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The National Public Health Performance Standards Program

Started in 1998, the National Public Health Performance Standards Program (NPHPSP) is a collaborative effort between the Centers for Disease Control and Prevention (CDC) and a variety of national organizations representing state and local public health agencies and other elements of the public health community: the National Association of County and City Health Officials (NACCHO), American Public Health Association, Association of State and Territorial Health Officials, National Association of Local Boards of Health, and Public Health Foundation (Halverson et al., 1998; NACCHO, 2001a). Designed to measure public health practices at the state and local levels, the mission of NPHPSP is to improve quality and performance, increase accountability, and increase the science base for public health practice.

The performance standards are based on the 10 essential public health services, and for each essential service there are model standards (descriptions of and conditions for optimum performance of the public health system) and measures (multiple-choice questions that address components of the model standard). The measurement instruments concentrate on three aspects of the public health system:

1. State-level measures that focus on the state-level public health system and on the agencies and partners that contribute to population health at the state level;

2. Local-level measures that focus on the local public health system and on the entities that contribute to public health within a community; and

3. Governance measures that focus on the governing body or bodies that are ultimately accountable for public health at the local level (including boards of health or county commissioners).

The development of a local-level instrument began in 1998. Since then, the instrument has been tested in local public health agencies throughout Florida, Hawaii, Minnesota, Mississippi, New York, Ohio, and Texas. This testing ensures that the instrument is responsive to the needs of communities, accurately assesses local performance and capacities, and addresses the broad variation in local public health infrastructures across the nation (NACCHO, 2001f). Recent pilot testing of the NPHPSP instruments indicates that the performance standards based on the 10 essential services have validity for measuring local public health performance (Beaulieu and Scutchfield, 2002). The local instruments were developed by the same NACCHO-CDC partnership that developed the community-wide strategic planning tool for improving community health, Mobilizing for Action through Planning and Partnerships (MAPP), as part of the Assessment Protocol for Excellence in Public Health project. The local instrument will be included in the new MAPP tool as a method for assessing the local public health system and identifying areas of improvement.

can be achieved when the resources to provide even the most basic services are often lacking. Linking federal funding to accreditation based on public health performance standards has been proposed, but there may not be adequate incentives for states and localities that do not receive significant portions of their overall funding from federal agencies. The promise of a long-term federal investment at the state and local levels linked to such a system could change the situation considerably.

To address these and other concerns, NACCHO has convened the Voluntary Accreditation Committee, which consists of eight local health officers who are charged with maintaining an ongoing discussion of the advantages and disadvantages of voluntary accreditation of local health departments. They are currently researching lessons that might be learned from other voluntary accreditation efforts, such as those for hospitals, managed care organizations, and law enforcement agencies. The Voluntary Accreditation Committee is also taking into account the work of states such as Florida, Illinois, Michigan, Missouri, Ohio, and Washington that are already active in the development of state-specific accreditation or performance standards for their local public health agencies.

Despite the controversies concerning accreditation, the committee believes that greater accountability is needed on the part of state and local public health agencies with regard to the performance of the core public health functions of assessment, assurance, and policy development and the essential public health services. Furthermore, the committee believes that development of a uniform set of national standards leading to public health agency accreditation could provide such a mechanism, but only if adherence to such standards is linked to a commitment of sustained federal investment in the state and local public health infrastructure to assure that resources are available. Moreover, such a mechanism could serve to increase levels of accountability among state and local elected officials in whose jurisdictions these agencies operate. The breakthrough concepts of NPHPSP provide a way to conceptualize the system as the unit of accreditation and, from there, to evaluate the role of the agencies in facilitating the work of the system.

Accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards. Accreditation mechanisms have helped to ensure the robustness of the health care delivery system (hospitals, clinics, programs) and medical and other educational programs. Accreditation processes also provide information to the public about the quality of the services they receive (e.g., National Committee for Quality Assurance report cards on health plans) (IOM, 2001). Governmental public health agencies currently have no such framework, and the communities they serve have little information on the quality of the services they receive. An accredita tion process could provide a structure for establishing quality assurance and improvements in governmental public health agencies. Therefore, the committee recommends that the Secretary of DHHS appoint a national commission to consider if an accreditation system would be useful for improving and building state and local public health agency capacities. If such a system is deemed useful, the commission should make recommendations on how it would be governed and develop mechanisms (e.g., incentives) to gain state and local government participation in the accreditation effort. Membership on this commission should include representatives from CDC, ASTHO, NACCHO, and nongovernmental organizations.

This commission should focus on the development of a system that will further the efforts of NPHPSP. The work of this commission should be closely linked to that of the commission whose creation the committee has recommended to examine issues related to the credentialing of public health workers, because it is conceivable that these mechanisms could be linked. In both efforts, the relationship of the official public health agency to its role in the larger public health system will be key to accreditation.

Special Concerns About the Capacity to Meet Local Public Health Needs

In The Future of Public Health (1988), the IOM committee concluded that "no community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system" (IOM, 1988: 144). The rationale behind this finding is clear: If a community is going to be able to meet its own health needs, it must have access to an identifiable public health infrastructure to provide the essential public health services. Today, concerns remain about the availability of an adequate local public health infrastructure, particularly in terms of staffing and communications systems, to provide these services.

Despite the presence of some 3,000 local public health agencies throughout the country, these agencies are not equally distributed across states or across rural and urban areas. For example, Bergen County, New Jersey, with a population of approximately 884,000 and an area of 234 square miles (Census Bureau, 2001a), is served by a strong county health department, 55 local boards of health, and 22 independent public health agencies that serve different and occasionally overlapping communities (T. Milne,

Either we are all protected or we are all at risk.

Dr. Jeffrey Koplan, Formerly, Centers for Disease Control and Prevention

NACCHO, personal communication, October 31, 2001). By contrast, the state of Maine, with a population of about 1.3 million distributed over 30,862 square miles (Census Bureau, 2001b), has two local public health agencies (T. Milne, NACCHO, personal communication, October 31, 2001). Challenges come from both an abundance of local public health agencies and their scarcity. When multiple public health departments serve the same geographic area, they may experience difficulties coordinating activities and aligning priorities. However, rural areas, with little or no local public health presence, may suffer from inadequate public health capacity or resources to address local needs and a paucity of educational and training support (Johnson and Morris, 2000).

Data from NACCHO (2001e) also point to substantial differences in the workforce available to local public health agencies. NACCHO's 19992000 survey found that 50 percent of all local public health agencies responding had 17 or fewer full-time employees or contract staff, but for those serving metropolitan areas, 50 percent had at least 28 full-time employees or contract staff. Some local public health agencies, however, currently have only one half-time employee as their entire public health agency staff. Staffing levels have shown little change over the past decade. A 1997 survey found that the median number of full-time employees was 16 (NACCHO, 1998), and in 1992-1993, NACCHO (2001e) reported that 42 percent of local public health agencies had less than 10 full-time staff members. Given the many responsibilities and wide-ranging duties inherent in the assurance of population health, the committee is concerned that these low numbers do not bode well for the core capacity of some local public health agencies to provide the 10 essential public health services to their communities.

Simply increasing the size of the local public health agency workforce appears problematic, however. The committee is concerned about reports by 68 percent of local public health agencies that budget restrictions prevent them from hiring needed staff, including public health nurses, environmental specialists, health educators, epidemiologists, and administrative personnel (NACCHO, 2001d). In addition, local public health agencies in smaller, nonmetropolitan jurisdictions indicated that they could not hire the necessary staff because of a lack of qualified candidates in their areas and difficulty attracting other candidates to their locations. Only 19 percent of the local public health agencies indicated that they needed new staff because of projected expansions of their programs and services (NACCHO, 2001d).

Many local public health departments also lack even the most basic tools necessary for rapid communication and access to information (GAO, 1999b). For example, a 1999 survey of 1,200 local public health departments found that 19 percent did not have the capacity to send and receive e mail via the Internet (Fraser, 1999). The most common barriers cited by the departments without Internet access were prohibitive costs (64 percent), the need for hardware (64 percent), and the need for staff training (63 percent). Additionally, only 48 percent of the health departments surveyed indicated that the director had continuous, high-speed Internet access at work, and only 44 percent indicated that the department had broadcast fax capabilities (Fraser, 1999). In all cases, public health agencies in smaller and more remote jurisdictions had the least access to information and communications technologies, even though these agencies may actually have the greatest need for such technologies.

Given the evidence concerning the local public health workforce and communication capacity as well as related observations made throughout this chapter, the committee finds that too little has been done to support and strengthen the local public health infrastructure. Over the past 14 years, governmental public health agencies have made great efforts in response to the recommendations concerning local public health agencies in The Future of Public Health (1988) (see Appendix C). Unfortunately, until recently, progress has been slow because of the lack of political and financial support that was needed long ago to fully realize the vision of the 1988 report. Recent increases in infrastructure support in connection with bioterrorism preparedness are somewhat encouraging, but there is concern that such efforts may reinforce the complex problems created by prior categorical funding if excellent specific services (e.g., surveillance are informatics) are built on the foundation of a crumbling infrastructure. For these reasons, the committee believes that every community, no matter how small or remote, should have identifiable and realistic access to the essential public health services, and that it is the responsibility of the states to ensure that such services are available. However, for states to meet this obligation, the committee recommends that DHHS develop a comprehensive investment plan for a strong governmental national public health infrastructure with a timetable, clear performance measures, and regular progress reports to the public. State and local governments should also provide adequate, consistent, and sustainable funding for the governmental public health infrastructure. This investment is crucial to assure the preparedness of public health departments and the protection of communities, regardless of their size or location.

Some communities provided comments to the committee noting that a more precise description of an essential minimum level of local official agency capacity would aid their efforts to obtain public health services. In an effort to be responsive to these requests, the committee struggled with the challenge to be more explicit with regard to the level of public health capacity that should be present in these small and remote communities. Not surprisingly, some familiar problems were encountered. For example, there are questions involving the proper definition of a "community" for this purpose and the appropriate response if a community has too small an economic base to sustain a formal public health agency with the necessary presence and capacity to provide public health protections.

The most robust approach to assessing need seems to be the use of a functional analysis based on the ability to provide the essential public health services, as recommended above. The committee recognizes the potential value of a recommendation regarding the development of a formula to determine the "critical mass" of services and population (e.g., a ratio of one of each of the critical professions per 50,000 or 100,000 population), the geographic accessibility of services, and the workforce capacity necessary for the effective development of local public health agencies to serve small or remote communities. Before such a recommendation can be made, however, solid, practice-oriented research must be conducted to provide the evidence on which to base a formula or other criteria.

The committee had hoped to be able to provide specific guidance to assist the nation in its efforts to rebuild and finance its public health infrastructure. However, a comprehensive search of the published literature and extensive information gathering yielded very little firm, generalizable evidence on which to structure public health practice recommendations like those noted. To remedy this situation, the committee recommends that CDC, in collaboration with the Council on Linkages between Academia and Public Health Practice and other public health system partners, develop a research agenda and estimate the funding needed to build the evidence base that will guide policy making for public health practice.

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