Performance Standards: Opportunities for Quality Improvement for Maternal and Child Health Dennis Lenaway, PhD, MPH Centers for Disease Control and Prevention Public Health Program Practice Office

1988 Institute of Medicine (IOM) Report Public health – “assuring conditions in which people can be healthy” Identified three core functions –Assessment –Assurance –Policy Development Focused attention on governmental public health

Institute of Medicine Report The Future of the Public’s Health (2002) Builds on the 1988 report but with a broader scope Recommendation #13 –“develop a research agenda … to build the evidence base that will guide policy-making for public health practice.” Other recommendations address specific aspects of public health practice and public health systems

Essential Public Health Services Developed by the Core Public Health Functions Steering Committee (1994) –Included reps from national organizations and federal agencies –Charge: To provide a description and definition of public health

Vision: Healthy People in Healthy Communities Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability

The Essential Public Health Services 1.Monitor health status 2.Diagnose and investigate health problems 3.Inform and educate 4.Mobilize communities to address health problems 5.Develop policies and plans 6.Enforce laws and regulations 7.Link people to needed health services 8.Assure a competent health services workforce 9.Evaluate health services 10.Conduct research for new innovations

Infrastructure

Building Public Health Infrastructure "...It’s vital that we take steps to address current inadequacies and ensure that our public health infrastructure is prepared to meet the challenges of any public health crisis.” –Senator Bill Frist, MD, June 2000

Infrastructure

A Growing Focus on the Public Health System More than just the public health agency “Public health system” –All public, private, and voluntary entities that contribute to the delivery of public health services within a jurisdiction. –A network of entities with differing roles, relationships, and interactions. –All entities contribute to the health and well- being of the community.

The Public Health System

NPHPSP Overview Began in 1998 Partnership effort between CDC and six national public health organizations –APHA, ASTHO, NACCHO, NALBOH, PHF, NNPHI –Numerous working groups Extensive Field Testing –TX, FL, HI, MO, OH, MN, MS, NY, MA National launch in June 2002

Healthy People 2010 Chapter 23 – Public Health Infrastructure Some examples: –#11 - “…meet performance standards for essential services.” –#12 “…have a health improvement plan.” –#16 “…categorize expenditures by essential services.” –#8 “…integrate competencies in essential services into personnel systems.”

MAPP Mobilizing for Action through Planning and Partnerships (MAPP) Developed by NACCHO and CDC Community strategic planning tool Web-based tool –

The MAPP Model

Coordination with MAPP Use of NPHPSP within MAPP ensures broad- based involvement MAPP provides the process for addressing strengths and weaknesses

NPHPSP Vision and Goals To improve the quality of public health practice and performance of public health systems by: 1.Providing performance standards for public health systems and encouraging their widespread use; 2.Engaging and leveraging national, state, and local partnerships to build a stronger foundation for public health preparedness; 3.Promoting continuous quality improvement of public health systems; and 4.Strengthening the science base for public health practice improvement.

Partners CDC – Overall lead for coordination ASTHO – State instrument NACCHO – Local instrument and MAPP NALBOH – Governance instrument APHA –Marketing & communications PHF- Research activities NNPHI – Support through institutes

The Assessment Instruments State public health system Local public health system Local governance International

Indicator Model Standard Measures Essential Service Instrument Format

Four Concepts Applied in NPHPS 1. Based on the ten Essential Public Health Services 2. Focus on the overall public health system 3. Describe an optimal level of performance 4. Support a process of quality improvement

1. The Essential Services as a Framework Provides a foundation for any public health activity Describes public health at both the state and local levels Instruments include sections addressing each ES

2. Focus on the “System” More than just the public health agency “Public health system” –All public, private, and voluntary entities that contribute to public health in a given area. –A network of entities with differing roles, relationships, and interactions. –All entities contribute to the health and well-being of the community.

3. Optimal Level of Performance Each performance standard represents the “gold standard” Provide benchmarks to which state and local systems can strive to achieve Stimulate higher achievement

4. Stimulate Quality Improvement Standards should result in identification of areas for improvement Link results to an improvement process NPHPSP Local Instrument - used within the MAPP planning process

Four components of a performance management system Source: Turning Point Performance Management Collaborative, From Silos to Systems: Performance Management in Public Health (in press).

Potential Uses of NPHPSP Data and Information Benchmarking Needs assessment Strategic planning Quality improvement Performance Management Community mobilization Alliance building Resource allocation Program evaluation Policy development Grant-writing Public accountability

NPHPSP: Moving Towards Quality Improvement Review scores and results Discuss comments and ideas made during the instrument completion process Identify priority areas to address Collectively develop strategies to address priorities Management of change

Using the Results for Quality Improvement: Examples from the Field Mississippi – Used the information to develop legislative language for a capital improvement bond Used data for BT grant proposal Used data for the Sunset Commission report Used data for a proposal addressing environmental health improvement

Coordinated Statewide Process Use of multiple NPHPSP instruments in a coordinated approach Benefits: –Coordinated orientation, training, and technical assistance –Aggregate reports of assessment results –Coordinated quality improvement planning

Statewide Activities Pilot / Field Test States Currently using or planning for use statewide

NPHPSP in Practice Ohio –establishing an accreditation process which sets minimum agency standards for local health agencies and also requires all local areas to complete the NPHPSP Local Instrument. New Jersey –by regulation, requires statewide use of local and governance instruments. Illinois –recently passed legislation with NPHPSP

Quality Improvement and Science Provide information and consensus-based direction for quality improvement Develop practice data about performance and models of effective public health systems

What gets MEASURED gets DONE ! What gets MEASURED gets DONE !