#  Using the National Environmental Public Health Performance Standards to Improve Services in Four Florida Counties

# 2007 - 2008 

# 

#  Environmental Public Health Leadership Institute Fellow(s):

# Keith Keene

*Environmental Administrator,*

*DeSoto County Health Department*

*34 S. Baldwin Ave.,*

*Arcadia, FL 34266*

*863-993-4604*

*Keith_Keene@doh.state.fl.us*

# Trevor Coke

*Miami-Dade County Health Department*

*1725 NW 167^th^ St*

*Miami Florida, 33056*

*305-623-3500*

*Trevor_Coke@doh.state.fl.us*

## **David Overfield**

*Environmental Administrator*

*Orange County Health Department*

*800 N Mercy Drive STE 1*

*Orlando FL 32808*

*407 445-5466*

*David_Overfield@doh.state.fl.us*

# Elizabeth Miller

*Florida Department of Environmental Protection*

*(formerly Madison County Health Department)*

*2600 Blair Stone Road*

*Tallahassee, FL 32399-2400*

*(850) 245-8159*

*Elizabeth.Miller@dep.state.fl.us*

# Mentor:

### **Dr. Sarah Kotchian, EdM, MPH, PhD**

*Public Health Consultant, formerly Research Assistant Professor and*
*Associate Director for Planning,* UNM Institute for Public Health

# (Acknowledgements):

Dr. Lisa Conti, DVM, MPH,

Director

Division of Environmental Health

Florida Department of Health

Carl Osaki, RS, RS, MSPH

Northwest Center for Public Health Practice

David Stroh, MA

Bridgeway Partners

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

As Florida is a global destination with an ever increasing population,
there is a corresponding increase in risk to public health and the
environment. Environmental Health in Florida has primarily focused on
regulatory functions. This approach has caused Environmental Health
staff to be reactive to new and emerging threats rather than building
capacity to prepare for and prevent those threats, and keeps the public
from receiving the full complement of environmental health services to
which they are entitled.

Four EPHLI Fellows, who were all Environmental Health Supervisors from
counties with different demographics within the State of Florida,
applied systems thinking to specify the root of this problem, possible
solutions and limits to success. They applied the National Environmental
Public Health Performance Standards (EnvPHPS) Local Environmental Health
Program Self Assessment Instrument to their individual counties to
complete a gap analysis of the Ten Essential Environmental Health
Services (EEHS).

The assessment results and county demographics were compared to look for
trends associated with each county's ability to provide the Ten
Essential Environmental Health Services. The team of Fellows developed
action plans to address the gaps identified, and concurred on a set of
conclusions and recommendations regarding the value and use of the tool
to build environmental health capacity.

To become proactive, Environmental Public Health programs must educate
and empower stakeholders to demand the health status and quality of life
that more comprehensive Environmental Health services can ensure. The
use of the EnvPHPS assessment tool provides an opportunity to educate
staff and the community and produces data that can be used to advocate
for additional resources and address gaps in environmental health
activities. With the assessment results, adequate funding and
appropriate staffing, Environmental Health will be better able to
prepare for and address emerging threats in order to protect the
environment to prevent human illness, injury and loss of life.

#  

# INTRODUCTION/BACKGROUND:

####### While environmental threats to public health have increased, funding to address those threats has not increased at the same rate. Efforts to increase the level of enforcement for violations of environmental public health regulations have not significantly improved health status nor have they allowed time for the provision of the full complement of the ten essential services. Local county health departments do not have a good measure of what level of service they are providing or how effective those services are at protecting public health.

####### ***Problem Statement:*** 

The unintended consequence of a classic regulatory approach to
Environmental Health issues in Florida is that citizens do not receive
the full complement of services needed to protect their health and
safety.

####### ***Behavior Over Time Graph:*** ![](media/image2.jpeg){width="6.500694444444444in" height="4.954861111111111in"} 

####### ***Causal Loop Diagrams and applicable archetypes:***

![](media/image3.jpeg){width="6.933333333333334in"
height="5.200694444444444in"}

####### ***10 Essential Environmental Health Services:***

This project seeks to aid Florida County Health Departments in providing
all of the 10 Essential Environmental Public Health Services by applying
the Local Environmental Health Programs Assessment Instrument to the
Environmental Health sections. The goal is to identify areas of
strengths and weaknesses as well as to identify areas where services are
not currently being provided. By involving community partners in these
assessments, the local county environmental health sections can
accomplish the above mentioned goal while concurrently educating
community partners about the scope of services possible. Once our
community partners become aware of the scope of services, public demand
for these services will lead to more dialogue and potentially more
resources being allocated towards the provision of the services.

