Priority Areas for Improvement of 

Quality in Public Health 

U.S. Department of Health and Human Services 

Office of the Assistant Secretary for Health 

Public Health Quality Forum 

November 2010
For more information contact: 

U.S. Department of Health and Human Services 

Office of the Assistant Secretary for Health 

Office of Healthcare Quality 

200 Independence Ave, SW, Room 719B 

Washington, DC 20201 

202-260-5184 

Suggested Citation 

Honoré, P.A., & Scott, W. (2010). Priority areas for improvement of quality in public health. 

Washington, DC: Department of Health and Human Services. 
Vision for Public Health Quality 

Howard K. Koh, MD, MPH 

Assistant Secretary for Health

November 6, 2010 

Priority Areas for Improvement of Quality in Public Health 

Improving the health of our nation remains a noble societal goal. Yet, for too 

long, people across America have not reached their full health potential. We 

need revitalized efforts to move toward a healthier nation. The advent of the 

Affordable Care Act serves as a catalyst for such change by promoting quality, 

access to care, and community and clinical prevention. We should maximize this 

transformative opportunity to elevate the health of our society. 

Improving quality lies at the heart of the Affordable Care Act. At this critical time, 

we should synthesize lessons learned from the seminal work in quality initially 

established in the healthcare arena and also broaden quality improvement 

efforts that can apply to populations. This will require commitment and 

coordination from many sectors of society, an approach requiring “health in all 

policies”. It will also require a vision that links quality, prevention, treatment and 

access to care. Public health professionals can help coordinate all these critical 

efforts. Strengthening the foundations for quality will surely help us fulfill our 

collective mission of ensuring conditions for a healthy population. 

As Assistant Secretary for Health, I believe our vision for public health quality is 

to focus on building better systems to give all people what they need to reach 

their full potential for health. This report represents a call to action for public 

health. The priority areas presented here represent important steps toward 

fulfilling that vision. Together, we can give priority to improving quality in the 

areas identified, raise quality and transform opportunity into actions that make a 

difference in the lives of all Americans. 

/Howard K. Koh/ 

Howard K. Koh, MD, MPH

vii 

Acknowledgements 

The Public Health Quality Forum (PHQF) provided direction for the 

development of this report. The Assistant Secretary for Health, Howard Koh, 

serves as chair of the PHQF. The project was led by the Office of Healthcare 

Quality, Don Wright, Deputy Assistant Secretary for Healthcare Quality. 

Don Berwick, Administrator, Centers for Medicare and Medicaid Services, 

provided direction for incorporating concepts for system-level results. 

Coordination and support was provided by the Office of Minority Health, 

Garth Graham, Deputy Assistant Secretary for Minority Health. The Office of 

HIV/AIDS Policy and Office on Women’s Health are also recognized for their 

support of the project. The PHQF benefited from expertise and presentations 

made by a panel of experts who informed the process. Authors of the report, 

Peggy Honoré and Wakina Scott, were supported by consultation from Yale 

University School of Public Health, several contributors serving as subject 

experts, and a broad continuum of external reviewers with vested interest and 

experiences with the public health system. Informants to the entire process are 

acknowledged below. 

_______________________________

Public Health Quality Forum 

Office of the Assistant Secretary for Health, Howard Koh, Chair 

Administration for Children and Families 

Administration on Aging 

Agency for Healthcare Research and Quality 

Centers for Disease Control and Prevention 

Centers for Medicare and Medicaid Services 

Food and Drug Administration 

Health Resources and Services Administration 

Indian Health Service 

National Institutes of Health 

Substance Abuse and Mental Health Services Administration 

Office of Healthcare Quality 

Office of Minority Health 

Office of the Assistant Secretary for Planning and Evaluation 

Office of the Assistant Secretary for Preparedness and Response 

Office of the National Coordinator for Health Information Technology 

Office of the Surgeon General 

Office on Disability 
viii 

Expert Participants 

American Public Health Association 

National Association of County and City Health Officials 

Association of State and Territorial Health Officials 

National Association of Local Boards of Health 

Academy Health 

Trust for America’s Health 

_______________________________ 

Authors 

Peggy Honoré, Director, Public Health Systems, Finance, and Quality Program, 

Office of Healthcare Quality and Office of Minority Health, U.S. 

Department of Health and Human Services, peggy.honore@hhs.gov

Wakina Scott, Public Health System Researcher, Office of Healthcare Quality 

and Office of Minority Health, U.S. Department of Health and Human 

Services, wakina.scott@hhs.gov

_______________________________ 

Consultants 

Paul Cleary, Dean, School of Public Health, Yale University 

Linda Degutis, Associate Professor of Emergency Medicine and of 

Epidemiology, School of Public Health, Yale University 

 _______________________________ 

Contributors 

Cheryll Lesneski, Clinical Assistant Professor, Gillings School of Global Public 

Health, University of North Carolina-Chapel Hill 

Suzanne Heurtin-Roberts, Health Scientist, Division of Cancer Control and 

Population Sciences, Behavioral Research Program, National Institutes of 

Health, U.S. Department of Health and Human Services

Patty Mabry, Senior Advisor, Office of Behavioral and Social Sciences 

Research, National Institutes of Health, U.S. Department of Health and 

Human Services. 

Richard Riegelman, Professor of Epidemiology-Biostatistics, Medicine and Health 

Policy, Founding Dean, School of Public Health and Health Services, The 

George Washington University 
ix

 

Reviewers 

Mark Bertler, Chief Executive Officer, Public Health Foundation Enterprises, 

Inc. 

Ron Bialek, Executive Director, Public Health Foundation 

Arnold Epstein, Chair, Department of Health Policy and Management, School of 

Public Health, Harvard University 

Melissa Hansen, Policy Specialist, National Council of State Legislators 

Jason Hsieh, Senior Policy Analyst, National Governors Association

Peter Jacobson, Professor of Health Law and Policy, Director, Center for 

 Law, Ethics, and Health, University of Michigan School of Public 

 Health

Walter Jones, Professor, Health Administration and Policy, College of Health 

Professions, Medical University of South Carolina 

Karen Minyard, Executive Director, Georgia Health Policy Center, Andrew 

Young School of Policy Studies, Georgia State University 

Anna Orlova, Executive Director, Public Health Data Standards Consortium

Mary Pittman, President and Chief Executive Officer, Public Health Institute 

Eileen Salinsky, Independent Consultant 

James Studnicki, Chair, Health Services Research and Professor, University of 

North Carolina-Charlotte 

Abraham Wandersman, Professor, Department of Psychology, University of 

South Carolina 

Douglas R. Wholey, Professor, Health Policy and Management, School of Public 

Health, University of Minnesota 

_______________________________ 

Special recognition to the Office of Minority Health Resource Center for graphic 

design.
x 

Contents 

EXECUTIVE SUMMARY ........................................................................................... 1

Coordinated Approach To Quality ...................................................................... 1

Priority Areas ....................................................................................................... 3

Moving Forward .................................................................................................. 6

CHAPTER 1: INTRODUCTION................................................................................ 11

Project Purpose ............................................................................................. 11

Study Process ................................................................................................. 12

Criteria ........................................................................................................... 13

Framework ..................................................................................................... 13

CHAPTER 2: PRIORITY AREAS FOR IMPROVEMENT OF QUALITY 

 IN PUBLIC HEALTH .......................................................................... 19

Priority Areas as Primary Drivers of Quality .................................................. 19

CHAPTER 3: DESCRIPTION OF PRIORITY AREAS .................................................. 27

Population Health Metrics and Information Technology ................................. 29

Evidence-Based Practices, Research, and Evaluation ....................................... 35

Systems Thinking ............................................................................................... 41

Sustainability and Stewardship ......................................................................... 47

Policy ................................................................................................................. 53

Workforce and Education ................................................................................. 57

Appendix A: Primary and Secondary Drivers of Quality for HAI, HIV 

 and Healtly Weight ......................................................................... 83

 
xi

List of Figures 

Figure ES-1 Institute for Healthcare Improvement concept of primary and 

 secondary drivers applied to public health..............................................5

Figure 1 Framework used to Identify Priority Areas ....................................... 14

Figure 2 Public Health Primary and Secondary Drivers of Quality .................. 23

Figure A-1 Public Health Primary and Secondary Drivers of Quality 

 for HAI ................................................................................................ 85

Figure A-2 Public Health Primary and Secondary Drivers of Quality 

 for HIV ................................................................................................ 87

Figure A-3 Public Health Primary and Secondary Drivers of Quality for 

 Healthy Weight .................................................................................. 89
xii 
xiii 
xiv 
1 

Executive Summary 

With the passage of the Affordable Care Act (2010), momentum for 

improving quality and population health has accelerated. Quality is in fact 

prominently positioned in the opening title of the law—Quality, Affordable 

Health Care for All Americans. Quality in patient care and increased emphasis on 

prevention are consistent themes throughout the law, as exemplified by the 

strong emphasis on population-based prevention and other community-based 

initiatives to promote population health. 

 The Affordable Care Act also provides an incentive for greater integration 

between health care and public health. Mandates for community health needs 

assessments by certain hospitals, a traditional public health activity, provides an 

opportunity for greater coordination between health care and public health on 

quality and population health issues (Patient Protection and Affordable Care Act 

[Affordable Care Act], 2010, sec. 9007). This heightened focus on quality should 

motivate us to identify areas in public health that lead to improved integration 

with health care and accelerated movement toward national health goals. 

 

COORDINATED APPROACH TO QUALITY 

At the close of the last century, a call to action was posed to the United 

States to embrace a coordinated approach to quality in health care. The 

President’s Advisory Commission on Consumer Protection and Quality in the 

Health Care Industry urged national leadership to commit to sustaining quality 

throughout all sectors of the industry (President’s Advisory Commission on 

Consumer Protection and Quality in the Health Care Industry, 1998). Their 

report, Quality First: Better Health Care for Americans (1998) included strategies 

to foster quality by developing a national consensus, aims, and shared goals. 

Over the past two years, the U.S. Department of Health and Human Services 

(HHS), Office of the Assistant Secretary for Health (OASH), acted on those 

recommendations with guidance from the Public Health Quality Forum (PHQF). 

Chaired by the Assistant Secretary for Health, the PHQF has members that 

represent all HHS agencies. In 2008, the PHQF developed a Consensus Statement 

on Quality in the Public Health System (Consensus Statement). Major 

components in the Consensus Statement to promote uniformity across the 

system include a definition of public health quality and nine aims representing 

characteristics of quality in the public health system (Department of Health and 

Human Services [DHHS], 2008). 
2 

• Definition: 

Quality in public health is the degree to which policies, 

programs, 

services and research for the population increase desired 

health outcomes and conditions in which the population can 

be healthy 

• Aims (Characteristics) of Public Health Quality: 

Population-Centered, Equitable, Proactive, Health Promoting, 

Risk-Reducing, Vigilant, Transparent, Effective, Efficient 

 

The next step in defining the field of public health quality is to identify 

priority areas. This report details recent activities led by the Assistant Secretary 

for Health to identify priority areas for improvement of quality in the public 

health system. 

Opportunities for Coordination 

As described by the World Health Organization (1978), health is not 

merely the absence of injury or disease, but also must include a barometer of 

social, mental, and physical well-being. Indeed, public health builds on the 

premise that the causes of health extend beyond the boundaries of individual 

biology and behavior (Leischow & Milstein, 2006) to advance and monitor the 

health of the population in communities throughout the nation. Accordingly, 

health must be measured, and quality improved, in the context of both 

individual and population-level interacting elements. This means extending 

beyond personal medical treatment to include an assessment of an individual’s 

community and personal environments (Bryant, 2006; Cohen, 2006; Weiner et 

al., 2010). Some even describe assessing individual health without considering 

elements of one’s surrounding environment as advancing contextual errors in 

patient care (Weiner et al., 2010). In essence, the overall health of the nation is 

determined by the health of individuals and health conditions in the 

communities where they live (Koh & Sebelius, 2010). This connection between 

individual health (health care) and community health (public health) illustrates 

the importance of having a systems-based coordinated approach to improve the 

quality of health in America. 

When developing initiatives to improve the health for the nation, it is 

essential to weave in principles and concepts of quality. Transforming the health 

care and public health systems to improve quality is in fact a primary strategic 

initiative of the HHS Secretary. New opportunities abound for building quality 

into both systems in order to aid all Americans in reaching their full health 

potential. For example, the Affordable Care Act requires development of both a 

National Strategy for Quality Improvement in Health Care (sec. 399HH) and 
3 

National Prevention and Health Promotion Strategy (sec. 4001), which in turn 

must include a broad population-based and community health focus beyond 

individual care (Affordable Care Act, 2010). HHS can demonstrate a strong 

leadership role for coordinating national quality efforts by integrating priorities 

for public health quality throughout all levels in the system and thereby drive 

improvements in population health outcomes as well as inform national 

strategies for improving quality, and prevention. By doing so, systems integration 

is advanced by synergistically aligning health care and public health. 

