Ned E. Baker Lecture:New Rules for Strengthening

the Public Health SystemLeslie M. Beitsch

Florida State UniversityCollege of Medicine

Center for Medicine and Public HealthMarch 30, 2007

Landscape• 3000 counties in the US

• 20,000 cities and towns

• 50 states

• 7 territories

• Federally recognized tribes

Landscape

• 3000 LHDs

• 75% have BOHs

• Home rule (Ohio), decentralization, centralization, city/county/district, urban, rural, tribal, state

Climate• Provision of “unique” set of services

• Kindly back up the Brinks’ truck to the loading dock

• Give us the $$$$$, and we will do good (things)

Climate

• Deming and variance

Punctuation

• The emphasis on differences and avoidance of accountability has not served us well in the present competitive marketplace

• We are more alike than we are diffferent

New Rule: We Are What We Eat

• A steady PH diet of– QI/PM– NPHPS– Turning Point– Exploring Accreditation Project– Multi-State Learning Collaborative

• And so are our organizations

New Rule: Mutual funds and PH Operate on Different Principles

• For mutual funds past performance does not guarantee future results

• For PH, past performance is a very good indicator of future performance

– Preparedness drills and exercises

A Challenge for Leadership• How do you take dedicated PH workers

struggling in the gulag and lead them to the promised land of improved health outcomes?

• Reflect back a decade or so: Isn’t that why we came to work everyday, day after day after day?

New Rule: Empower the Public Health Workforce

• Enhance confidence through training and skills acquisition

• Models: – state and regional leadership institutes– Preparedness Centers (CDC)– Training Centers (HRSA)– State and local financed MPH sponsorship

A Challenge for Leadership

• We know what to do to enable our WF to perform better

• But what about our organizations????

A Challenge for Leadership

• How do you know when your agency is performing well???

• How do you know when it is improving???

• Or perhaps more importantly, when efforts are deteriorating

Some Qualitative Data Points to Consider

• Your staff tell you

• Your BOH tells you

• The Mayor is happy

• The Governor remembers your first name

• The press write positive stories about the health department

• You have a devoted cult following

Some Quantitative Data Points to Consider

• You benchmark your health department against others nationally

• Your agency is accredited (maybe I am getting ahead of the story)

Research Has Found Four Barriers to Strategic Implementation

Only 5% of the work force understand the strategy

60% of organizations don’t link budgets to strategy

Only 25% of managers have incentives linked to strategy

85% of executive teams spend less than one hour/ month

discussing strategy

9 of 10 companies fail to execute strategy

The People Barrier

The Vision Barrier

The Management Barrier

The Resource Barrier

Today’s Management Systems Were Designed to Meet The Needs of Stable Industrial Organizations That Were Changing Incrementally

You Can’t Manage Strategy With a System Designed for Tactics

A Challenge for Leadership

• A high priority among your numerous and competing responsibilities is to assess organizational capacity so you can outline a trajectory for future directions that may lead to better health outcomes– What is our baseline– What are our organizational needs– What are our strengths

New Rule: It is every citizens right to receive quality PH

services wherever in the U.S. they may reside

• 10 Essential Services of PH as key building blocks

New Rule: PH systems should be accountable for the services they

provide (or fail to provide)

New Rule: PH systems should be accountable for the services they

provide (or fail to provide)

• Accountable to citizens

• Accountable to BOHs

• Accountable to other funders

New Rule: Accreditation and Standards Are Not Just for

Everyone Else

• Why is it that PH thinks it doesn’t need standards or accreditation, but everyone else should have them?

New Rule: Standards Actually Mean Something, like a Standard

New Rule:Quid Pro Quo Applies

• Local

• State

• Federal!!!!!!

A Challenge for Leadership

• All kidding aside (well maybe not ALL)

• The NPHPS can assist you and your leadership team with:– Establishing a baseline– Prioritization– With establishing performance goals– Allocating scarce resources

PublicHealth

LawEnforcement

EmergencyManagement

MedicalServices

Agriculture

Federal, State and Local Program Silos

A Challenge for Leadership• The NPHPS can assist you and your

leadership team with:– Permeating and infusing program knowledge

broadly across silos– Communicating performance progress to staff– Improving performance– Benchmarking

A Challenge for Leadership

• Is this beginning to sound like a case for a performance management system?

• If so (hum quietly to yourself…), the NPHPS are an integral component…

• Consider…

Quid Pro Quo• Turning Point PMC findings

– Most PM activities are local– When present at state level, tendency for silo

orientation

• Local buy-in fostered by state participation

• NPHPS are excellent means to initiate state PM

How do NPHPS relate to QI/PI/PM?

• NPHPS are capacity and performance standards

• Standards are the first quadrant in the Turning Point model

• QI program in FL and other states focus on outcomes and systems processes

• These activities are complementary• Successful QI/PI/PM may/should include both

How do the NPHPS Fit into the National Scene?