![](media/image4.png){width="3.75in" height="3.8125in"}

Figure 1: This picture is from the Ten Essential Services of
Environmental Health- as developed by Carl Osaki, RS, MSPH, and the
Northwest Center for Public Health Practice.

####### 

####### ***National Goals Supported*** 

This project, *Using the National Environmental Public Health
Performance Standards to Improve Services in Four Florida Counties,*
supports all of the **CDC Health Protection Goals** because
Environmental Public Health is involved in every aspect of people's
lives. Our environment is critical to how we grow, learn, and develop,
how safe we feel, how well we're taken care of when we're ill or aging,
and how easy (or difficult) it is for us to incorporate physical
activity into our daily lives. If the Ten Essential Environmental Public
Health Services are provided, we are not only ensuring that hospitals,
schools, playgrounds, neighborhoods, etc. are safe and clean but also
that people are prepared for emerging health threats and natural
disasters. Our physical, emotional, and mental health is greatly
dependent upon our environment, whether it's the environment where we're
born; go to school, exercise, or even the environment within our own
home.

This project meets the following goals of **Healthy People 2010**: #8)
Environmental Health, #15) Injury & Violence Prevention, #18) Mental
Health & Mental Disorders, #19) Nutrition & Overweight, #20)
Occupational Health & Safety, and #22) Physical Activity & Fitness.
Because Environmental Public Health is involved in our schools,
workplaces, assisted living facilities, mental health residential
facilities, hospitals, and our communities as a whole through programs
like PACE-EH, we can often serve as sentinels to observe areas where
environmental public health risks may exist or potentially exist.

This project supports the **National Strategy to Revitalize
Environmental Public Health Services** by enabling local Environmental
Public Health Programs to assess themselves, identify strengths,
weaknesses, and gaps in services, and create dialogue with community
partners. It provides local programs with information they can use to
market themselves to build capacity and better serve the community. The
project contributed to a number of the outcomes on p. 33 of the
Strategy, such as increasing the environmental public health capacity at
the local level and implementing more effective public health programs.

The core competencies recommended in the **Environmental Health
Competency Project: Recommendation for Core Competencies for Local
Environmental Health Practitioners**, play a vital role in this project.

-   Assessment -The application of the (National Environmental Public
    Health Performance Standards (EnvPHPS) Local Environmental Health
    Program Self Assessment Instrument required extensive use of
    assessment competency to evaluate the resulting gaps in services and
    develop viable action plans. Continued re-assessment is expected as
    we move forward with our project.

-   Management -- In particular, organizational knowledge and partnering
    are imperative to the success of this project. We must know what are
    current services are, what services our stakeholders deserve and
    partner with them and the entities that can provide support.

-   Communication -- a large part of this project will be with
    communicating and educating staff and stakeholders, especially the
    policy makers in government. Communicating this program to the
    public will need different methods of communication based upon the
    level of understanding.

####### 

####### ***Project Logic Model:*** ![](media/image5.jpeg){width="6.511805555555555in" height="3.6638888888888888in"}

# 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal:*** Improve the health of the public by ensuring that local county health departments have the capacity to provide the ten essential environmental public health services

####### ***Health Problem:*** While environmental threats to public health have increased, funding to address those threats has not increased at the same rate. Efforts to increase the level of enforcement for violations of environmental public health regulations have not significantly improved health status nor have they allowed time for the provision of additional services within the ten essential services. Local county health departments do not have a good measure of what level of service they are providing or how effective those services are at protecting public health.

***Outcome Objective:***

***Determinant:*** If local county health departments apply the Local
Environmental Health Programs Assessment Instrument to their current
operations, they can identify strengths and weaknesses in the services
they provide as well as identify areas where they are not currently able
to provide service.

####### ***Impact Objective:*** By December 31^st^, 2007, a pilot set of Florida counties, including DeSoto, Madison, Miami-Dade, and Orange, will use the Local Environmental Health Programs Assessment Instrument to assess their Environmental Health Programs.