PRIORITY AREAS 

Six priority areas for improvement of quality in public health are unveiled 

in this report. Three distinct but related selection criteria – impact, improvability, 

and practice variability – guided the PHQF in the identification of the priority 

areas. 

 Based on Institute for Healthcare Improvement concepts (Nolan, 2007), 

the priorities represent primary drivers of public health quality and outcomes 

(Figure ES-1). The priority areas identified function as system-level interacting 

drivers that impact across the entire public health system (i.e., diseases, services, 

organization, performance, financing), including health care. The priority areas 

also reflect the complex interactive nature of the public health system, since lack 

of quality in one area can potentially negatively impact quality in another. 

Secondary drivers, also shown in Figure ES-1, are initiatives that play an essential 

role for achieving strategic improvements by supporting the primary drivers to 

ensure quality and achievement of outcomes. In Chapter 2 comprehensive sets 

of secondary drivers are presented that support strengthening each priority area 

discussed throughout this report. 

Quality First: Better Health Care for Americans (1998) noted the need to 

make quality a driving force in health care. Specific health care areas 

recommended for national attention were evidence-based practices, 

organizations adaptable to change, collaboration between health care workers, 

and information systems. The public health priorities identified here are 

consistent with those themes. Identifying the public health priorities which 

serve as primary drivers of quality and outcomes can improve alignment of 

efforts with those already occurring in the health care system. This is particularly 

relevant for tax-exempt hospitals given their mandates, as previously 

mentioned, for community health needs assessments with input from public 

health (Affordable Care Act, 2010, sec. 9007). 

These priority areas, noted in this report as primary drivers, represent 

major cross-cutting avenues for advancing outcomes when supported by 

appropriate secondary drivers. They represent both opportunities and gaps. 
4 

Chapter 3 of this report offers details for each priority area, including 

illustrations of how using this framework of primary and secondary drivers can 

help systematically address quality in specific areas. These descriptions can also 

help identify specific elements of the priority areas that require the greatest 

attention for improving quality and achieving desired results. The list and 

description of the primary drivers identified as priorities are presented below: 

Population Health Metrics and Information Technology — 

Improve methods and analytical capacity to collect, evaluate, and disseminate 

data that can be translated into actionable information and outcomes in 

population health at the local, state, and national level. Make the improvement 

of data collection for population subgroups a core value of public health. The 

informed use of health care quality data can serve as a catalyst to build 

population-based public health programs as a strategy to improve population 

health, eliminate health inequities, and bridge gaps between health care and 

public health. 

Evidence-Based Practices, Research, and Evaluation — 

Bridge research and practice and institutionalize evidence-based approaches to 

achieve results-based accountability. Support effective and safe practices that 

can be used by practitioners. 

Systems Thinking — 

Advance systems thinking in public health. Foster systems integration strategies 

by analyzing problems using systems science methodologies (i.e., network 

analysis) while taking into account the complex adaptive nature of the public 

health system. Complex adaptive systems are described as those based on 

relationships of diverse and interconnected agents that have the capacity to 

learn, change, and evolve (i.e., hospitals, emergency medical services systems, 

educational systems, emergency preparedness and response systems). 

Sustainability and Stewardship—

Strengthen system sustainability and stewardship through valid measures and 

reporting of performance and quality. Ensure efficient funding 

methodologies that align resources with goals, demonstrated need, 

responsibilities, measurable results, and ethical practices. 

Policy—

Strengthen policy development and analysis processes and advocacy to ensure 

that evidence is integrated into policymaking to improve population health. 

Workforce and Education—

Develop and sustain a competent workforce by ensuring that educational and 

skills content are appropriately aligned with core and discipline-specific 
5 

competencies. Assure that public health education is accessible at all academic 

levels, and that life-long learning is encouraged and valued. 

Figure ES-1. Institute for Healthcare Improvement concept of primary and 

secondary drivers applied to public health 

Figure ES-1 displays the Institute of Healthcare Improvement concept of 

primary and secondary drivers applied to public health using the six priority 

areas for improvement of quality. In this model for strategic improvement, the 

likelihood of achieving health outcomes (i.e., national goals) is influenced by 

primary drivers of quality (i.e., six priority areas for improvement of quality in 

public health). Secondary drivers provide the necessary support to strengthen 

the primary drivers. For example: 

• Outcome: National Goals for Population Health Improvements 

• Public Health Primary Drivers of Quality (i.e., six priority areas): 

• Population Health Metrics and Information Technology

• Evidence-Based Practices, Research, and Evaluation

• Systems Thinking

• Sustainability and Stewardship 

• Policy

• Workforce and Education

• Public Health Secondary Drivers of Quality: a portfolio of initiatives or 

projects to support and strengthen the priority set of primary drives. 
6 

MOVING FORWARD 

We are poised at a transformative time for our country’s health. As 2010 

concludes, the Department of Health and Human Services will be unveiling its 

2020 version of Healthy People, a time-honored national process of setting 

overarching health goals and objectives for the country (Koh, 2010). The launch 

of the Affordable Care Act this year also brings many opportunities, including 

producing a National Strategy for Quality Improvement in Health Care and 

National Prevention and Health Promotion Strategy. Now, this report 

contributes to the identification of priority areas that are primary drivers of 

quality and outcomes and represent avenues for addressing many Healthy 

People goals. These priority areas represent the best venues to focus valuable 

human and financial resources to ensure conditions for a healthy population. 

In practical terms, the public health primary drivers of quality and 

outcomes prioritized in this report can now serve as a frame of reference and a 

starting point. Organizations can use this framework to assess quality, identify 

weaknesses and redesign them when necessary to achieve greater levels of 

improvement. Identifying such drivers also allows the launch of continuous 

improvement processes to overcome barriers toward national goals and move 

toward better health improvement strategies. A relevant Healthy People 2020 

objective is to increase the number of public health agencies that implement 

agency-wide quality improvement processes (DHHS, 2009). 

Recommendations 

In the following chapters of this report, we add detail for each of these 

drivers and also employ diagrams to demonstrate how the priorities facilitate 

achievement of outcomes. The narrative on each priority area in Chapter 3 and 

illustrations of secondary drivers in Chapter 2, point to specific system-level 

elements to review for quality weaknesses. Additionally, within each priority 

area, we can point to a specific recommendation for improvement. They are: 

• Improve the analysis of population health and move toward achieving 

health equity 

• Improve program effectiveness 

• Improve methods to foster integration among all sectors that impact 

health (i.e., public health, health care, and others) 

• Increase transparency and efficiencies to become better stewards of 

resources 

• Improve surveillance and other vigilant processes to identify health 

risks and become proactive in advocacy and advancement of policy 

agendas that focus on risk reduction 
7 

• Implement processes to advance professional competence in the 

public health workforce 

HHS is committed to achieving quality in public health. In particular, 

OASH continues to build the foundations for quality in public health and 

advancing Healthy People 2020. We look forward to collaborations with many 

partners to move toward a vision of true public health quality for the country. 
8 

References 

Bryant, B. (2006). Politics, public police, and population health. In: D. Raphael, 

T. Bryant, & M. Rioux (Eds.). Staying alive: Critical perspectives on health, 

illness, and health care. (pp. 193-216). Toronto: Canadian Scholars. 

Cohen, B.E. (2006). Population health as a framework for public health practice: 

 A Canadian perspective. American Journal of Public Health, 96, 1574-

1576.

Department of Health and Human Services. (2008). Consensus statement on 

quality in the public health system. Washington, DC: Author. 

Department of Health and Human Services. (2009). Healthy People 2020 public 

meetings: 2009 draft objectives. Retrieved July 30, 2010, from 

http://www.healthypeople.gov/hp2020/Objectives/files/Draft2009Objec

tives.pdf. 

Koh, H.K., & Sebelius, K.G. (2010). Promoting prevention through the 

Affordable Care Act. New England Journal of Medicine. doi: 

10.1056/nejmp1008560. 

Koh, H.K. (2010). A 2020 vision of healthy people. New England Journal of 

Medicine, 362, 1653-1656. 

Leischow, S.J., & Milstein, B. (2006). Systems thinking and modeling for public 

 health practice. American Journal of Public Health, 96, 403-405. 

Nolan, T. (2007). Executing for system-level results: Part 2. Retrieved July 30, 

2010, from 

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Imp

rovementStories/ExecutingforSystemLevelResultsPart2.htm

Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), Pub. 

L. No. 111-148 (2010). 

President’s Advisory Commission on Consumer Protection and Quality in the 

 Health Care Industry. (1998). Quality First: Better health care for all 

 Americans. Retrieved July 30, 2010, from 

http://www.hcqualitycommission.gov/final/. 

Weiner, SJ., Schwartz, A., Weaver, F., Goldberg, J., Yudkowsky, R., Sharma, G., 

et al. (2010). Contextual errors and failures in individualizing patient care: 

A multicenter study. Annals of Internal Medicine, 153, 69-75. 

World Health Organization. (1978). Declaration of alma ata. Retrieved July 30, 

2010, from 

http://www.who.int/social_determinants/tools/multimedia/alma_ata/en

/index.html. 
9 
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11

CHAPTER 1 

INTRODUCTION 

The U.S. Department of Health and Human Services (HHS) is the lead 

federal agency for protecting and improving the quality of health for all 

Americans. The public health system plays a critical role in the quality of health 

by ensuring conditions for a healthy population. Yet to date, most attention and 

research on quality has focused on the healthcare setting and not more broadly 

on population health. 

Within the federal government, the Assistant Secretary for Health (ASH) 

serves as senior advisor to the HHS Secretary and works to promote population 

health. To advance this mission, the Office of the Assistant Secretary for Health 

(OASH) led a process to identify dimensions of quality as they apply to broad 

population health. Now, identifying priority areas for public health quality is the 

next step necessary for advancing this field. This report provides an overview of 

that process, introduces the priority areas identified and describes these areas as 

primary drivers of quality improvement. 

 

PROJECT PURPOSE 

The purpose of this project was to continue HHS efforts to build 

foundations for quality in the public health system and identify specific priority 

areas. In Crossing the Quality Chasm: A New Health System for the 21st Century, 

the Institute of Medicine (IOM) Committee recommended the identification of 

priority areas for the improvement of health care quality (Institute of Medicine 

[IOM], 2001). The Committee proclaimed that doing so would systematically 

focus attention on achieving substantial progress on a short list of areas needing 

improvement. Also, the priority areas were viewed as a logical starting point to 

achieve improvements in the six aims (characteristics of patient care) for the 

improvement of patient care—safe, timely, effective, efficient, patient-centered, 

equitable—that were identified by the IOM Committee (IOM, 2001). 

HHS acknowledged the relevance of recommendations made by the IOM 

Committee and the 1998 President’s Advisory Commission on Consumer 

Protection and Quality and used them as a starting point for recommendations 

applicable to broader population health. In an earlier project, OASH developed a 

Consensus Statement on Quality in the Public Health System that included both a 
12

definition of public health quality and nine aims (characteristics) of public health 

quality (Department of Health and Human Services [DHHS], 2008). These aims —

population centered, equitable, proactive, health promoting, risk-reducing, 

vigilant, transparent, effective, and efficient—represent characteristics that 

should be present in the system when fulfilling a public health mission and are 

consistent and aligned with the IOM’s six aims for quality in patient care. The 

Affordable Care Act, which became law in March 2010, provides a platform for 

building a vision for quality in public health 

Vision 

Building better systems to give all people what they need 

to reach their full potential for health.

STUDY PROCESS 

The vehicle within HHS for developing foundations for public health 

quality is the Public Health Quality Forum (PHQF). The PHQF, chaired by the ASH, 

is represented by each HHS agency and staff and operating division director or 

their designee. Accomplishments of the PHQF over the past two years include 

development of the: Consensus Statement on Quality in the Public Health 

System, definition of public health quality, and nine aims for quality 

improvement in public health (DHHS, 2008). To promote uniformity across the 

system, the PHQF defined public health quality as: 

Quality in public health is the degree to which policies, programs, 

services, and research for the population increase desired health 

outcomes and conditions in which the population can be healthy. 

 

The nine aims that represent characteristics of quality in the system are: 

 

Population-Centered, Equitable, Proactive, Health Promoting, 

Risk-reducing, Vigilant, Transparent, Effective, and Efficient 

Identifying specific priority areas for improvement of quality in public 

health represented the next project for the PHQF, with key public health 

stakeholders presenting on issues relevant to their areas of expertise. To this 

end, in May 2010 the PHQF was reconvened and charged by the ASH with: 

Identifying areas of greatest priority where public health should 

improve quality to facilitate achievement of better population health 

outcomes.
13

 

CRITERIA

 

The PHQF selected the set of priority areas based on three criteria—

impact, improvability, and practice variability: 

• Impact—the extent of significant improvements in population health, 

heath equity, quality, and safety that could result from changes in this 

area 

• Improvability—the potential for changes that could lead to desired 

health, process, or given changes in system outcomes 

• Practice Variability—the potential for standardizing areas where 

wide variability in practices exist and where gaps between current 

practices and knowledge, evidence, or best practices can be closed 

without hindering innovation 

Each of the criteria is distinct but connected. When examining for impact, 

the extent that changes can result in improvements is documented. The 

improvability criteria document the possibility for changes in a given area. In 

practice variability, gaps and lack of standardization that potentially influence 

impacts and improvements are examined. 

