# Presentation: 519478

## National Public Health Performance Standards ProgramOverview Presentation

## Providing performance standards for public health systems and encouraging their widespread use;
Engaging and leveraging national, state, and local partnerships to build a stronger foundation for public health preparedness; 
Promoting continuous quality improvement of public health systems; and 
Strengthening the science base for public health practice improvement.

- Engaging and leveraging national, state, and local _partnerships_ to build a stronger foundation for public health preparedness;
- Promoting continuous _quality improvement_ of public health systems; and
- Strengthening the _science base_ for public health practice improvement.

- To improve the quality of public health practice and performance of public health systems by:

**Program Vision and Goals**

**Notes:**
The NPHPSP will:
Provide performance standards for public health systems.  Up until this point, there had been no standards for public health practice, like there are in other sectors (managed care, hospitals, law enforcement). 
Through the use of standards, we will engage and leverage partnerships to create a stronger foundation for public health preparedness.  
By setting optimal standards, we promote continuous quality improvement of public health systems --– the standards will give systems benchmarks to strive for.
And lastly, the NPHPSP gathers data on what state and local public health systems and governing bodies look like, in comparison to the standards.  This will provide us with a much stronger science base for public health practice improvement and a stronger understanding of our state and local public health infrastructure.  This data can be ultimately used for making policy decisions, allocating resources, and establishing new benchmarks for public health improvement.  

So, for the first time, we’ll be able to answer questions such as “What are the activities, competencies and capacities of public health systems across the nation?” and how do they differ from state to state?  We’ll be able to use this information to identify best practices, improve coordination, and lobby for policy changes or an increased emphasis on low-scoring areas.

## Assessment Instruments
State public health system
Local public health system
Local public health governance

- State public health system
- Local public health system
- Local public health governance

**Partners**
- CDC
- APHA
- ASTHO

- NACCHO
- NALBOH
- NNPHI
- PHF

**NPHPSP**

## CDC – Overall lead for coordination
ASTHO – Develop and support state instrument
NACCHO – Develop and support local instrument; MAPP
NALBOH – Develop and support governance instrument
APHA –Marketing and  communications
PHF- Performance improvement; data collection and reporting system
NNPHI – Support through institutes, training workshop and user calls

**CDC** – Overall lead for coordination
**ASTHO** – Develop and support state instrument
**NACCHO** – Develop and support local instrument; MAPP
**NALBOH** – Develop and support governance instrument
**APHA** –Marketing and  communications
**PHF****-** Performance improvement; data collection and reporting system
**NNPHI** – Support through institutes, training workshop and user calls

**Partners**

**Notes:**
Without the productive partnership between CDC’s Public Health Practice Program Office and five national public health organizations:  APHA, ASTHO, NACCHO, NALBOH, and PHF the NPHPSP would not have gotten off the ground.
CDC conducts the overall coordination, with each partner playing a lead role in a specific piece of the program.  ASTHO, NACCHO, and NALBOH led the development of performance standards for state and local public health systems and governing entities.  APHA has been a leader in the area of marketing and communications.  And the Public Health Foundation has been active in several research areas, such as validity testing and researching technical assistance resources.   
And we are pleased to have a new partner, the National Network of Public Health Institutes, who will provide a crucial link between the program and state public health institutes across the nation. 

## History of the NPHPSP

**Key Dates**
- Began in 1998
- Version 1 instruments released in 2002
- 2002-2007 – Version 1 instruments used in more than 30 states
- Development of Version 2 instruments – 2005-2007
**Comprehensive Development of Instruments**
- Practice-driven development by CDC and ASTHO, NACCHO and NALBOH Work Groups
- Field testing

## Four Concepts Applied in NPHPSP

**Four Concepts Applied in NPHPSP**

**Notes:**
To truly understand the value and uniqueness of the NPHPS, it is important to realize that there are four concepts that underpin the instruments and standards:
1.   The instruments are based on and built around the Ten Essential Public Health Services

2. The standards focus on the overall public health system, as opposed to a single organization or entity; 

3. The performance standards describe an optimal level of performance; and 

 The standards are intended to support and stimulate a process of quality improvement

The next few slides describe each of the concepts in a little more detail.

## 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

## 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
Developed the “Public Health in America” statement

- Included reps from national organizations and federal agencies
- Charge: To provide a description and definition of public health
- Developed the “Public Health in America” statement

**Essential Public Health Services**

## Monitor health status
Diagnose and investigate health problems
Inform, educate and empower people
Mobilize communities to address health problems
Develop policies and plans

- Diagnose and investigate health problems
- Inform, educate and empower people
- Mobilize communities to address health problems
- Develop policies and plans

- Enforce laws and regulations
- Link people to needed health services
- Assure a competent workforce - public health and personal care
- Evaluate health services
- Conduct research for new innovations

**The Essential Public Health Services**

**Notes:**
The ten essential services are shown here on the screen and include:
Monitor health status to identify and solve community health problems.
Diagnose and investigate health problems and health hazards in the community.
Inform, educate, and empower people about health issues.
Mobilize community partnerships to identify and solve health problems.
Develop policies and plans that support individual and community health efforts.
Enforce laws and regulations that protect health and ensure safety.
Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
Assure a competent public and personal health care workforce.
Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
Research for new insights and innovative solutions to health problems

These are the foundation of any public health activity. 
For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries.  As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. 

Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

## Slide 10

## “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 public, private, and voluntary entities that contribute to public health in a given area.
- A network of entities with differing roles, relationships, and interactions.

**Focus on the “System”**

- All entities contribute to the health and well-being of the community.

- More than just the public health agency

**Notes:**
The second concept addresses the fact that the NPHPS focuses on the overall “public health system.” 
This assures that the contributions of all entities are recognized in assessing the provision of public health services.  Clearly, the governmental public health agency – either at the state or local level – is a major player in the public health system, but agencies cannot provide the full spectrum of essential public health services alone.  Hospitals, public safety, voluntary health organizations, mental health centers, schools, civic groups, faith institutions and others all contribute to accomplishing the actions necessary to achieve public health.  
When we talk about  public health systems, a definition we commonly use is: 

 “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.”  

Another way of looking at it is to say that a public health system is a network of entities with differing roles, relationships, and interactions. All of these entities contribute to the health and well-being of the community.  

## Public Health System

**Public Health System**

## A system of partnerships that includes, but is not limited to . . .

- Federal DHHS
- State Health Department
- Local Health Departments
- Tribal Health

## Our goal is an integrated system of partnerships 

- Federal DHHS
- State Health Department
- Local Health Departments
- Tribal Health

## Each performance standard represents the “gold standard”

Provide benchmarks to which state and local systems can strive to achieve

Stimulate higher achievement

- Provide benchmarks to which state and local systems can strive to achieve
- Stimulate higher achievement

**Optimal Level of Performance**

**Notes:**
Third, the standards describe an optimal level of performance ("the gold standard") rather than provide minimum expectations.  Minimum standards often do not stimulate organizations to strive for higher levels of achievement.  Optimal standards will stimulate organizations for a higher level of achievement and will provide a level to which all public health systems can aspire to achieve. 

Optional to add - additional reasons for optimal level standards include:
-- with the broad diversity in public health infrastructure across the nation, it would be difficult to determine where to “set the bar” if we were to use minimal standards.
-- optimal level standards can assist public health system partners in advocating for increased funding or activities, in order to attain the higher levels of performance.

## Standards should result in identification of areas for improvement

Link results to an improvement process

NPHPSP Local Instrument -  used within the MAPP planning process

- Link results to an improvement process
- NPHPSP Local Instrument -  used within the MAPP planning process

**Stimulate Quality Improvement**

**Notes:**
Finally,  the NPHPS are intended to promote and stimulate quality improvement.  The major outcome of responding to the performance standards instrument should be the identification of strengths and weaknesses within the state or local public health system.  This information should be used to determine areas and methods for improvement.  Ideally, this information should feed into a health improvement process and should result in planning and action around identified priority areas.

The development of the local public health system instrument, in particular, has already been linked to a recently-developed community health improvement process, called MAPP.

## Coordinated statewide approach
Benefits in technical assistance and coordinated improvement planning

Individual System / Board Use

Common Catalysts for Use
Statewide interest in improvement planning
Interest in performance improvement
Bioterrorism and emergency response planning
Use within the MAPP process
Interest in accountability

- Benefits in technical assistance and coordinated improvement planning
**Individual System / Board Use**
**Common Catalysts for Use**
- Statewide interest in improvement planning
- Interest in performance improvement
- Bioterrorism and emergency response planning
- Use within the MAPP process
- Interest in accountability

**NPHPSP Use in the Field**

## NPHPSP State Instrument Use (Thru August 2007, n = 22 states)

- *Also includes sites using field test versions of the NPHPSP State Public Health System Performance Assessment.

***NH***

***MA***

***RI***

***CT***

**Notes:**
Completed (Blue): States that completed implementation of the state instrument

Field Test (Yellow): States that participated in pilot/field testing of the state instrument, only

## NPHPSP Local Instrument Use (Thru August 2007)

- *Also includes sites using field test versions of the NPHPSP Local Public Health System Performance Assessment.

***HI***

**Notes:**
Significant Use (Dark Blue): Completion range = 67% or greater of local health departments completed use of the local instrument
(Total number of significant use states = 6)

Moderate Use (Blue): Completion range = 33% - 66% of local health departments completed use of the local instrument
(Total number of moderate use states = 4)

Limited Use (Light Blue): Completion range  = 1% – 32% of local health departments completed use of the local instrument
(Total number of limited use states = 12)

Field Test (Yellow): States that participated in pilot/field testing of the local instrument, only
(Total number of field test states = 8)

NOTE: TEXAS, FLORIDA, AND MISSOURI ALSO SERVED AS PILOT/FIELD TEST SITE FOR THE LOCAL INSTRUMENT, ALTHOUGH ARE NOT SHADED IN YELLOW

NOTE: Completion rate for Maine (1/1 = 100%)

## NPHPSP Governance Instrument Use (Thru August 2007)

**No Boards of Health**

- *Also includes sites using field test versions of the NPHPSP Local Public Health Governance Performance Assessment.

***NJ***

***DE***

***MD***

***NH***

***MA***

***RI***

***CT***

***HI***

**Notes:**
Significant Use (Dark Blue): Completion range = 67% or greater of local health departments completed use of the local instrument 
(Total number of significant use states = 1) 
Note: New Jersey is the only state showing significant use of the governance instrument.

Moderate Use (Blue): Completion range: 33% - 66% of local boards of health completed use of the governance instrument 
(Total number of moderate use states = 0
Note:  There are no states showing moderate use of the governance instrument.  

Limited Use (Light Blue): Completion range = 1% - 32% of local boards of health completed use of the governance instrument 
(Total number of limited use states = 8)

Field Test (Yellow): States that participated in pilot/field testing of the governance instrument, only
(Total number of field test states = 4)

## NPHPSP Use in the Field(What the evaluation data* tell us)

**NPHPSP Use in the Field****(What the evaluation data* tell us)**

- Reasons for Using NPHPSP – State and Local
- Establish a baseline measure of performance
- Wanted a national developed & recognized assessment tool to help improve performance
- NPHPSP the best tool available for improving public health system effectiveness
- Was part of the MAPP process *(local users only)*
- *State evaluation data gathered through ASTHO survey 10/05-1/06 – 80% response rate (9 respondents reporting completion of State NPHPSP).  Local evaluation data gathered through NACCHO survey to known NPHPSP and MAPP users in 01/06 – 05/06; 212 total respondents (149 respondents reporting completion of Local NPHPSP).

## NPHPSP Outcomes Achieved

**NPHPSP Outcomes Achieved**

- Percentage of respondents indicating achievement of these outcomes was partial/medium or high

## Impact of NPHPSP Use on the State / Local Public Health System

**Impact of NPHPSP Use on the ****State / Local Public Health System**

- Percentage of respondents indicating moderate to major effect

## Policy support
Healthy People 2010 Objective 23-11
Institute of Medicine reports
State legislation that provide for or mention use of NPHPSP (e.g., IL, OH, NJ)

Related initiatives
Turning Point Performance Management Collaborative
MAPP
Operational Definition of a Local Health Department
Accreditation 

- Healthy People 2010 Objective 23-11
- Institute of Medicine reports
- State legislation that provide for or mention use of NPHPSP (e.g., IL, OH, NJ)
**Related initiatives**
- Turning Point Performance Management Collaborative
- MAPP
- Operational Definition of a Local Health Department
- Accreditation

**Strategic Linkages**

## Online Toolkit at: 
www.cdc.gov/od/ocphp/nphpsp
State, Local, and Governance Instruments 
User Guide
Sample letters, agendas, and reports from users
Performance improvement resources and links
And much more!

Contact 1-800-747-7649 or email: phpsp@cdc.gov  

- _www.cdc.gov/od/ocphp/nphpsp_
- State, Local, and Governance Instruments
- User Guide
- Sample letters, agendas, and reports from users
- Performance improvement resources and links
- And much more!
- Contact 1-800-747-7649 or email: _phpsp@cdc.gov _

**For More Information**

**Notes:**
Going through the assessment process and evaluation provides some terrific benefits for the system partners and, by extension, the communities that they serve.  
Obviously, it improves communication among stakeholders
Brings partners to the table to discuss issues, needs and activities, and promotes collaboration among the system members
Provides a systems view of public health services delivery
Provides a benchmark for improvement
And finally Provides information for policy development, program evaluation and grant-writing

## Strengthening systems, 

*improving the public’s health** *

**Notes:**
The NPHPS is a partnership effort – with national public health organizations - to improve the practice of public health and the performance of public health systems through the establishment and implementation of standards.  Currently, there are program standards in some public health related areas (e.g., laboratory standards) but no national standards for overall public health systems like there are in other sectors (e.g., hospital standards through JCAHO, law enforcement agency standards through CALEA).  So this is a much-needed and ground-breaking effort.