####### ***Contributing Factors:*** 

1.  Lack of public awareness regarding the scope and level of services
    that are available to them under the umbrella of Environmental
    Health Services.

2.  Lack of knowledge in the local county health department's
    Environmental Health Programs of what level of service is being
    provided, what the gaps in service are, and what effect services are
    having on public health.

####### ***Process Objectives:*** 

1.  By September 30, 2007, DeSoto, Madison, Miami-Dade, and Orange
    Counties in Florida will have applied the National Environmental
    Health Performance Standards Assessment Tool to their Environmental
    Health Programs.

    a.  Introduce individual staff members to the Ten Essential
        Environmental Public Health Services

2.  By October 31, 2007, each environmental health program will have
    reviewed results of self assessment tool, identifying gaps and
    creating an action plan to meet objective of closing at least one of
    the gaps.

3.  By November 31, 2007, compare the results of the survey to determine
    commonalities and difference to see what relationship exists for
    programs of different size.

4.  By December 31, 2007, each of these Environmental Health Programs
    will also identify whether or not additional tools are needed to
    properly assess their programs since each county's needs may differ
    because of size, location, and other demographics of the county.

5.  Prepare feedback to the CDC Environmental Health Services Branch on
    the usefulness of the EnvPHPS Assessment tool and any recommended
    improvements.

# 

# METHODOLOGY:

####### ***Events and Activities***

In order to begin this project, the team first worked to identify mental
models that perpetuate the problem statement and lead us away from
implementing a long term fix.

Fellow, Keith Keene, participated in the NEnvPHPS Workshop: Building
Local and National Excellence at the NEHA meeting in June 2007. He
applied the EnvPHPS Assessment tool to his local environmental Health
program. He shared his results with the team fellows, and the
instructions for completing the assessment. During the months of
September through November, the other three county environmental health
directors applied the tool to their individual environmental health
programs. We shared our results with each other and collaborated on
scoring of the results to ensure that we were all using the same scoring
criteria. For each performance gap identified, each director mapped out
an action plan to address that gap. Results for each county were graphed
to compare results. Demographics for each of the four counties were also
graphed to look for trends in the performance results that might be
correlated to demographics (i.e. population, staffing and budget). The
team then participated in several conference calls to discuss the
results, observations, recommendations and further steps to be taken.

# RESULTS:

1.  In implementing the assessment, those of us who did not attend the
    NEnvPHPS Workshop realized that we weren't sure how to score the
    results of our assessment. In order to be consistent amongst
    ourselves, we agreed to assign 100 points (100%) to each Standard
    within the assessment. Those 100 points were then equally
    distributed to each Indicator within a Standard. For instance, for
    Essential Environmental Public Health Service #1, there were six
    indicators. Therefore, each indicator was worth 16.67 points each.
    Within in indicator were sub-indicators. If a program met only a
    portion of those sub-indicators, that 16.67 points had to be further
    subdivided. We all agreed that to a certain extent our scoring was
    subjective based on our perception of whether our program met a
    standard or not. This emphasizes the importance of involving all
    environmental health staff in the assessment and the value of having
    community partners complete the assessment as well to see what
    outside perceptions are. We all agreed that scoring needs to be
    addressed more clearly and completely in the instructions for
    completing the assessment.

2.  Once we identified the value in involving community partners in the
    assessment, we also realized that the assessment could be used as an
    opportunity for some public relations work with our community
    partners. If we can raise awareness in the community of what
    Environmental Public Health means and all of the services that it
    includes, that would inspire our citizens to demand these services.
    The down side of that public pressure is that, due to budget
    constraints, we probably would not be able to immediately provide
    these services. There is a certain amount of fear among
    Environmental Public Health professionals when we realize what we
    may be getting ourselves into.

3.  As we worked through the assessment, we also realized that by
    involving our environmental inspectors in the assessment, we can
    also use it as a training tool to educate and inform our inspectors
    about the many facets of environmental public health. When a new
    inspector begins, they spend countless hours in training on how to
    conduct inspections; how to apply statutes in different program
    areas and the technical aspects of some of the methods they must
    perform in order to do their job. By participating in the
    assessment, they will be better informed about the scope of services
    that environmental public health covers and in turn, they will be
    better inspectors.

