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

Sustainable Improvement in Health Priority Sustainable Improvement in Health

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

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)

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?

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

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

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

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

DNR and INDOT

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

State Fair

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?

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?

Decrease Tobacco Use and Addiction Priority Decrease Tobacco Use and Addiction

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

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

Tobacco Free School Map 2001 2008

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.

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

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

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?

Improve Immunization Rates Priority Improve Immunization Rates

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?

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

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

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

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

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.

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.

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

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 1.1 Population-Based Community Health Profile 33.7% Model Standard 1.2 Current Technology to Manage/Communicate Health Data 39.6% Essential Service 4: Mobilize Community Partnerships to Identify and Solve Health Problems Model Standard 4.2 Community Partnerships 43.2% Essential Service 5: Develop Policies and Plans that Support Individual and Community Health Efforts Model Standard 5.3 Community Health Improvement Process/Strategic Planning 34.5% Essential Service 8: Assure a Competent Public and Personal Workforce Model Standard 8.1 Workforce Assessment, Planning, and Development 31.7% Essential Service 9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Model Standard 9.3 Evaluation of Local Public Health Systems 37.3%

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?

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?

Improve Public Health Preparedness Priority Improve Public Health Preparedness

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?

Improve Patient Safety Priority Improve Patient Safety

Indiana Medical Error Reporting System

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

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

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

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

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

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

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?