FRAMEWORK 

The framework used to guide the identification of the priority areas is 

shown in Figure 1. The Three Core Functions for Public Health—Assessment, 

Policy Development, and Assurance—that describe the role of public health, 

combined with an additional category of System, are the foundation of the 

framework. This foundation provided the boundaries for identification of the 

priority areas. Requests to propose areas for consideration that significantly 

limit the ability to achieve positive health outcomes guided this process. 
14

Figure 1. Framework used to identify priority areas 
15

Figure 1 displays the framework used to identify the priority areas. The Three 

Core Functions for Public Health—Assessment, Policy Development, and

Assurance—and an additional category of System are the foundation of the 

framework. This foundation provided the boundaries for identifying potential 

areas to examine. Three criteria—impact, improvability, and practice 

variability—were used to analyze a list of potential areas provided by the 

PHQF. 

• Foundation

• Assessment: Regularly and systematically collect, assemble, 

analyze, and make available information on the health of the 

community. 

• Policy Development: Promote the use of the scientific 

knowledge base in decision-making about public health and by 

leading in developing public health policy. 

• Assurance: Assure the provision of services necessary to 

achieve agreed upon goals.

• System: Ensure a systems integration approach to analysis and 

programming with emphasis on building synergistic linkages 

with health care and contributors to the multiple determinants 

of health.

• Criteria

• Impact: The extent of improvements in population health, 

heath equity, quality, and safety that could result given 

changes in this area.

• Improvability: The potential for changes that could lead to 

desired health, process, or system outcomes. 

• Practice Variability: The potential of standardizing areas where 

wide variability in practices exist and where gaps between 

current practices and knowledge, evidence, or best practices 

can be closed without hindering innovation.

• Priority Areas for Improvement of Quality in Public Health

• The final set of priority areas identified through this process are 

presented in Chapter 2.
16
17
18
19

CHAPTER 2 

PRIORITY AREAS FOR IMPROVEMENT OF QUALITY IN 

PUBLIC HEALTH 

The consensus building process of the PHQF led to the identification of 

the six priority areas listed below. The PHQF intentionally did not rank the 

priorities and, as such, they are not presented in any prioritized order. 

• Population Health Metrics and Information Technology 

• Evidence-Based Practices, Research, and Evaluation 

• Systems Thinking 

• Sustainability and Stewardship 

• Policy 

• Public Health Workforce and Education 

A detailed description and analysis of each area is presented Chapter 3. The 

narrative in this chapter describes how the priority areas facilitate achievement 

of outcomes, a key element in the charge to the PHQF. 

PRIORITY AREAS AS PRIMARY DRIVERS OF QUALITY 

The concept of primary drivers, taken from an Institute of Healthcare 

Improvement model for Breakthrough Goals and Drivers (Nolan, 2007), is used 

to demonstrate how improvements in the priority areas can be used to advance 

quality and achieve outcomes. In this illustration of the model, the priorities 

represent essential system-level cross-cutting areas, described as primary 

drivers that function as pathways for achieving desired outcomes (Institute for 

Healthcare Improvement, n.d.). As primary drivers, the priority areas can 

individually and collectively contribute to fulfilling system-wide outcomes as 

illustrated in Figure 2. The figure notes primary drivers, as well as sets of 

secondary drivers that flow in a cascading manner to achieve an outcome. The 

secondary drivers in this illustration represent system-level cross-cutting 

functions that:

• support critical elements of the primary drivers 

• Increase the likelihood of achieving improved outcomes 

• strengthen the public health infrastructure 
20

 Additionally, the secondary drivers can contribute to strengthening the 

quality and function of several other primary drivers identified as priorities. 

For example, as illustrated in Figure 2, establishing actionable real-time data 

capacities is a secondary driver that directly contributes to strengthening the 

Population Health Metrics and Information Technology primary driver, but 

also could support identification of evidence-based practices, advancement of 

systems thinking, and strengthening the analytical capacities of the workforce. 

The secondary drivers are strengthened when aligned with appropriate aims 

(characteristics) of public health quality. At a minimum, actionable real-time 

data could promote practice characteristics that are proactive, vigilant, and 

risk reducing through activities such as early alerts to the population as well as 

individual patients. 

 Both primary and secondary drivers are essential for strategic 

improvements in the system (Nolan, 2007). Secondary drivers presented in 

Figure 2 also highlight areas in each priority to review for quality weaknesses. 

The illustrations in Appendix A provide specific examples of secondary drivers 

unique to outcomes and quality improvements in healthcare-associated 

infections (HAI), human immunodeficiency virus (HIV), and healthy weight. 

Elements and processes within all drivers should be continuously examined 

and improved for quality to ensure achievement of outcomes. 

Coordination Opportunities 

The six priorities represent opportunities to coordinate national efforts 

for improving public health outcomes, particularly in areas with high potential 

for improvement and where variability of practices and lack of evidence can be 

reduced. They also represent interacting system-level areas needing 

improvement in order to generate the path for achieving desired outcomes. 

The relationship between the six priority areas underscores the value for 

coordinating elements in a complex adaptive system. Complexity in a system is 

created “when dependency among elements in the system becomes important” 

(Miller & Page, 2007, p. 9). In fact, research by organizational theorists 

conceptualizes complex systems as interdependent tasks performed by teams or 

units within the complex system (March & Simon, 1958). A relationship between 

the priority areas exists and this connectedness leads to benefits. For example, 

quality improvements in public health workforce and education impact all other 

areas. Tasks (processes) within the six priority areas are interdependent as well 

(March & Simon, 1958; Simon, 1962). An example of interdependency is 

provided to illustrate this point. Mandates for community health assessments by 

hospitals in collaboration with public health can be best accomplished with the 

aid of actionable real-time data coupled with appropriate analytical capacities. 
21

When such metrics to measure population health are present, the process of 

community health assessment is significantly strengthened. National strategies 

for health quality can build on this interdependence of public health quality 

throughout the health care system. 

Improvement Opportunities 

A list of improvement opportunities is provided in the Executive 

Summary and as secondary drivers in Figure 2. However, the list is neither 

comprehensive nor exhaustive. Organizations should design activities to evaluate 

processes in each of the six cross-cutting areas to determine where to focus 

quality improvement efforts tailored to their specific needs. 
22

 
23

Figure 2. Public health primary and secondary drivers of quality 
24

Figure 2 displays the influence and relationship of the public health primary and secondary drivers of quality to achieve 

desired outcomes. The secondary drivers support critical elements of the primary drivers and, in this illustration, both 

drivers represent system-level cross-cutting functions and activities. Strengthening of the primary drivers increases the 

likelihood of achieving desired health outcomes. The bulleted structure explains how the drivers flow in a cascading 

manner. 

• National Goals for Population Health Improvements (defined as an outcome)

• Population Health Metrics and Information Technology (primary driver). The secondary drivers are: 

• Enhance vigilance by establishing actionable/real time data accessible to providers and public 

health necessary for designing healthcare for populations and population-based public health 

programs

• Build systems (local, state, regional) to merge public health, EHR , and other provider, 

community, and environmental data to improve provider and public health practices 

• Align public health and hospital community health assessments and analysis 

• Implement electronic reporting and conform to reporting standards for population subgroups to 

advance health equity

• Implement/interact on state-of-science IT (i.e., data warehouses, data mining, visualization 

software) to improve public health and healthcare 

• Evidence-Based Practices, Research, and Evaluation (primary driver). The secondary drivers are:

• Translate evidence into community/population-based programs 

• Regularly document and monitor results of system changes

• Establish evidence-based support systems 

• Build transparency through standards and measurement reporting in a national quality system 

• Conduct cross-national comparative research to inform system design

• Systems Thinking (primary driver). The secondary drivers are: 

• Integrate interventions for health care, public health, and others that impact health (i.e., 

avoidable hospitalization reduction, HAI reduction, healthy weight, safety) 

• Implement proactive practices for Health Impact Assessments of policies to reduce risk of 

negative impacts 

• Integrate organizational (i.e., laboratory, epidemiology, policy development) and healthcare 

surveillance activities to enhance capacities for alerts and other risk reducing interventions

• Develop population-based programs (i.e., health education/promotion) based on vigilant 

practices of monitoring healthcare data

• Sustainability and Stewardship (primary driver). The secondary drivers are: 

• Develop standards of public health practice and related systems for monitoring

• Mobilize private/public partnerships and advocacy 

• Sustain interventions/improvements through mandates (i.e., inspections, reporting )

• Redesign funding/payment structures (i.e., align with need/goals, allow flexible funding, build 

dedicated tax base when appropriate)

• Conduct routine quantitative financial analysis to improve transparency and measure 

agency/system sustainability

• Analyze proactively and routinely to monitor economic development impacts on public health 

funding and health

• Policy (primary driver). The secondary drivers are: 

• Develop/advocate for proactive policies targeting health improvements

• Incorporate Health in all Policies as routine practices to proactively assess health impacts 

• Develop policies that mandate the reporting of specific conditions, events, etc.

• Workforce and Education (primary driver).The secondary drivers are: 

• Create professional/learning culture

• Build workforce analytical capacity (i.e., data analysis, data interpretation, reaction aptitude)

• Establish condition specific education/training

• Conduct workforce and market analysis of public health and healthcare industry trends 

• Expand educational and outreach programs at high schools and community colleges
25
26
27

CHAPTER 3 

DESCRIPTION OF PRIORITY AREAS 

The narrative that follows provides a detailed description of the six 

priority areas for improving quality in public health. Discussion on each of the six 

areas is framed by the three selection criteria – impact, improvability, and 

practice variability – used by the PHQF. 
28
29

Population Health Metrics and Information Technology 

Description 

Improve methods and analytical capacity to collect, evaluate, and 

disseminate data that can be translated into actionable information and 

outcomes in population health at the local, state, and national level. Make the 

improvement of data collection for population subgroups a core value of public 

health. The informed use of health care quality data can serve as a catalyst to 

build population-based public health programs as a strategy to improve 

population health, eliminate health inequities, and bridge gaps between health 

care and public health. 

Rationale for Selection 

Impact 

In the 1988 report, The Future of Public Health, the Institute of Medicine 

recommended the regular and systematic collection and analysis of health data 

by every public health agency. It also recommended that this information be 

made available to the communities they serve (IOM, 1988). The availability of 

data by subpopulations such as racial and ethnic groups, persons with 

disabilities, elderly, gender, geographic region, and socioeconomic status is 

critical for conducting comprehensive analysis of community health conditions. 

When data are not available to communities, neither leaders representing public 

health and their governance structures, local governments, community 

organizations, health care providers, nor the public have information to guide 

resource allocations or to set and prioritize goals or outcomes. 

Responding to the need for information, HHS is planning the launch of a 

Health Indicators Warehouse website that will serve as the data hub of the 

Community Health Data Initiative (CHDI) (DHHS, n.d.). The purpose of CHDI is to 

enhance understanding of health and health care system performance in 

communities, and spark and facilitate action to improve performance and 

value. Additionally, in this era of healthcare reform, access to appropriate data 

for cross-national comparative research adds to a global dialogue on health 
30

policy and health system performance (Bauer & Ameringer, 2010; Murray & 

Frenk, 2010; Thorpe, Howard, & Galactionova, 2007). 

The capacity to collect and analyze data is critical for implementing public 

health interventions and designing health care for populations. Health care 

providers are mandated to report data on certain diseases and conditions and 

the data are used to populate components of public health information systems. 

However, complexities caused by some outdated public health reporting 

requirements often leads to provider frustration, duplication, and potential 

underreporting of conditions and diseases (Public Health Data Standards 

Consortium [PHDSC], 2007). Such complexities in data reporting formats and 

lack of system interoperability can inhibit the ability of public health agencies to 

provide real-time information back to providers useful for disease prevention 

and care coordination (PHDSC, 2007). 

However, data alone are of limited utility absent the capacity to analyze, 

interpret, and react. A traditional function of public health is the transformation 

of data into information to assess, monitor and improve the health of the 

population. Analyzing data allow measurement of change over time and serve as 

the foundation for epidemiology, surveillance, planning, and evaluation. Failure 

to exploit the growing volume of data, to have the right data, and to paint a 

complete picture of population health can often be attributed directly to the lack 

of data, trained personnel, and tools to evaluate, analyze, and interpret the data. 