4.  Results of the assessment and county demographics are attached as
    Figure 2 and Figure 3 below.

![](media/image6.wmf){width="5.996527777777778in"
height="4.081944444444445in"}

Figure 2

![](media/image7.wmf){width="5.998611111111111in"
height="4.081944444444445in"}

Figure 3

# CONCLUSIONS:

The results applying the EnvPHPS, when used in the proper context, will
provide local environmental health programs with valuable insight into
their strengths and weaknesses. The tool provides provide information
that can be used to educate and inform not only environmental health
professionals but also community partners who may not be aware of the
full scope of services potentially available. When community partners
and the public become aware of these services and the benefits to having
these services, they will begin to put pressure on lawmakers and
regulators to provide those services. Strengthened awareness by these
stakeholders is what is needed for them to become advocates for support.

Because Environmental Health Departments are evaluated almost
exclusively on our ability to conduct regulatory activities, the process
of evaluation will need to be adjusted to match the 10 Essential
Environmental Public Health Services. Using the EnvPHPS is a broader way
to evaluate the performance of environmental health related to public
health outcomes rather than outputs. By basing our responsibility and
evaluation on the big picture we will be better prepared to adapt to
emerging threats without fear of under performing. Although the growing
pains that may be experienced between public demand and resources being
allocated to enable environmental health programs to build capacity may
be uncomfortable, in the end, it will lead to a safe and healthier
public. In addition Public Health will never be truly public health
until all communities are working jointly with the health division to
create a healthy community through collaboration.

# 

# 

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Keith Keene***

I am extremely blessed to have participated in Cohort III of the
Environmental Public Health Leadership Institute. The lessons learned
have made me an effective leader in the work place and my community. The
Skillscope 360 and resulting individual development plan has proved
invaluable. I have achieved many of my goals and continue to seek out
areas for additional self improvement. The systems thinking approach is
a tool I use each day as I meet the ever increasing issues facing
environmental health. The opportunity to network with my peers from
around the country and the relationships that have resulted from working
on a team project are priceless. The principles and skills learned have
definitely enhanced my leadership ability in environmental health.
Participating in EPHLI has enriched my life professionally and
personally.

***David Overfield***

What a wonderful experience. When I applied to the Environmental Public
Health Leadership Institute, I assumed they would help me examine one of
the problems I am working on for my County Health Department. I never
dreamed how much they would teach me about myself or the tools they
would give me to solve many of my department's challenges, truly
teaching a man to fish. I learned about my personality, my leadership
style, problem solving, leverage, systems thinking, negotiation and had
the privilege of meeting and networking with Public Health professionals
from all over the United States. This opportunity afforded me the
ability to learn how things are done else where as well as share my
challenges and successes with other health minded individuals. I was
incredibly fortunate to be paired with Trevor, Liz, Keith and our Mentor
Sarah. Without their input, guidance and support, this project and my
growth as a Leader and Health Professional would not have been possible.
I wish to thank my team, mentor, coach, the staff of EPHLI, instructors,
Cohort III and the CDC making this experience possible.

####### ***Elizabeth Miller***

Participation in the Environmental Public Health Leadership Institute
has challenged by mind in many ways. I've learned to think through
problems differently, and I've learned that some of my characteristics
that I thought were weaknesses are only weaknesses if I don't understand
them and know how to make them work for me. During the course of this
program, I left the Department of Health and returned to my previous job
at the Department of Environmental Protection. As a result of working in
Environmental Health for three years and participating in this program,
I am much more aware of the intertwining responsibilities of the two
agencies, and I have many more connections. I know that the leadership
skills I have learned will be valuable to me wherever I go. Working with
the team I was blessed to be associated with has been a wonderful
experience. We meshed so well as a group, and we understood and
supported each others strengths and weaknesses. I am truly grateful to
Keith Keene, David Overfield, Trevor Coke, and Dr. Sarah Kotchian for
their support and the way in which they challenged me to think.

***Trevor Coke***

Over the last year, I have been very pleased to be a part of this most
prestigious institute. The knowledge gained through my coach, my mentor
and my team has been just awesome. I learned tips through several
classes on how to manage time and most importantly on how not to be
caught in fixes that backfire. I have also learned to manage time better
by delegating some of my responsibilities. This has helped me greatly in
accomplishing more work during the day. The contacts made with fellow
cohorts have been very valuable to me and my local health department.
Due to collaborations with fellow cohorts I was successful in getting a
grant for a rodent control program worth \$700,000 dollars.

