prescribed in the NPHPS and the 10 essential services

Standards are tied back to state statutes, the administrative code for North Carolina Divisions of Public Health and Environmental Health, and contract and program monitoring requirements

Accreditation of Public Health Agencies (7 of 12)

NCLPHAP is a three-part process, which includes an agency self-assessment, onsite peer review team visit, and formal determination of accreditation status by the Accrediting Board

A review team is comprised of five members: a LPHA director, a public health nurse, an environmental specialist, a local board of health member, and an accrediting board representative

Accreditation of Public Health Agencies (8 of 12)

After the site visit, the team leader prepares a consensus report complete with accreditation status recommendation

The Accrediting Board reviews the report and votes officially on accreditation

An appeals process is also in place

Another model of “accreditation” is Project Public Health Ready (PHR), with its more program-centered emphasis on preparedness

Accreditation of Public Health Agencies (9 of 12)

This collaboration between NACCHO, CDC, and the Center for Health Policy at Columbia University School of Nursing was developed to serve as a means for LPHAs to offer concrete evidence of their capacity to respond to terrorism threats, and to improve overall preparedness

In many respects PHR is similar to the examples cited above

Source: Estrada LC, Fraser MR, Cioffi JP, et al. Partnering for preparedness: the project public health ready experience. Public Health Rep. 2005;120 Suppl 1:69-75.

Accreditation of Public Health Agencies (10 of 12)

LPHAs that participate are “recognized” by the PHR Oversight Council as Public Health Ready if they demonstrate readiness to respond to public health emergencies by documenting compliance with three criteria:

Goal 1. Preparedness Planning: The pilot site’s emergency response plan specifies the responsibilities of the public health agency, its relationship with other emergency response plans, and the roles of its staff when responding to bioterrorism

Goal 2. Workforce Competency: All members of the pilot site’s workforce are competent to perform the nine core emergency preparedness competencies

Goal 3: Exercise Simulation: The pilot site demonstrates emergency readiness by participating in and/or conducting an exercise, or exercises, in which the public health emergency response plan is tested and individual worker emergency preparedness competencies are successfully demonstrated

Source: Project Public Health Ready. NACCHO. Available at: http://www.public-health-ready.org/. Accessed October 23, 2005.

Accreditation of Public Health Agencies (11 of 12)

Voluntary accreditation of public health organizations could lead to greater interest in the possibility of credentialing various segments of the public health work force

In one form or another, there are already credentials for some public health workers, including sanitarians, health educators, public health nurses, and public health physicians

Accreditation of Public Health Agencies (12 of 12)

Public health performance standards with accompanying performance management activities will improve quality if they focus on all aspects of the public health system—its capacity, its processes, and the links between them and important community health outcomes—and if the public health community accepts, values, and uses them

Early attention to and consensus around these issues will determine the quality and relevance of public health practice in the twenty-first century

Future Outlook

Performance management leading to performance improvement initiatives were undertaken in many different settings during the 1900s, including the public sector

The opportunity for more use of performance standards and measurement, emphasizing performance management and quality improvement strategies, is great

Discussion Questions (1 of 2)

What tools can public health leaders and managers use to address performance challenges at many different levels of the public health system, including the performance of individuals, programs, agencies, interorganizational collaborations, and the system-wide enterprise itself?

Define performance management and its elements within public health.

Most public health agencies do not yet have fully developed performance management systems. Describe the status of performance management in health departments with which you are familiar. What are the elements of performance management? How can their introduction be facilitated?

Discussion Questions (2 of 2)

How is a performance measure different from a performance standard?

How have community assessment tools such as MAPP advanced community health assessment and improvement?

Explain the role of the 10 Essential Public Health Services in the development of other important tools and frameworks.

What role might accreditation have in improving performance in health departments?