Setting quality standards to measure fulfillment of the health assessment 

component of a public health mission absent any process improvements in data 

and analytical capacity does not serve to improve population health. 

Racial and ethnic disparities in health remain prevalent in the United 

States, with gaps widening in many categories. Health and medical care 

disparities and inequalities are also found in rural area populations, individuals 

with disabilities, and certain socioeconomic groups (Agency for Healthcare 

Research and Quality [AHRQ], 2004; Havercamp, Scandlin, & Roth, 2004; Pappas, 

Hadden, Kozak, & Fisher, 1997). Eliminating health disparities remains one of the 

overarching goals of Healthy People 2010 and now Healthy People 2020 (Koh, 

2010). Yet, as Berwick, Nolan, and Whittington (2008) state, “the gain in health 

in one subpopulation ought not to be achieved at the expense of another 

subpopulation” (p.760). This issue was underscored in the 1985 Report of the 

Secretary's Task Force on Black and Minority Health, which outlined the 

magnitude of health disparities between majority and minority populations and 

proposed that one step toward better addressing these problems would be 

improving the quality and availability of data to better measure and understand 

these disparities (DHHS, 1985). Yet data collection methods and reporting at the 

state and local levels do not always adhere to federal guidelines (Office of 

Management and Budget) (Bilheimer & Sisk, 2008). As a result, transparency, 
31

one aim for improvement of quality in public health (DHHS, 2008), is absent 

since data for certain segments of the population are missing. This lack of 

transparency impacts other aims such as the ability to be proactive, vigilant, or 

risk reducing. It also inhibits the ability to fully communicate to decision makers, 

governance structures, or even the community, the information needed to 

establish goals and outcomes. 

The 2006 National Health Disparities Report noted information gaps 

caused estimation problems related to access and quality measures for select 

racial and ethnic populations (AHRQ, 2006). In another study examining the 

capacity of states to track health disparities across population sub groups using 

the Healthy People 2010 Leading Health Indicators, data were not available 

across specific age groups (Dodd, Neuman, & Gold, 2007). Moreover, even as 

data distribution systems have proliferated, analytic methodologies have 

stagnated. Most population health assessments resemble static report card style 

lists--county-level, pre-aggregations of a parsimonious set of indicators--ignoring 

wide variations often hidden within population sub groups. 

Local data can serve as a powerful instrument for improving quality and 

population health in the community. Data can be a driver and foundation for 

public health policy and health services delivery while providing a baseline for 

evaluation and quality improvement efforts. In fact, using local information to 

illustrate community health needs is an effective strategy for building advocacy 

in the community and advances opportunities to garner political support to fund 

interventions that address those needs (Dodd et al., 2007; Luck, Chang, Brown, & 

Lumpkin, 2006). For example, in the 1998 report Quality First: Better Health Care 

for All Americans, the President’s Commission on Consumer Protection and 

Quality in the Health Care Industry recommended the use of health care quality 

data to build public health programs that address needs identified through 

analysis of the health care quality measures (President’s Advisory Commission on 

Consumer Protection and Quality in the Health Care Industry, 1988). 

Improvability 

A history of frameworks, report cards and internet websites has evolved 

over the past two decades to support the assessment of community health 

status. While these tools play an important role in providing access to useful 

information, there is little compelling evidence that these endeavors have 

resulted in demonstrable improvement (Friedman & Parrish, 2009). Now, the 

escalating attention on the Patient Protection and Affordable Care Act 

(Affordable Care Act) to population health, data quality, and information 

technology provides a favorable climate for improved methods to evaluate 
32

population health across the nation (Patient Protection and Affordable Care Act 

[Affordable Care Act], 2010). 

The ability to improve the health of populations requires a powerful 

analytical capability and vast amount of data; modern online analytic processing 

software for modeling; a cadre of specially trained analysts with expertise in the 

public health measurement sciences and information technology; and a 

community of users to stimulate development of the system (Studnicki, Fisher, & 

Eichelberger, 2008). Incentives for strengthening health information exchange 

and technology through initiatives such as the Beacon Community Program 

made possible through the American Recovery and Reinvestment Act, illustrate 

the growing recognition of the value to be gained from such capacities 

(American Recovery and Reinvestment Act, 2009). 

A sophisticated infrastructure composed of state-of-the-science 

information technology (data warehouses, data mining, and visualization 

software) also helps to reach the vision of better systems. For example, the 

hospital/public health collaboration associated with the community health needs 

assessment requirements of the Affordable Care Act moves us closer to a true 

systems environment. Inclusion of population health measures (collected and 

reported by governmental public health agencies) that comply with meaningful 

use requirements for Electronic Health Records (EHR) is another. Section 4302 of 

the Affordable Care Act that sets forth standards for uniform categories and data 

collection requirements also offers tremendous opportunities to improve data 

collection, analysis, and quality especially as it relates to vulnerable populations 

and identifying and eliminating disparities (Affordable Care Act, 2010). Aligning 

technology and data standards could add value to the evolving system for public 

health agency accreditation. 

Critical to population health improvements in communities, especially for 

eliminating disparities and inequities, are systems that unify the structures, 

processes, and impact of the multiple levels that influence health. Reciprocal 

interactions needed for achieving improvements are capacity to monitor 

multiple indicators of health status, flexible analytical capability for problem 

alerts and priority setting, ability to inform action alternatives, and methods for 

evaluation of program impacts. 

Management of systems knowledge also must include having the 

appropriate level of internal controls, such as confidentiality practices regarding 

electronic health information. A survey of state health agencies revealed that 

over a 2-year period, 25% of all public health agencies had at least one security 

breach (Myers, Frieden, Bherwani, & Henning, 2008). Principles for public health 

ethical practices include statements on protecting confidentiality and also for 

respecting the rights of the community (Cobus, 2008). From a quality 
33

improvement perspective, redesigning processes to ensure confidentially would 

be strategically aligned with these ethical guidelines and language in section 

3101 of the Affordable Care Act to develop data management security system 

(Affordable Care Act, 2010). 

Practice Variability 

Reports document the wide variability in data collection, data reporting, 

and analytical capacity across states (Gold, Dodd, & Neuman, 2008). At the time 

of this writing in 2010, three states still did not collect hospital discharge data (D. 

Love, personal communication, August 19, 2010), and among the remaining 47, 

there are many differences in data elements and definitions and collection 

requirements (Love, Rudolph, & Shah, 2008; Schoenman, Sutton, Kintala, Love, & 

Maw, 2005). Hospital discharge data are essential to analyses related to public 

safety and injury surveillance, disease registries and surveillance, health 

planning, measuring hospital quality and performance, conducting research, and 

informing policy debates. 

Data needed to measure population health and especially vulnerable 

populations, such as the elderly and disabled, are often not available. The lack of 

an adopted set of standards for public health data and uniform data elements 

results in a system that lacks interoperability and transparency. This limits the 

exchange of data between information systems and public health entities and 

makes it difficult to measure and contrast performance and effectiveness. 

The practice of public health is information and data driven yet because 

information exchange varies greatly throughout the system, there is no 

assurance that data are collected, shared, or applied to its fullest capability. And, 

there are currently no consistently agreed upon methods for measuring the 

health of populations from a quality improvement perspective. Rather, a variety 

of tools and indicators make up several national models for health status 

assessment. 
34
35

Evidence-Based Practices, Research, and Evaluation 

Description 

Bridge research and practice and institutionalize evidence-based 

approaches to achieve results-based accountability. Support effective and safe 

practices that can be used by practitioners. 

Rationale for Selection 

Impact 

Evidence-based public health is defined as “the process of integrating 

science-based interventions with community preferences to improve the health 

of populations” (Kohatsu, Robinson, & Torner, 2004). As in industry, doing the 

“right things right” is critical to assuring quality in public health practice and in 

programs designed to ensure conditions for a healthy population (Dever, 1997). 

Building public health interventions based on the best scientific evidence from 

research and proven best practices, as determined by rigorous program 

evaluation, maximizes the probability of achieving desired results. 

The success of some of the most notable public health interventions—

such as childhood vaccinations, fluoridation of water systems, and risk factor 

control to prevent stroke and heart disease—is attributable to research and 

evidence-based public health practices translated into community-based 

programs (Fielding & Briss 2006). One of the best examples of the successful 

integration of research, policy, and practice is tobacco control. Knowledge from 

research, in part, drove programs and policies that have significantly reduced 

population prevalence of smoking. Increasing the excise tax on tobacco, for 

example, is an evidence-based practice that led to dramatic reductions in 

smoking rates in California and Massachusetts (Fichtenberg & Glantz, 2000; Koh, 

Judge, Robbins, Celebuck, Walker, & Connolly, 2005; Pierce et al., 1998). Social 

marketing, perhaps an underutilized population-based strategy in public health 

to improve population health, also had an impact on reducing smoking rates 

(Greenwood, 2009). 

Documentation of program results, centrally important to performance 

measurement and quality management systems, provides the evidence of what 

works and by how much to continuously improve quality. Furthermore, 
36

evaluation of public health policies and interventions can provide vital 

information on costs, benefits and utility of specific approaches for decision 

makers. Such analyses are critical because difficult choices are always made in 

the context of limited public health resources. For example, physical inactivity, a 

significant factor in the national epidemic of obesity, is estimated to result in up 

to $77 billion a year in excess health care costs (Pratt, Macera, & Wang, 2000). 

Documenting successful interventions such as school-based physical education 

programs that show an 8% increase in aerobic fitness when school curricula are 

modified can assist in deciding where to put limited resources (Task Force on 

Community Preventive Services, 2005a). 

Improvability 

Changes in the use of evidence-based practices, research, and evaluation 

have significant potential to facilitate improved outcomes across the system. 

Research has been shown to improve quality in at least two areas: 1) the utility 

and translation of research for practice, and 2) evidence-based support systems 

to enhance the quality of widespread implementation of evidence-based 

practices. 

However, translation of science into practice remains slow (Kerner, 

Rimer, & Emmons, 2005). The potential for change in translation practices could 

be improved by increasing practice-based research as a strategy to improve the 

relevance and quality of research needed by practitioners and 

consumers/citizens. Community-based participatory research that involves an 

academic-community partnership has proven to be a successful research model 

for improving health outcomes (Viswanathan et al., 2004). For example, 

Horowitz, Williams, and Bickell (2003) used a community-based approach to 

identify areas of concern in diabetes care and assess the needs of adults with 

diabetes residing and obtaining care in East Harlem. A community-based 

participatory research project, BRIDGE, was also used to successfully reduce 

marijuana and other drug use and HIV/AIDS among African American 

adolescents in an urban setting (Marcus et al., 2004). As a community-based 

initiative, BRIDGE was sustained as a part of a church ministry that was extended 

to other churches in a large metropolitan community. Novel approaches such as 

this that build competencies in community-based organizations are noted as 

important to advancing innovation in research design and benefits to 

communities (Koh, Oppenheimer, Massin-Short, Emmons, Geller, & Viswanath, 

2010). 

Effectiveness is an aim for improvement of quality in public health. 

Opportunities to improve effectiveness abound since many areas of public 

health have not fully utilized or disseminated a large amount of scientific 
37

evidence (e.g., obesity prevention, HIV infection prevention, teen pregnancy 

prevention) (IOM, 2010a; Kelly et al., 2000; Lesesne, Lewis, White, Green, Duffy, 

& Wandersman, 2008). Also, authority in the Affordable Care Act and the 

Pandemic and All Hazard Preparedness Act for the advancement of public health 

systems and services research—a field focused on examining the organization, 

financing, and delivery of public health services—will add to the base of 

knowledge on effective strategies regarding prevention, preparedness and 

response, and other public health interventions (Affordable Care Act, 2010; 

Pandemic and All-Hazards Preparedness Act, 2006). The definition of public 

health quality includes research as a component of system elements that 

contributes to achieving desired health outcomes (DHHS, 2008). Ensuring the 

quality of public health research is noted as important by the Task Force on 

Community Preventive Services (2005b) and focusing on evidence that can be 

used to make improvements and achieve outcomes will create greater 

probabilities for implementation (Kelly et al., 2000). 

To promote widespread use of evidence based programs, accessible 

syntheses and translations of the literature can guide practitioners, 

policymakers, and communities through the essential steps needed to plan, 

implement, evaluate and sustain evidence-based practices, programs, or policies. 

For example, Getting to Outcomes (GTO) is a 10-step, results-based 

accountability approach that guides practitioners through the key steps of 

assessment, policy development, assurance, and system collaboration to achieve 

outcomes (Wandersman, Imm, Chinman, & Kaftarian, 2000). Another example is 

Using What Works. This train-the-trainer course teaches users how to adapt a 

research-tested intervention program to the local community context (National 

Cancer Institute, n.d.). Chinman and colleagues (2008) found that use of GTO in 

community settings increased prevention capacity, program performance, and 

documented outcomes. Enhancement of The Guide to Community Preventive 

Services, under mandates in the Affordable Care Act, is expected to augment 

evidence-based practices and knowledge needed for systems such as GTO. 

Accelerating the dissemination and implementation of evidence-based 

practices requires developing the field of evidence-based support systems that 

include tools, training, and technical assistance (Wandersman, 2009; 

Wandersman, Chien, & Katz, 2010). An example of evidence-based support is 

provided by Kelly et al. (2000), who randomized communities into one of three 

arms of support for evidence-based HIV prevention programming: 1) provision of 

an intervention manual alone, 2) provision of an intervention manual in tandem 

with a training workshop, and 3) provision of an intervention manual, training, 

and proactive TA. Communities within the third arm of support demonstrated 

the highest level of quality in the delivery of evidence-based HIV prevention. 
38

In a complex adaptive system such as public health, innovation requires 

variation from standard practice (Plsek & Wilson, 2001) However, it can lead to 

inconsistent outcomes (Pawson, 2002). Hence, evaluation should include 

questions of “what works for whom *and+ in what circumstances” (Pawson, 

2002, p. 213). Encouraging innovation and conforming to the quality aim for 

equity when designing programs and services requires being cautious about 

implementing initiatives proven to be effective in one population group but not 

examined for effectiveness or accepted as culturally appropriate by other 

groups. 

Practice Variability 

Significant variability exists in the capacity to integrate science-based 

interventions and the communities they serve. Further, experts have varying 

perspectives on why evidence-based public health is not more widespread, and 

even how much it is already in practice. Some authors attest that evidencebased practices have a long standing tradition in public health (Fielding & Briss, 

2006), but others proclaim it to be a relatively new concept in the practice of 

public health (Anderson et al., 2005). A contributor to practice variability 

regarding the application of evidence-based practices in public health could be 

the availability and access to credible information on the scientific basis and best 

practices for specific programs and interventions. The Guide to Community 

Preventive Services (Community Guide), established in 2001 and produced under 

the auspices of the Task Force on Community Preventive Services, is a database 

of recommendations for public health programs based on evidence of practices 

that have worked to improve health (Briss, Brownson, Fielding, & Zaza, 2004). As 

highlighted earlier, the Affordable Care Act includes mandates to continue this 

work, with emphasis on developing new topic areas for review and updating 

existing topics, integrating recommendations with federal objectives (Affordable 

Care Act, 2010). 

Effective use of evidence based practices varies widely according to level 

of organizational capacity (e.g., leadership, organizational climate) and 

innovation capacity (ability to implement an evidence-based practice) at the 

state, local, organizational, and individual levels (Flaspohler, Duffy, Wandersman, 

Stillman, & Maras, 2008). Varying levels of capacity across delivery systems can 

have implications for practice, quality, performance, and outcomes. Establishing 

a role for an appropriately skilled professional to lead research, translate 

evidence into practice, and provide coaching (as found to be effective by Fixsen, 

Naoom, Blasé, Friedman, & Wallace, 2005), could be an effective means for 

standardizing and institutionalizing the research into agencies with a public 

health mission. 
39

Gaps between research and practice, but also in sharing successful 

practices represent major barriers to widespread implementation of evidence 

based practices. To bridge these gaps, the Interactive Systems Framework for 

Dissemination and Implementation, developed by the Centers for Disease 

Control and Prevention (CDC) with the collaboration of funders, researchers, and 

practitioners, integrates research to practice models with communitycentered/practice-centered models (Wandersman et al., 2008). The Framework

indicates that support to practitioners (e.g., training and technical assistance) is 

essential to utilization of knowledge. A meta analysis by Joyce and Showers 

(2002) showed theory and discussion plus training was associated with 0% use in 

the field by practitioners, while direct coaching in the field led to 95% use. 
40
41

Systems Thinking

Description 

Advance systems thinking in public health. Foster systems integration 

strategies by analyzing problems using systems science methodologies (i.e., 

network analysis) while taking into account the complex adaptive nature of the 

public health system. Complex adaptive systems are described as those based on 

relationships of diverse and interconnected agents that have the capacity to 

learn, change, and evolve (i.e., hospitals, emergency medical service systems, 

educational systems, emergency preparedness and response systems). 

Rationale for Selection 

Impact 

The Three Core Functions of Public Health and Ten Essential Public Health 

Services describe the scope of responsibilities for the public health system. The 

public health system in the United States encompasses governmental and nongovernmental entities (IOM, 1988). While these documents are useful for 

articulating the capacities needed for a public health system, no single agent 

within the system (e.g., public health agencies, federal agencies, mental health 

institutions, health care organizations, non-profit organizations, and academia) 

can independently meet these responsibilities for a given population. These 

functions and services are what the system does collectively to ensure conditions 

for a population to be healthy. 

The founding principle of public health is based on the premise that 

causes of health, disease, and illness extend beyond the boundaries of individual 

human biology and behavior (Leischow & Milstein, 2006). This principle supports 

the concept of systems thinking in that gaining knowledge of the interactions 

and linkages of individual agents in the system is critical to understanding the 

entire system. Healthy People underscores that the “health of the individual is 

almost inseparable from the health of the larger community” (Koh, 2010) and 

recognizes the social determinants of health, i.e., the social, political, and 

economic forces that impact population health. The connections and associated 

behavior of the multiple agents in the system produce current levels of 

population health, with influences from multiple domains outside what we 

usually consider the health professions (Frieden, 2010). An understanding of 
42

these multiple interconnected societal components (e.g., economic 

development, education, income, and transportation) can provide important 

insights into opportunities to improve population health as well as barriers that 

may negatively impact health. As summarized by the Tobacco Control Research 

Branch of the National Cancer Institute, “systems thinking in public health 

cannot be encompassed by a single discipline” (Trochim, Cabera, Milstein, 

Gallagher, & Leischow, 2006). 

A core concept of systems thinking and complex adaptive systems is that 

relationships between system components impact the system and so finding 

solutions to public health problems requires a better understanding of such 

interactions (Leischow et al., 2008). The absence of needed preparations at 

multiple levels, despite warnings of imminent dangers in advance of Hurricane 

Katrina, arguably represents a dramatic example of problems emerging from a 

lack of a systems approach to public health issues. This example also provides 

insights into the interconnectedness of the public health system to other 

systems such as social networks and even the military. 

A variety of working models support systems thinking philosophies that 

promote integrating public health with other components in the system. Local 

efforts to form partnerships between public health and the business community 

have been successful at improving preparedness (Buehler, Whitney, & 

Berkelman, 2006). Linkages between public health and health care entities (as 

previously described in the Plsek example) that included efforts such as 

partnerships, surveillance, outreach and messaging helped to reduce the 

incidence of health care-associated infections. For example, following 

implementation of these activities in the first six months of 2009, the incidence 

of central line-associated bloodstream infections declined 18% nationally 

compared to the previous three years (Centers for Disease Control and 

Prevention [CDC], 2010a; DHHS, 2009). A systems approach to build surge 

capacity was similarly successful when collaboration was fostered for outreach 

and training, needs assessments, and curriculum development between 

community health centers, academia, and government agencies (Koh et al., 

2006). Most notably, Rust, Satcher, Fryer, Levine, and Blumenthal (2010) 

concluded that innovations in epidemiology and clinical research combined with 

public health and medical care practices resulted in a 50% reduction in mortality 

for seven of the nine leading causes of death categories for the period 1950–

2000.

The most obvious system relationships that requires strengthening is 

between public health and health care organizations. This message resonated 

prominently both in The Future of the Public’s Health in the 21st Century, which 

described the collaboration between governmental public health agencies and 

the health sector as weak (IOM, 2003b), and also in Crossing the Quality Chasm: 
43

A New Health System for the 21st Century (IOM, 2001), which recognized the 

essential role of the public health system but focused primarily on the health 

care delivery system. 

Improvability 

 Promoting linkages through systems thinking and considering public 

health and health care as components of a complex adaptive system can lead to 

enhanced understanding and integrated knowledge through activities such as 

health awareness campaigns to benefit the population. As an example, Plsek and 

Wilson (2001) note how setting a quality standard for the administration of a 

drug within 30 minutes of arrival at a hospital may not have the full potential for 

saving lives if the standard should be drug administration within one hour of the 

onset of patient symptoms. Other activities in the system, such as symptom 

awareness campaigns by public health agencies and emergency medical service 

(EMS) response times, could affect a patient’s outcome. If a patient waits one 

hour following symptoms to seek help or if EMS systems are not functioning 

optimally, the likelihood of negative patient outcomes is increased. 

The CDC’s newly implemented Program Collaboration and Service 

Integration Initiative attempts to demonstrate an integrated approach to 

addressing HIV/AIDS, viral hepatitis, STDs, and TB (CDC, 2009a). Another CDC 

program based on a systems thinking approach is REACH US. This multilevel 

program works to eliminate racial and ethnic health disparities through 

environmental change and policies (CDC, 2010b). Positive outcomes for 

intervention communities compared to controls include a 5% increase in pap 

smears, a 12% and 4% increase in cholesterol screenings for Hispanics and for 

African Americans, respectively, and a 22% decrease in cigarette smoking among 

Asian American men (CDC, 2010b). The Kellogg Foundation’s Food and 

Community Program to advance a national movement for healthy living is using 

system-level initiatives to improve healthy eating behavior at home and in 

schools, and increase access to physical activity environments through linkages 

between public health agencies, schools and academia, foundations, 

policymakers, agriculture, and members of the community (W.K. Kellogg 

Foundation, n.d.). Another example of system linkages is between system agents 

at the state and local levels. The State Incentive Grants Program funded by the 

Center for Substance Abuse Prevention (CSAP) of SAMHSA links state and local 

communities to provide effective substance abuse prevention. CSAP has 37 

states with 600 local sub-recipients, with approximately 80% implementing 

science-based substance abuse prevention programs (Substance Abuse and 

Mental Health Services Administration, n.d.). 
44

 Public health agencies are the only organizations with a legal mandate to 

deliver population-based health services which can lead to large scale system 

improvements (e.g., access to care, data interoperability, and food safety) that 

can improve population health. There is a growing movement to employ such 

strategies. Recent examples include strategies for hypertension (IOM, 2010b) 

and obesity prevention (Kumanyika et al., 2008). The Affordable Care Act also 

includes opportunities to reinforce systems thinking philosophies. As an 

example, the National Prevention, Health Promotion, and Public Health Council 

is composed of members representing diverse interests across government such 

as agriculture, transportation, labor, and education. Among others, there are 

opportunities for systems thinking in the areas of community health assessments 

and electronic health records (Affordable Care Act, 2010). 

 The concept of Health Impact Assessment (HIA) should be considered as 

a method for institutionalizing systems thinking in public health. HIA is defined 

as a process to assess the potential health impact to the population of a 

program, project or policy (CDC, n.d.). The concept for HIA is similar to 

Environmental Impact Assessment (EIA) that is mandated through the National 

Environmental Policy Act (NEPA). The NEPA mandates that federal agencies 

assess the potential social, economic, cultural and natural resource impacts that 

may result from a proposed program or policy (National Environment Policy Act, 

1970). The law specifically mandates that HHS conduct an assessment of public 

health impacts that may result from these proposed activities. HIA assessments 

of programs and policies at the federal, state, and local levels ensures that public 

health has a voice in proposed activities of disciplines that impact health (e.g., 

agriculture, transportation, education, economic development) and can 

proactively reduce any potential risks or advance health promoting benefits. The 

concept of Health in All Policies is similar in concept to HIA and is discussed in the 

Policy section of this report. 

System science methodologies are analytical strategies based on 

concepts for systems thinking i.e., network analysis, microsimulation, system 

dynamics modeling. The National Institutes for Health (NIH) are increasingly 

investing in systems science methodologies to address complex public health 

problems. For example, in 2007, NIH began to include system science as part of 

its research portfolio by requiring utilization of these methods as an award 

requirement (e.g., NIH Program Announcement (PA) Number: PAR-08-224). 
45

Practice Variability 

Too many agents in the public health system continue to work as 

independent entities in disconnected silos, often contributing to variations in 

public health practice. For example, during the Hurricane Katrina disaster, longterm care providers such as nursing homes were not incorporated into existing 

emergency response systems, and as a result, many nursing homes did not 

evacuate in a timely manner to prevent the deaths of their elderly patients 

(Hyer, Brown, Berman, & Polivka-West, 2006). 

Having a workforce that is knowledgeable about and able to employ 

systems thinking can help close the gaps in practice variability and improve 

linkages in the public health system. The Association of Schools of Public Health 

has identified systems thinking as a core competency for public health education 

(Association of Schools of Public Health [ASPH], n.d.). This strategy works to 

close knowledge gaps regarding systems thinking. Also, embedding these 

competencies in public health education promotes institutionalization of the 

concept into public health practice. 
46
47

Sustainability and Stewardship 

Description 

Strengthen system sustainability and stewardship through valid measures 

and reporting of performance and quality. Ensure efficient funding 

methodologies that align resources with goals, demonstrated need, 

responsibilities, measurable results, and ethical practices. 

Rationale for Selection 

Impact 

Sustainability is defined by Claquin (1989) as the capacity to maintain 

service coverage at a level that will provide continuing control of a health 

problem. Sustaining a public health system has led to a 25-year increase in life 

expectancy in the United States over the last century, much of which can be 

attributed to advances in public health (CDC, 1999). Garrett (2000) also made a 

compelling case in Betrayal of Trust: Collapse of Global Public Health by 

dramatically drawing attention to increases around the world in premature 

death, infant mortality, and chronic and infectious diseases when public health 

systems were no longer sustainable. Another timely example in the United 

States is the reemergence in the 1980s and 1990s of tuberculosis as a public 

health threat, which some attribute to funding cutbacks and premature 

termination of relevant programs (General Accounting Office, 2000; Institute of 

Medicine, 2000). 

Dramatic declines in the sustainability of programs in all sectors of public 

health highlight a serious risk to the system. Recently, thirty-one states have 

made cuts to public health (Center for Budget and Policy Priorities, 2010). 

Responding to distressed economic conditions in 2009, 25% (approximately 700) 

of local public health departments (LHD) made cuts to programs and services 

(National Association of County and City Health Officials [NACCHO], 2010). 

Population-based primary prevention programs targeted most frequently for 

cuts were those to improve childhood nutrition, increase physical exercise, 

support tobacco cessation, and reduce chronic disease (NACCHO, 2010). A 

survey of state health departments (SHD) documented cuts or elimination of 
48

programs for immunizations, emergency medical services, tobacco cessation and 

prevention of HIV, asthma, and teen pregnancy (Association of State and 

Territorial Health Officials [ASTHO], 2010). The erosion of LHD revenues resulted 

in the elimination of 23,000 jobs (15% of the LHD workforce) during the calendar 

years 2008–2009 (NACCHO, 2010), impacting approximately 73% of the U. S. 

population residing in those jurisdictions (NACCHO, 2010). 

Budget reductions are also impacting the sustainability of services in 

areas of mental health and disability services. State cuts of $670 million in 

mental health services were made in 2009 contributing to, among other areas, 

some treatments being provided only at the crisis-intervention stage (National 

Council for Community Behavioral Healthcare, 2009). Also, reductions in 

program services for low-income elderly and disabled people were made in at 

least 29 states (Center on Budget and Policy Priorities, 2010). State revenues 

have fallen sharply during the economic downturn and may not recover until the 

end of the decade, making continued declines or redesign of services possible 

(Thomasian, 2010). 

Any erosion of tax-exempt hospital revenues also has the potential to 

negatively impact the public health components of their community-benefit 

mandates if these activities are cut as costs saving measures. The best developed 

health goals and population health improvements will never be achieved if 

programs and agencies that fulfill the public health mission are not sustained. 

It is also important to note the negative impact that lack of stewardship 

has on the system. Public health lags behind other sectors of health with 

analyzing the financial status and sustainability of agencies and programs. While 

there are suspicions about the fiscal health of the system, there are no widely 

applied uniform measures to confirm the magnitude and impact. Professionals, 

even those in non-financial positions, across all sectors of the systems (i.e., 

managers, governance boards/structures, national organizations, and federal 

agencies) must be good stewards of public funding. Yet, many academic 

programs do not require public health students to take a finance course (Honoré, 

Gapenski, Morris, Fos, & Lean, 2010). 

Valid and value-adding measures and reporting of performance and 

quality used to inform stakeholders, including the public, must be embedded as 

standard operating practices of public health. Ensuring responsible stewardship 

and program integrity through an increased focus on eliminating waste is in fact 

a component of the HHS Secretary’s Strategic Initiatives and Key Agency 

Collaborations (DHHS, n.d.). Additional funding of $15 Billon through the Public 

Health and Prevention Trust Fund should provide a sense of urgency to ensure 

that effective stewardship and accountability are in place. 
49

Stewardship must be used as a means to ensure sustainability of the 

system. Program sustainability is important but not all programs should be 

sustained, especially when a poor performing program negatively impacts the 

sustainability of the system. The Government Performance and Results Act 

(GPRA) mandates the establishment of standards by federal agencies to measure 

performance (Government Performance & Results Act, 1993). Effective 

stewardship practices such as continuous evaluation, implemented to comply 

with GPRA, should aid government agencies in identifying those programs, 

services, and contracts that should be sustained, sustained but improved, or 

eliminated. Another challenge is related to programs that are implemented in 

the context of either community-based participatory research, or demonstration 

programs that are evaluated for their impact on outcomes. When these 

programs are demonstrated to be effective and important to the community, 

sustainability becomes an issue, as resources to operate the program must be 

shifted from other programs, or new resources must be obtained. As with other 

programs, the continuity of even the most effective programs is often judged in 

the context of other community needs and priorities and limited resources. 

Consequently, relying on efficiency and effectiveness as a sustainability strategy 

may not be sufficient. Seeking partnerships with the private sector, which may 

share common goals, may be an underutilized strategy in public health especially 

during periods of economic distress. 

Improvability 

Building advocacy for public health funding is critical for sustainability. 

The World Health Organization (WHO) (2009) warns that countries should not 

allow critical public health systems to become victims of distressed economic 

conditions. Conversely, when new economic development activities produce 

substantial revenue increases in state and local jurisdictions, public health should 

proactively make the case for additional financial resources while also 

monitoring for any association of increased community revenues on population 

health (Honoré, Simoes, Moonsinghe, Wang, & Brown, 2007). Advocates can join 

public health leaders to make the case to sustain critical functions during 

downturns and for carving out additional funding when new revenue streams 

emerge. 

While advocating for funding that is sustainable, predictable, and flexible, 

the WHO also underscores the need to be accountable by focusing on funding 

programs and services that demonstrates effectiveness and results (World 

Health Organization, 2009). This is consistent with aims for quality in public 

health for initiatives to be effective and efficient (DHHS, 2008). Also, a consistent 

theme from participants and reviewers of this process was to advance flexible 

funding streams. 
50

Responsible stewardship practices by both the funder and recipient 

organization can advance and uphold accountability. Responsible stewards of 

public organizations focus on mission, customers and stakeholders, continuous 

quality improvement, and transparency. Agency and program performance 

measurement is also central to quality improvement and responsible 

stewardship. The Reinventing Government Movement of the 1990s actually grew 

out of a sense of urgency during a period when only 10% of Americans felt that 

government programs were effective (Kehoe, Dodson, Reeve, & Plato, 1995) and 

reports suggested that $0.48 of every dollar was wasted (Gore, 1993). 

Nonprofit contributors to the public health system also struggle to 

demonstrate stewardship. In a recent United Way administered survey, 

respondents indicated that they don’t believe that nonprofits adequately 

achieve their mission of assisting people. Only 11% believe that nonprofits wisely 

spend money and 71% indicated that trust was compromised due to the lack of 

transparent practices on how money is spent (United Way, n.d.). The United Way 

responded by establishing both an Accountability Statement and Standards of 

Excellence to increase stewardship through uniform and transparent governance 

and operational processes throughout the United Way system (United Way, 

n.d.). 

Managing processes to achieve improvement is a fundamental 

component of quality improvement. The economic cost of poor processes can 

negatively impact quality and, consequently, program and organizational 

sustainability (Isaksson, 2006). The integration of accountability, continuous 

quality improvement, and sustainability creates a synergistic approach to 

effective stewardship. This linkage also facilitates transparency by connecting 

actions to results and improves integrity by reinforcing goals with actions that 

have the highest likelihood of success. Being transparent with performance and 

quality outcomes through systems comparable to HEDIS is important for 

improvement advances as well (National Committee for Quality Assurance, n.d.). 

Similar systems are also important for ensuring valid measures of performance 

and are consistent with recommendations in Quality First (President’s Advisory 

Commission on Consumer Protection and Quality in the Health Care Industry, 

1998). Establishing standards of practice combined with appropriate reporting 

and monitoring systems would serve to advance improvements in this area. 

 Improving quality alone, however, may not be sufficient to ensure 

sustainability. Pluye, Potvin, & Denis (2004) suggest that sustainability planning 

must be woven into the initial stages of planning for a program. A requirement in 

the Centers for Medicare and Medicaid Services’ Medicaid Infrastructure Grant 

to States to Support the Competitive Employment of People with Disabilities

mandates that applicants identify how programs will be sustained if funded 

(Centers for Medicare and Medicaid Services, 2010). The Health Resources and 
51

Services Administration (HRSA) Healthy Start Program also includes a 

requirement for sustainability planning (Health Resources and Services 

Administration [HRSA], 2006). Pluye et al. (2004) also found that 

institutionalizing a program through the use of standardized organizational 

routines such as policies or rules (e.g., restaurant inspections, mandatory new 

born screenings, disease reporting) were critical to sustainability. Koh et al. 

(2007) used a systems approach to successfully improve the quality of an organ 

donation program in Massachusetts. While funding issues and other challenges 

limited sustainability in the state, the lessons learned served as a forerunner for 

subsequent national programs led by HRSA. 

Practice Variability 

Reports document the ongoing decline in public health funding for 

programs and services and call for accountability in the public health system 

(Trust for America’s Health, 2010). Barriers to accountability in public health 

include the lack of transparency in financial as well as operational issues. There 

are mandates for financial data reporting in other sectors of health (e.g., 

community health centers) but not public health. While such analysis can be 

accomplished for other sectors (Shi, Collins, Aaron, Watters, & Shah, 2007), it is 

difficult to comprehensively measure practice variability and agency 

sustainability across the public health system (Honoré, Clarke, Mead, & 

Menditto, 2007). 

In 2009, a National Association of County and City Health Officials 

(NACCHO) report showed that only 20% of LHD revenues are from local sources 

(NACCHO, 2009), highlighting the reliance of sustainability on other sources 

outside of their immediate control. When compared to other public services, 

public health’s share of dedicated tax revenues is small as well, another signal of 

reliance on external sources of funding. This reliance makes it difficult for local 

agencies and communities to direct funding to local prioritized health needs. 

Conversely, when funding from other sources lack flexibility, resources that 

could be directed to areas of greatest local need are instead applied to less 

pressing areas. 

Another threat to sustainability in the public health system is the 

variability and transiency in how governmental public health is funded. A 2009 

NACCHO report on all LHDs reveals a median range in per capita expenditures 

from $32 to $42 (NACCHO, 2009). Current efforts to develop and implement a 

system of accreditation for public health are intended to provide a framework of 

standards and measures for measuring and reducing practice variability. 

Incorporating appropriate standards can reduce variability and assure inclusion 

of measures for stewardship and sustainability. The National Association of 
52

Local Boards of Health and National Association of County and City Health 

Officials are demonstrating leadership to achieve this outcome by educating its 

members on practices for measuring agency fiscal sustainability. Quantitative 

analysis using an agency Financial Risk Ratio or a system-wide jurisdiction Public 

Health Sustainability Index (considering indicators such as county tax base, 

county health status, poverty rates, public health revenue per capita, disability 

rates, and unemployment) could serve as index components to monitor and 

proactively mitigate risk to sustainability in the system (Honoré et al., 2010). 

Using such a systems perspective to measuring sustainability ensures inclusion of 

linkages to other sectors that directly or indirectly impact health. 
53

Policy 

Description 

Strengthen policy development and analysis processes and advocacy to 

ensure that evidence is integrated into policymaking to improve population 

health. 

Rationale for Selection 

Impact 

Despite the lack of a definitive definition of health policy, one relevant for 

this discussion is: “a statement of a decision regarding a goal in health care and a 

plan for achieving that goal” (Mosby’s Medical Dictionary, 2009). Laws are 

probably the most obvious and frequently used mechanism for implementing 

policy (Honoré, 2010). Public Health Law is defined, in part, as “the study of the 

legal powers and duties of the state to assure the conditions for people to be 

healthy” (Gostin, Koplan, & Grad, 2003, p. 8). 

Policies are also “intended to direct or influence the actions, behaviors, 

or decisions of others” (Longest, 2010). Policymaking is, in fact, an essential part 

of implementing meaningful initiatives to improve the health of the population. 

Policies can be effective when implemented internally as authoritative decisions 

from administrative and governance structures, or externally as laws, 

regulations, rules, etc. Funders can also use organizational policies to increase 

positive health outcomes by mandating the inclusion of specific activities or 

criteria in the design and implementation of programs (Valdiserri, Aultman, & 

Curran, 1995). 

While U.S. health policy and health spending are dominated by a focus on 

payment for medical treatment, many of the conditions driving the need for 

treatment are preventable. Policies designed to promote health and reduce risky 

behaviors can have a major impact on individual and population health (i.e., 

reportable health conditions, sanitation, food safety, vaccination, workplace 

wellness, fluoridation, safety belts). Laws, one of several forms of policies, have 

played a critical role in public health since the founding of the United States 

(Gostin et al., 2003). The Public Health Law Association serves a key role by 

providing a platform to promote “dialogue, partnership, education, and research 
54

in public health law” (Public Health Law Association, n.d.). The link between 

effective laws and the impact on population health are supported with evidence. 

The examples below illustrate this point. 

• Cigarette smoking constitutes the single greatest preventable source of 

premature death in developed countries. The development and 

enforcement of workplace smoking laws and policies improve both the 

health of smokers (by reducing cigarette consumption and providing a 

powerful incentive to enroll in cessation programs) and their coworkers 

(through the reduction of ambient tobacco smoke and passive 

consumption) (Moskowitz, Lin, & Hudes, 2000). A meta-analysis of 26 

studies on the effects of smoke-free workplaces in the United States, 

Australia, Canada, and Germany found that smoking bans not only 

reduced the risk of passive smoking, but also reduced the proportion of 

workers who remained smokers, and lowered the consumption by 

continuing smokers by 29% (Fichtenberg & Glantz, 2002). Research from 

nine studies has also shown that significant reductions in 

hospitalizations for acute myocardial infarction (AMI) were associated 

with laws making indoor workplaces and public places smoke-free (CDC, 

2009b). In one of these studies, AMI hospitalizations decreased 27% in 

the 18 months post implementation of the policy (CDC, 2009b). 

• Methamphetamine is a very addictive synthetic stimulant used by 5.2% 

of the U.S. population over 12 years of age (Buxton & Dove, 2008), with 

an estimated economic burden of $25 billion a year (Nicosia, Pacula, 

Kilmer, Lundberg, & Chiesa, 2009). The primary circumstances of injury 

associated with methamphetamine use are motor vehicle crashes and 

violence (Sheridan, Bennett, Coggan, Wheeler, & McMillan, 2006). With 

passage of an Oregon state law in 2005 making the main ingredient of 

methamphetamine, pseudoephedrine, available only by prescription, the 

number of methamphetamine lab closures by law enforcement in that 

state dropped from 472 in 2004 to only 10 in 2009, interpreted by 

enforcement as a decline in methamphetamine production (Oregon’s 

Methamphetamine Control Strategy, 2010). 

These examples show that well-targeted health policies can impact 

population health through promotion of healthier behaviors and reduced 

morbidity and mortality. Health policies that successfully promote healthier 

behaviors will also reduce the toxicity of the environment, thus having a 

beneficial “multiplier” effect on population health and social well-being. 
55

Improvability 

Local, state, and national policy initiatives and initiatives across multiple 

sectors outside of health collectively play a critical role in improving population 

health. In policymaking, as well as in public health practice, governance, and 

advocacy, a key feature to advancing an agenda is garnering political support to 

enact policy interventions that address pressing health issues. Improving 

weaknesses at all levels of government in the identification and advancement of 

policy agendas could play a critical role in improving population health. 

A learning culture must emerge within agencies with a public health 

mission, along with mechanisms for improving the interaction between research 

and policy (Killoran, Swann, & Kelly, 2006). Educating and informing 

policymakers, the public, and researchers on the role of public health is also 

important. Also, as Kohatsu, Robinson, and Torner (2004) noted, having research 

influence policy requires not simply producing research but making the evidence 

readily available to policymakers and others who advocate for policies. Greater 

community engagement in public health decision-making is needed to promote 

the formation of policy as a “genuinely civic endeavor” (Gostin, 2008, p. 18). 

Informing policymakers means being vigilant to produce research and 

information for them that is clearly articulated, concise, relevant, and provided 

when it is needed (Greenlick, Goldberg, Lopes, & Tallon, 2005). The pace of the 

academic research cycle is not consistent with these urgent demands of the 

policy-practice cycle (Killoran et al., 2005). This creates a “paradox of health 

services research: If it is not used, why do we produce so much of it?” (Shulock, 

1999). Effective health policymaking also includes making evidence available on 

how policies in non-health areas (e.g., education, agriculture, economic 

development, etc.) impact health. The theory of Health in all Policies (HiAP) 

recommends the integration of policies in other sectors to improve evidencebased health policymaking (Georgia Health Policy Center, 2008; Ståhl, Wismar, 

Ollila, Lahtinen, & Leppo, 2006). 

The National Prevention and Health Promotion Strategy (sec. 4001), 

mandated under the Affordable Care Act, represents a timely opportunity to 

prioritize evidence-based policy and program interventions to address the 

leading causes of death and disability and the risk factors that underlie these 

causes, including tobacco use, obesity, poor nutrition, physical inactivity, and 

excessive alcohol use (Affordable Care Act, 2010). To ensure that relevant 

research can play a significant part in policymaking in these areas, we should 

increase the interaction between health researchers and policymakers, and 

make sure that both of these groups understands the needs of the other (Clancy 

& Eisenberg, 1998; Kothari, Birch, & Charles, 2005).
56

The increased implementation of safety belt laws is an example of the 

potential to improve policy through research. One of the most effective means 

of reducing motor vehicle crash fatalities and nonfatal injuries is promoting the 

use of safety belts. New York was the first state to implement a primary safety 

belt law in 1984 (National Highway Traffic Safety Administration, n.d.). Other 

states followed but many enacted secondary laws for enforcement of safety belt 

use—allowing law enforcement to stop and cite a driver only if some other 

violation is observed. Masten (2007) found that during the period 1994 to 2004, 

changing from secondary to primary laws was associated with an increase in 

safety belt use during daytime and nighttime hours. Supporting this is a 2005 

study by the Insurance Institute for Highway Safety found that a change from 

secondary to primary laws reduced motor vehicle death rates by an estimate of 

7% (Farmer & Williams, 2005). Following these studies, more jurisdictions have 

changed from secondary to primary safety belt laws in an attempt to increase 

the use of safety belts and improve population health. 

Practice Variability 

The relevance of policymaking to improving population health ranks as 

one of the three core functions of public health—assessment, assurance, and 

policy development (IOM, 1988). Yet many policies informed by strong evidence 

and with demonstrated positive outcomes when implemented are not being 

adopted. For example, despite six decades of research showing the health 

benefits of fluoridation (CDC, 1995), only 69.2% of the U.S. population in 2006 

was served by a public water supply system with fluoridated water (CDC, n.d.). 

Also, as noted earlier, primary safety belts laws have proved to save lives. 

However, only 31 states and the District of Columbia currently have primary 

safety belt laws (Insurance Institute for Highway Safety, 2010). 

There is also wide variability across the United States in the capacity of 

various public health agencies and other organizations to analyze and influence 

policy agendas—described by Longest (2010) as policy competency. While the 

IOM recommended that every public health agency create comprehensive public 

health policies, some states are unable to fully address this responsibility due to 

the lack of adequate population-based data and the necessary scientific 

knowledge base for creating effective policy (IOM, 2003b). The variability and 

absence of specialized units within organizations to fulfill the policy function also 

impacts the ability to successfully push a policy agenda. This lack of policy 

competency impacts the capacity for policy analysis to examine issues such as 

effectiveness, unintended consequences, and potential linkages of public health 

policy to other interest such as economic prosperity, a determinant of health. 
57

Workforce and Education 

Description 

Develop and sustain a competent workforce by ensuring that educational 

and skills content are appropriately aligned with core and discipline-specific 

competencies. Assure that public health education is accessible at all academic 

levels, and that life-long learning is encouraged and valued. 

Rationale for Selection 

Impact 

The public health workforce represents the backbone of the public health 

system (DHHS, 1997). There are approximately 500,000 workers in governmental 

public health agencies and educational institutions (Moore, Perlow, Judge, & 

Koh, 2006) representing multiple disciplines such as epidemiology, 

environmental health, health education, preventive medicine, nursing, 

information technology, law, and management. Public health professionals also 

work in other settings such as hospitals, foundations, nonprofit organizations, 

and insurers. 

A public health professional is defined as “a person educated in public 

health or a related discipline who is employed to improve health through a 

population focus” (IOM, 2003a). The public health workforce includes many 

workers who lack training in public health (Koo & Miner, 2010). For example, a 

survey of all employees (state and local level) in a centralized state health 

department revealed that more than 60% lacked a college degree (Honoré, 

Graham, Garcia, & Morris, 2008). Educating this sector of the workforce is a 

challenge given the limited number of undergraduate public health education 

programs (Riegelman, 2008) and the unique learning needs of adult students 

(Koo & Miner, 2010), which may not be considered in many existing public 

health academic programs. Also, many of these employees may be in jobs where 

educational requirements and applicable competencies that should be aligned 

with educational content are not available. Lack of these standards impact the 

ability of workers to align personal educational goals with job expectations. 
58

There are additional daunting challenges facing the public health 

workforce that will impact the effectiveness and sustainability of the system. 

Wages are non-competitive (NACCHO, 2007) and the workforce is small or 

shrinking relative to needs. For example, in 2009, there were 10% fewer 

epidemiologists (0.72 epidemiologists per 100,000 population nationally) at state 

health departments than in 2006 (CDC, 2009c). It is estimated that a 68% 

increase (1.21 epidemiologists per 100,000 population nationally) is needed to 

achieve ideal epidemiology and surveillance capacity for infectious diseases, 

bioterrorism/emergency response, chronic disease, maternal and child health, 

environmental health, injury, occupational health, oral health, and substance 

abuse. Twenty-three percent of the public health workforce (110,000 workers) 

will be eligible to retire by 2012 (ASPH, 2008), and due to the economic 

downturn, 23,000 workers were lost in local health departments alone between 

2008 and 2009 (NACCHO, 2010). An additional 250,000 workers will be needed 

by 2020 (ASPH, 2008) and a 2007 IOM report noted that the current shortage of 

public health physicians was 10,000 (IOM, 2007). Also, minority populations are 

underrepresented in the public health workforce with 68% of local health 

department jurisdictions being less diverse than the populations that they serve 

(NACCHO, 2007).The Sullivan Commission on Diversity in the Healthcare 

Workforce concluded that the health workforce did not resemble the population 

that they serve and, most importantly, this inequity had the impact of making 

those populations feel excluded from a seemingly distant and uncaring system 

(Sullivan Commission on Diversity in the Healthcare Workforce, 2004). 

Equally important to ensuring an adequate public health workforce is the 

competency of the workforce to face existing and emerging challenges. In order 

to improve population health, the workforce should have a broad view of public 

health and understand the social factors, such as economic conditions and 

culture that affect health (Beaglehole, Bonita, Horton, Adams, & McKee, 2004). 

The public health system is a complex adaptive system. Educating and training 

the public health workforce must emphasize a systems-thinking approach that 

looks at the broad range of socioeconomic, political, and other factors that affect 

health, rather than the traditional approach that is often limited to courses in 

epidemiology, biostatistics, and environmental health. However, reports suggest 

that the current public health workforce is not prepared to meet the challenges 

of the 21st century (DHHS, 1997). This is contrary to a principle for ethical 

practices in public health that calls on public health institutions to “ensure the 

professional competence of their employees” (Cobus, 2008). Accordingly, it 

seems reasonable that training in cultural competencies should be a 

requirement as well. 
59

Improvability 

There is consensus on the need to improve the quality and readiness of 

the public health workforce as well as for increasing access to and the quality of 

content in educational offerings (Borders, Blakely, Quiram, & McLeroy, 2006; 

IOM, 2003a; Olson, Hoeppner, Larson, Ehrenberg, & Leitheiser, 2008). The IOM 

in 2003 recommended that public health education should be accessible to all 

undergraduates (IOM, 2003a). Initiatives such as the Consensus Conference on 

Undergraduate Public Health Education (Riegelman, 2008) have promoted this 

concept. Improvements can be documented by the increasing number of 

undergraduate public health programs. The Association of Schools of Public 

Health (ASPH) is leading an effort in collaboration with the Association of 

American Colleges and Universities (AAC&U) and the Association for Prevention 

Teaching and Research (APTR) to develop and disseminate undergraduate public 

health competencies built upon the AAC&U’s Liberal Education and America’s 

Promise (LEAP) essential learning outcomes. The Healthy People Curriculum Task 

Force, a collaboration of clinical health professional organizations with public 

health organizations has developed an Education for Health framework designed 

to serve as an educational underpinning for Healthy People 2020 (Koh, Nowinski, 

& Piotrowski, in press). Undergraduate public health education serves as the 

centerpiece of this framework. 

The nation’s community college system continues to be an 

underappreciated partner for ameliorating the crisis regarding the public health 

workforce (Honoré et al., 2008; Riegelman, 2010). Only 1.6% of community 

colleges offer a public health degree or certificate program (Kirkwood & 

Reigelman, in press). With more than 1,200 colleges nation-wide, community 

colleges can serve as one rung on a ladder that connects high school students to 

four-year and graduate degree public health programs, introduce public health 

as a career option early in a student’s educational experience, facilitate 

improvements in recruiting minority students to public health careers, foster 

opportunities for life-long learning through continuing education programs, and 

provide a convenient venue for existing public health workers to increase their 

training opportunities and educational attainment levels. As new technologies, 

knowledge, and crises and threats (e.g., Katrina, 9/11) emerge, venues for 

continuous education and training are needed (Gebbie & Turnock, 2006). 

Continuing education programs where participants are trained intensively on 

new methods, and view the methods as effective, can serve as a model to assist 

public health programs in adopting new evidence-based HIV prevention methods 

(Kelly et al., 2000). Also, research on an Environmental Protection Agency smallindustry worker certification program found measurable and statistically 

significant improvements as a result of certification (Enander et al., 2007). 
60

 Community colleges share with public health the mission to be intimately 

linked to their immediate service regions. The North Carolina Community Health 

Ambassador Program, an initiative of the state health department, illustrates 

one example of constructive collaboration. The training program, focused on 

improving diabetes awareness, management, and prevention, uses a systems 

thinking approach to bring together a diverse range of system stakeholders (i.e., 

health care, public health, faith-based organizations) for diabetes related 

training on community-based interventions in the state’s community college 

system (Pullen-Smith, Carter-Edwards, & Leathers, 2008). An objective to 

increase the number of two-year colleges that offer associate degrees or 

certificate programs in public health is expected to be included in Healthy People 

2020 and potentially can stimulate such collaborations. 

Effectiveness, an aim for public health quality, can be improved when 

workforce competencies are aligned with professional responsibilities. The 

Council on Linkages between Academia and Public Health Practice (Council on 

Linkages, 2010) and ASPH (ASPH, 2006) independently developed public health 

core competencies. There are also improvements in identifying discipline-specific 

competencies for areas such as finance and business management (Calhoun, 

Ramiah, Weist, & Shortell, 2008; Honoré & Costich, 2009). Development of 

discipline specific competencies is supported by previous studies indicating a 

need in targeted areas (Halverson et al., 1997). 

There are serious challenges in preventing current and future shortages 

in the public health workforce, but there are ongoing efforts to address 

workforce issues through accreditation criteria, training, and strategic workforce 

planning. As a criterion for accreditation, the Council on Education for Public 

Health (CEPH) requires schools of public health to demonstrate that they address 

the training needs of the workforce that lack any formal training as well as for 

professionals needing advanced training (Council on Education for Public Health, 

2005). The Health Resources and Services Administration (HRSA) currently 

supports Public Health Training Centers that play a vital role in providing 

opportunities to expand training opportunities (HRSA, n.d.). Under the 

Affordable Care Act, an additional $15.4 million was awarded in September 2010 

to the Training Centers to enhance skills development (HRSA, 2010). A site 

evaluation of a training center found that enhanced job performance was linked 

to completion of coursework in the program (ASPH, 2004). States are engaging in 

strategies such as web-based recruiting, job fairs and academic partnerships to 

market state public health careers to address the shortage (ASTHO, 2008). 

Blended Learning, described as combining face-to-face instruction with 

technology enhanced teaching methodologies, is also gaining traction in public 

health (Moore et al., 2006). The TrainingFinder Real-Time Affiliate Integrated 

Network (TRAIN) is a nationwide learning management system of the Public 

Health Foundation that connects registered users to public health training 
61

materials from a network of affiliates (Public Health Foundation [PHF], n.d.). 

Currently there are more than 17,000 courses and 360,000 registered users who 

have access to TRAIN materials made available by 3,300 providers. 

Practice Variability 

Wide variability in the size, structure, educational levels, capability, and 

skills of the workforce argues for standardization of continuing education and 

skills development. In a survey of TRAIN users (N=11,000), participants reported 

their highest educational attainment level: 12% had a high school degree, 18.5% 

an associate’s degree, 3.4% a bachelor’s degree in public health, 31.7% a 

bachelor’s degree other than in public health, 8.1% held master’s in public 

health, 17.5% a master’s other than public health, .6% a doctorate in public 

health, 2.6% a doctorate other than in public health, and 4.9% held an advanced 

degree (e.g. medicine, J.D., etc.) (PHF, 2010). A 2009 survey of state health 

department epidemiologist showed that 57% had a degree in epidemiology, 29% 

had completed academic coursework or training in epidemiology, and 13% had 

no formal academic course work of training in epidemiology (CDC, 2009c). 

 Efforts to close gaps and reduce variability are on the horizon. The 

release of the ASPH undergraduate public health learning outcomes in the spring 

of 2011 should offer an opportunity to close gaps and better standardize 

undergraduate public health in all undergraduate institutions. The linkage of 

these learning outcomes to the AACU’s LEAP initiative should provide an 

opportunity for national academic discussion and standardization of objectives 

for undergraduate public health education. The inclusion of objectives for 

undergraduate public health education in Healthy People 2020 should provide 

additional opportunities to highlight the needs of the public health workforce 

and the opportunities for colleges and universities. 

As part of the Healthy People 2020 effort, the Office of Disease 

Prevention and Health Promotion (ODPHP) is supporting the collection and 

dissemination of resources on undergraduate public health for inclusion in the 

Healthy People 2020 website. Successful practices by undergraduate institutions 

will be highlighted. This should assist in disseminating examples of high quality 

undergraduate public health practices and gaining the attention of 

undergraduate institutions and faculty. 

Gaps and variability also exist in discipline-specific competencies and 

academic program content. Development of competencies in discipline-specific 

areas such as business and financial management is supported by research 

conducted over many years (Halverson et al., 1997; Liange, Renard, Robinson, & 

Richards, 1993; Sorensen & Bialek, 1993). However, even though public health 
62

competencies are now available for the finance and business management 

workforce, as well as for public health leaders as noted above, recent research 

found the absence of appropriate content (e.g., focus on health care rather than 

public health) in graduate level public health finance coursework (Honoré et al., 

2010). There is also increasing emphasis in quality improvement in public health. 

Yet, it is unclear to what extent public health academic programs include 

educational content on quality concepts applied to the field of public health. 
63
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65
66
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Appendix A 

Primary and Secondary Drivers of Quality for: 

Healthcare-Associated Infections (HAI) 

Human Immunodeficiency Virus (HIV) 

Healthy Weight 
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85

Figure A-1. Public health primary and secondary drivers of quality for HAI 
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Figure A-1 displays public health primary and secondary drivers of quality for healthcare associated infections (HAI). The bulleted 

structure explains how the drivers flow in a cascading manner. 

• Reduce National Incidence of Healthcare Associated Infections (defined as the outcome) 

• Population Health Metrics and Information Technology (primary driver). The secondary drivers are: 

• Develop standard definitions and measurements for HAI 

• Establish mandatory national data collection standards by race and geography 

• Standardize and integrate reporting systems for all levels of government and healthcare organizations 

• Evidence-Based Practices, Research, and Evaluation (primary driver). The secondary drivers are: 

• Identify gaps in the existing knowledge base of current infection control practices in healthcare organizations 

• Support collaborative trials to establish the efficacy of new preventive interventions 

• Systems Thinking (primary driver). The secondary drivers are: 

• Improve coordination of HAI activities and surveillance across all levels of government 

• Mobilize healthcare, public health, consumers, and academia to support innovative efforts for prevention, research, 

information technology infrastructure, incentives and oversight, and public messaging and outreach to reduce HAI 

• Sustainability and Stewardship (primary driver). The secondary drivers are: 

• Support effective public/private partnerships for reducing HAI through funding streams, national committees, and 

working groups. 

• Develop standard effective tools and protocols for healthcare providers to investigate outbreaks, clusters, or 

unusual cases of HAI 

• Policy (primary driver). The secondary drivers are: 

• Establish incentives and penalties through government insurance programs to prevent HAI in healthcare 

organizations 

• Identify and explore policy options for regulatory oversight of recommended practices 

• Workforce and Education (primary driver). The secondary drivers are: 

• Develop standard training competencies for preventing HAI 

• Support special training for healthcare providers and healthcare organization surveyors on HAI 

• Educate lay community workers on HAI 
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Figure A-2. Public health primary and secondary drivers of quality for HIV 
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Figure A-2 displays public health primary and secondary drivers of quality for HIV. The bulleted structure explains how the drivers flow in a 

cascading manner. 

• Reduce National Incidence of HIV Infections (defined as the outcome) 

• Population Health Metrics and Information Technology (primary driver). The secondary drivers are: 

• Comply with standardized data collection and grantee reporting requirements 

• Use electronic medical record systems to facilitate linkage, coordination, and care management for people living with HIV/AIDS 

• Develop HIV community viral load measurements as a means of identifying communities and populations in need of improved HIV 

prevention, treatment and care services 

• Evidence-Based Practices, Research, and Evaluation (primary driver). The secondary drivers are: 

• Promote routine, voluntary HIV screening—including, where appropriate, rapid testing. 

• Develop and license 4th generation HIV diagnostic tests to better detect incident HIV infections 

• Evaluate promising community-generated HIV prevention interventions 

• Implement and evaluate demonstration projects to test which combinations of effective interventions are cost-efficient, produce 

sustainable outcomes, and have the greatest impact in preventing HIV in specific communities 

• Systems Thinking (primary driver). The secondary drivers are: 

• Develop coordinated planning models across all levels of government, including coordinated prevention and care planning and 

resource allocation activities. 

• Support the mobilization of faith communities, businesses, schools, health care providers, community-based organizations, social 

gathering sites, and all types of media outlets to support people living with HIV and high risk communities, to reduce stigma 

• Sustainability and Stewardship (primary driver). The secondary drivers are: 

• Ensure that HIV funding is allocated consistent with the latest epidemiological data and is targeted to the highest prevalence 

populations and communities 

• Bridge short-term gaps in health coverage for persons with HIV/AIDS until the ACA is fully implemented 

• Policy (primary driver). The secondary drivers are: 

• Use a shared, unique identifier to allow for better coordination (and reporting) of HIV/AIDS services at the local, state, and federal 

levels 

• Support programs that promote age-appropriate HIV and STI prevention education for all Americans 

• Workforce and Education (primary driver). The secondary drivers are: 

• Collaborate across the system on workforce training to increase the number of health providers who are culturally competent 

• Collaborate across the system on workforce training to increase the number of clinical providers who can deliver high-quality HIV 

care—especially for rural and underserved populations 
89

 

Figure A-3. Public health primary and secondary drivers of quality for Healthy Weight 
90

Figure A-3 displays public health primary and secondary drivers of quality for healthy weight. The bulleted structure explains how the drivers flow in a cascading 

manner. 

• Reduce National Incidence of HIV Infections (defined as the outcome) 

• Population Health Metrics and Information Technology (primary driver). The secondary drivers are: 

• Employ new technologies to integrate self-report with biologic and/or sensor measures of physical activity, diet/nutrition, and energy 

balance/obesity in real time. 

• Develop valid measures of community food access and deserts, nutrition, and environments friendly to physical activity 

• Integrate surveillance and other public/private IT systems to monitor population BMI, physical activity, food purchasing, and screen time (i.e., 

video games, TV, etc.) 

• Develop and implement national data standards for healthy weight/obesity, physical activity and healthy food consumption across the life span. 

• Evidence-Based Practices, Research, and Evaluation (primary driver). The secondary drivers are: 

• Create a network for knowledge-sharing on healthy weight and related factors 

• Conduct research to understand the etiology and pathophysiology of obesity and weight gain from a multi-level systems perspective 

• Support and conduct analysis and dissemination of practice-tested interventions for diverse populations and settings to promote behaviors and 

create environments leading to achieving and maintaining healthy weights. 

• Implement continuous monitoring processes, incorporating a feedback loop, to evaluate change in BMI, physical activity, nutrition, and change 

resulting from policies 

• Systems Thinking (primary driver). The secondary drivers are: 

• Develop, implement, multi-level and multi-sector interventions 

• Implement initiatives to improve the worksite wellness and food environments of hospitals, universities, business complexes, etc. 

• Sustainability and Stewardship (primary driver). A secondary driver is: 

• Develop a participatory open culture engaging all stakeholders in advocacy to support sustaining programs to achieve healthy weight at the 

population level. 

• Policy (primary driver). The secondary drivers are: 

• Coordinate national, state, and local policies to support each other 

• Develop and implement policies for child care/early learning centers and schools for physical activity, nutrition, limited on-site screen time (i.e., 

video games, TV, etc.) 

• Develop and implement workforce policies to promote healthy weight and physical activity, to be adapted to employer size, industry-type, and 

workforce characteristics. 

• Develop economic and agricultural policies to make fresh, healthy foods available and affordable across all communities 

• Advocate for policies for healthy community environments 

• Workforce and Education (primary driver). A secondary driver is: 

• Provide the workforce with knowledge necessary to achieve goals for healthy weight. 
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