# ABOUT THE EPHLI FELLOW(s)

**Keith Keene**

Keith Keene is the Environmental Administrator of the DeSoto County
Health Department in Arcadia, Florida. He holds a Bachelor of Chemistry
degree from the University of South Florida. He began his career as an
Environmental Health Specialist at the Charlotte County Florida Health
Department in 1989. His has oversight of environmental health programs
including but not limited to onsite wastewater, migrant housing,
swimming pools and mobile home parks, and petroleum storage systems. He
is in the second year of a PACE-EH program in two local communities.
Additionally, the epidemiology programs (EH, STD and TB) and the WIC
program report to him. Mr. Keene is member of the Florida and the
National Environmental Health Associations. He is the Environmental
Health Section Co-Chair for the Florida Public Health Association. He
serves as the Florida Department of Health representative on the Peace
River Basin Management Advisory Committee.

**David Overfield**

David Overfield has been employed by the Orange County Health Department
since 1999. His current position is that of Environmental Administrator.
His current duties include the management of the Orange County Health
Department's office of Environmental Health. David served as a Corpsman
for the United States Navy, received his Bachelor of Science degree in
Biology from the University of Central Florida and was most recently
selected to attend the 2007 Environmental Public Health Leadership
Institute. Some of his most recent accomplishments include the
establishment of County fees for Environmental Health, participation on
Orange County's Meth Lab Taskforce, management of the 2006 Incident
Command Center for the Apopka mouse invasion and participation on the
Orange County Climate Change Summit.. When not working, he enjoys
attending church, running, astronomy and spending time with his wife and
children.

**Trevor Coke** is an Environmental Supervisor II with the Miami Dade
County Health Department, Environmental Health and Engineering Division.
He has worked at the MDCHD for 27 years. He is the program manager for
the community hygiene program funded by a grant from the county. This
program focuses on improving the hygiene in low moderate income
communities throughout unincorporated Miami Dade County. In addition he
is in charge of disaster preparedness for Environmental Health,
Continuity of Operations Plan, Rodent Control program, and Dead bird
collection, On Call for Environmental Health, work across all core
programs and special projects for environmental health.

**Elizabeth Miller**

Elizabeth Miller is currently an Environmental Manager in the Biology
Laboratory of the Florida Department of Environmental Protection in
Tallahassee, Florida. She holds a Bachelor degree in Biology from
Florida State University. She began her work in Environmental Health in
June, 2004 as an Environmental Health Inspector with the Madison County
Health Department. After a year, she was promoted to the position of
Environmental Health Director and served in that position until October,
2007 when she decided to return to her position at Environmental
Protection where she had previously worked for 14 years. Ms. Miller is a
member of the Florida Environmental Health Association. In her current
position, she is responsible for supervision of taxonomists in the
laboratory, writing and reviewing technical reports dealing with surface
water quality, and has been chosen to be involved with the Harmful Algal
Bloom Task Force, which involves several different state agencies
including Environmental Protection, Health, and Agricultures. She also
acts as assistant programmer of the Statewide Biological Database, which
houses taxonomic and water quality data for water bodies that have been
sampled in the state of Florida.

# REFERENCES

1.  Osaki C, RS, MSPH, Northwest Center for Public Health Practice,
    *Essential Services of Environmental Health.*

2.  Rowitz L., PhD, Public Health Leadership-Putting Principles into
    Practice, Jones and Bartlett Publishers, Inc, 2003

3.  Goodman M, Stroh D, Immediato S, "Introduction to Systems Thinking",
    Bridgeway Partners and Innovation Associates Organizational
    Learning.

4.  Senge PM, Kleiner A, Roberts C, Ross RB, Smith BJ. The Fifth
    Discipline Field Book. New York, NY, Doubleday;

5.  CDC Health Protection Goals,
    http://www.cdc.gov/about/goals/default.htm

6.  Healthy People 2010 Objectives,
    http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm

7.  National Strategy to Revitalize Environmental Public Health
    Services, http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf.

8.  Environmental Health Competency Project: Recommendation for Core
    Competencies for Local Environmental Health Practitioners,
    http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm.