1. Indiana’s Public Health Priorities
Judy Monroe, MD FAAFP
Indiana State Health Commissioner

2. Sustainable Improvement in Health
Priority
Sustainable Improvement in Health

4. Sustainable Improvement
Appropriate goals
Transparent prioritization
Identification of real causes
System based countermeasures that address underlying causes
Explicit strong actions
Measurement of actions
Top leadership involvement/visibility

5. Systems Simple : standard recipe for success
Complicated: combines multiple subsystems and recreates by following the same procedures (rocket to moon)
Complex: multiple subsystems but each application is unique (raising a child)

6. Research Questions What is the right thing to do?
How do you get people to do the right thing? (implementation is tougher)
How do we close the gap between promise and delivery?

7. The Research Question
Systems fail because we try to manage the pieces.
How do we best manage the integration of the pieces?

8. Tools for Population Level Behavior Change
Education
Marketing/Motivating
Risk Communication
Leadership
Policy
Law

10. Improve Nutrition & Physical Activity
Priority
Improve Nutrition & Physical Activity
(Decrease Obesity)

13. Evidence-Based Strategies
Physical activity - increase
Fruits/vegetables - increase
Breastfeeding – promote and increase acceptance
Consumption sugar- sweetened beverages – decrease or eliminate
Intake of high density foods - decrease
TV and screen time - decrease

14. DNR and INDOT

16. Born to be Breastfed – A Call to Action to Promote Breastfeeding
Senate Bill 219 breastfeeding policy passed (work place accommodation and storage)

18. State Fair

20. Research Questions
How does urban planning/built environment affect obesity and how does it interplay with individual choice?
What is the public health and dollar cost of overweight/obesity?
What evidence is there that school nutrition policies impact childhood obesity?
How can we create healthier environments so as to reduce/eliminate health disparities?
What are the most effective health messages for general community, youth, or communities of color?
What are the economic barriers to healthy eating and physical activity?
How does the availability of bike-friendly streets/walking trails impact obesity?
How do we best educate our policymakers?

21. Research Questions
How can a local health departments most effectively impact nutrition and physical activity?
How can the public health system most effectively work together to positively impact nutrition and physical activity?
How can public health and providers work more effectively together?

22. Decrease Tobacco Use and Addiction
Priority
Decrease Tobacco Use and Addiction

23. Evidence Based Strategies
Increase the price (tax)
Mass media campaigns*
Telephone quit lines*
Smoking bans
Provider reminder systems*
Reducing patient out of pocket costs (NRT)
* in combination with other strategies

24. House Enrolled Act (HEA) 1678
Effective July 2007
Increased cigarette tax
All of the revenue went to health

29. Tobacco Free School Map 2001 2008

30. 100% Tobacco Free Colleges and Universities
Baseline 2001
1 tobacco free college campus- Anderson College
2008
34 completely tobacco free college and university campuses
As of January 1, 2008, all Indiana University campuses system-wide have enacted individually tailored smokefree policies.

31. 100% Smoke Free Hospital Grounds
2001
No 100% smoke free hospital grounds
2008
124 hospitals 100%
32 of 36 critical access hospitals
By hospital and health care facilities have tobacco free campuses
RISE=Rural Indiana Smoke free Environment award from ITPC and IRHA

32. % Hoosiers Protected by Effective Local Smokefree Workplace Laws
Effective=meets SGR recommendations for strong policy.

33. Research Questions How do we light the fires that motivate people?
How can research help move the tobacco issue further onto the public policy agenda, particularly in the developing world?
How do we improve cessation rates?
How can public health and providers more effectively work together?

34. Improve Immunization Rates
Priority
Improve Immunization Rates

35. Research Questions How do we increase use of CHIRP?
Is CHIRP the best registry system?
How can we eliminate double entry of data?
What impact will anti-vaccine sentiment have on
immunization rates?
How do we use CHIRP (or other registry system) across the life continuum?

36. Priority Integrate Quality Improvement into Public Health Practice
(and get ready for accreditation)

37. Indiana Public Health System Quality Improvement Program
Judith A. Monroe, M.D.
Indiana State Health Commissioner
Julie Novak, DNSc, RN, MA, CPNP
Director, Purdue School of Nursing Clinics
Professor of Nursing
Principal Investigator
David McKinnis, PhD
Director
Technical Assistance Program
Co-Principal Investigator

38. Local Public Health System Assessments
Distribution by Region
Northern Region n=5
Central Region n=9
Southern Region n=6

39. Purpose
To engage Indiana’s local public health system partners in a continuous quality improvement process integrating:
participation in the NPHPSP, Local, Version 2.0 assessments
empowerment at the local level through a process of team building, leadership and problem solving
development of a unique, evidence-based, public health program designed to enhance delivery and quality of public health
demonstration of performance improvement related to the 10 Essential Services of public health and Healthy People 2010 objectives

40. Phase I – Assessment CDC’s National Public Health Performance Standards Program
Early user of Version 2.0 Local Instruments.
Collaboration with partners is critical to developing clear, measurable standards for local public health systems.
Final report provides a means of evaluating system-wide performance
Results provide a foundation for public health system quality improvement processes.

41. Phase II - Training Four Day Training Course: Team Building, Leadership and Problem Solving
Participants learn team building and leadership skills.
Teams learn how to apply problem solving methodologies and tools to identify primary causal factors limiting program success in public health.
Teams create a foundation for implementation plans to mitigate/remove primary causal factors and improve program performance related to the 10 Essential Services and Healthy People 2010 objectives.

42. Phase III Performance Improvement Programs
Identify written performance objectives based on RCA
Identify key public health partners to collaborate
Create strategies to meet objectives
Design and implement plan

43. Findings of the first 20 local public system assessments revealed the following areas for performance improvement in the pilot counties:
Essential Service 1: Monitor Health Status to Identify Community Health Problems
Model Standard Population-Based Community Health Profile %
Model Standard Current Technology to Manage/Communicate Health Data %
Essential Service 4: Mobilize Community Partnerships to Identify and Solve Health Problems
Model Standard Community Partnerships %
Essential Service 5: Develop Policies and Plans that Support Individual
and Community Health Efforts
Model Standard Community Health Improvement Process/Strategic Planning %
Essential Service 8: Assure a Competent Public and Personal Workforce
Model Standard Workforce Assessment, Planning, and Development %
Essential Service 9: Evaluate effectiveness, accessibility, and quality of personal and
population-based health services.
Model Standard Evaluation of Local Public Health Systems %

44. Research Question
Following the completion PHSQI Year 1, survey of the pilot counties indicates an overwhelming response that - focus on evaluation of the local public health system has strengthened both communication and collaboration among partners.
However, by far, the majority of counties indicate that it has not improved 'capacity' of their local public health system.
How can effective approaches be developed to utilize existing and now more recognized local partnerships to improve and enhance the 'capacity' of the public health services delivered within the system - such that there is an improved infrastructure and measurable outcome in the population served?

45. Research Questions
With the knowledge that the local public health department workforce is aging, that recruitment is difficult due to salaries, and there exists in many areas minimal competency for the type of essential services required to be performed (accreditation requirements), what is the potential/future status of maintaining the local public health department workforce? 
What strategies should be considered now to prevent a brain-drain/ experience drain when retirements occur and new practitioners are not available to support the LHD services? 
How close are we in IN to experiencing a reduction in LHD workforce?  Would salary increases make a difference or is it the type of work that does not interest nurses and environmentalists?

46. Improve Public Health Preparedness
Priority
Improve Public Health Preparedness

48. Research Questions How do we improve the usefulness of training?
What is the optimal design and implementation of training?
What is the optimal design and structure for integrating preparedness into public health?
How do we improve communication?
What are the factors for successful response/recovery in a community?
How should we measure preparedness?
How do we effectively stockpile resources?

49. Improve Patient Safety
Priority
Improve Patient Safety

51. Indiana Medical Error Reporting System

52. Goal of the Medical Error Reporting System
Obtain data
Assess data to identify patient safety issues and issue annual report
Utilize information to develop and implement patient safety initiatives
Evaluate outcomes

53. Goal of the Medical Error Reporting System
Obtain data
Assess data to identify patient safety issues and issue annual report
Utilize information to develop and implement patient safety initiatives
Evaluate outcomes

54. Number of reported events
2006: 85 – total reported events
2007: 105 – total reported events

55. Top four reported events for 2006 and 2007
Stage 3 or 4 pressure ulcers acquired after admission – 26 in 2006 / 27 in 2007
Retention of a foreign object in patient after surgery – 23 in 2006 / 24 in 2007
Surgery performed on the wrong body part – 11 in 2006 / 23 in 2007
Death or serious disability associated with a medication error – 6 in 2006 / 8 in 2007

56. Outcomes of Medical Error Reporting
Increased awareness of medical errors
Allocation of resources to patient safety
Increase in number and activity of patient safety coalitions
Outcomes:
1. media attention / increased public awareness
Development of regional coalitions
Development of Indiana Patient Safety Center
Expectation that problem will be addressed
2008 plans:
Publishing the 2007 Report in August
Number of events will increase
Update reporting rule

57. Quality Indicator System
ISDH will contract with an entity to collect, analyze, interpret, and disseminate findings on a statewide basis regarding patient safety
Entity will develop policies, best practices, and procedures that enhance patient safety

58. Research Questions
How do we make catching and reporting mistakes the norm and reward this behavior?
How do we speed up our journey of culture change?
How do we make it easy to do the right thing?