• PH Preparedness (CDC and HRSA CA)

• Accreditation Movement

• HP 2010/ HP 2020

• Nat’l PH Performance Improvement Institute (PHF’s AARO)

A Challenge for Leadership

• This data can be utilized as a starting point for a strategic plan

• It can be a major foundational underpinning for constructing a quality improvement system

• Compare this approach with what you may be using now…

Accreditation Movement• No longer a controversial topic for CDC, funders,

and PH organizations• PH unique among health disciplines in lacking

national accreditation mechanism• States have been the laboratory thus far• Focus has been limited largely to locals; no

consensus approach• State agency accreditation vision lacking• Could NPHPS be an integrating factor (NC)?• Role for Governance bodies????

RWJF/CDC

• Convened nat’l public health stakeholders meeting December ’04

• Consensus from gathering– Valuable to investigate feasibility of

establishing voluntary nat’l accreditation sys– Sys defined as development of

• Set of standards• Process for validation• Recognition and/or incentives

Exploring Accreditation Project• CDC/RWJF financed• An APHA, ASTHO, NACCHO and

NALBOH collaboration to:• A nat’l steering committee was established

to make definitive recommendations regarding the feasibility and desirability of a voluntary nat’l accreditation system

• Final recommendations recently released

The Nat’l Steering Committee Utilized 4 Workgroups

• Governance and Implementation:– Consideration of overall system structure

• Single point of entry• Network of states meeting nat’l standard• Other alternatives

– Relationship among levels of PH practice (fed/state/local)

– Leadership and implementation of accreditation sys– Remediation

• Standards Development:– Identify principles for standard setting– Role of NPHPS?

The Nat’l Steering Committee Utilized 4 Workgroups

• Financing and Incentives:– How is system to be financed?– Appropriate incentives (avoiding unintended

consequences)– Study business case for nat’l accreditation sys

• Research and Evaluation:– Establish research agenda to promote evidence-

based approach to accreditation methodology– Evaluate NACCHO/ASTHO collaborative process

MLC 1• Concurrently, through a grant from RWJF,

NNPHI/PHLS led a multi-state learning collaborative to explore and advance accreditation-like programs already in implementation

• IL, MI, MO, NC, WA: • Selected states received up to $150,000 to

enhance existing accreditation/assess. systems for 12 months– Variety of TA resources and eval available– Influenced EAP recommendations

MLC 2• MLC 2 currently underway

• Focus is on QI within contest of accreditation

• Ohio one of 10 participating states

• FL, IL, KS, MN, NH, MI, MO, NC, WA

• MLC operates on 3 levels

Four components

of a performance

management system

Source: Turning Point Performance Management Collaborative, From Silos to Systems: Performance Management in Public Health (in press).

In a performance

managementsystem...• All components should

be driven by the public health mission and organizational strategy

• Activities should be integrated into routine public health practices

• The goal is continuous performance and quality improvement

Source: Turning Point Performance Management Collaborative.

11LeadershipLeadership

77BusinessBusinessResultsResults

66Process Process

ManagemenManagementt

33Customer & Customer &

Market Market FocusFocus

2 2 Strategic Strategic PlanningPlanning

Baldrige Criteria For Organizational Baldrige Criteria For Organizational Performance ExcellencePerformance Excellence

44Information and AnalysisInformation and Analysis

5 5 Human Human

Resource Resource FocusFocus

New Rule: Peggy Lee Was Right

• EAP Steering Committee has drafted a work plan and recommendations

• Although ultimate outcome remains to be seen…

• the need for QI/PI/PM non-controversial

New Rule: Peggy Lee Was Right

• Potential organizational outcomes from an accreditation process:– Great organization– Organization has transformed from good to

great– Organization is good, but not great– Organization is neither good nor great!

New Rule: Peggy Lee Was Right• To successfully achieve accreditation,

some form of a QI/PI/PM system is a prerequisite

• Both good and great organizations will have successfully employed QI/PI/PM techniques

• Remediating organizations will need to build QI/PI/PM capacity

New Rule: Peggy Lee Was Right

• Bottom line:– Acceptance of accreditation remains an open

question– QI/PI/PM will be a centerpiece regardless– NPHPS remain a cornerstone in the

evolutionary process

The Relationship Between Accreditation and QI

Improved community health indicatorsPH Agencies Buy-into

Accreditation and receive technical Assistance for pursuing Accreditation

Accrediting Agency:•Staff•Resources•Accrediting Standards and support materials

PH agencies: •Interest in accreditation•Readiness for accreditation•Perceived value of accreditation

More visibility of the work of PH agencies

Inputs Strategies Outputs Short-Term Outcomes Long-Term Outcomes

Create incentives for participation

PH Sector as a whole has a clear set of benchmarks and mechanism for contextualizing strengths and weaknesses

PH agencies more effectively and efficiently use resources:•Staff•Other resources•Funding

Public Health Agency Accreditation System Implementation (Simplified)

Increased public recognition of public health role and value

Improved PH Sector:•Better and more uniformly trained staff•Increased ability to collaborate•Improved quality of services

July 21, 2006

Broader Public:•Local/State/Federal public policy-maker•General public

Research and Evaluation of Accreditation

PH agencies are better ability to communicate work and results to public

Legend

Accrediting Agency Individual PH Agencies

PH Field Public/Policy Makers

Multiple Groups

Accrediting Process:•Self-review•Outside review•Reaccreditation

PH Agencies meet Accreditation Standards and are Accredited

Strengthened public health system-Preparedness-Infrastructure-Capacity-Results

Achieving 9 HP 2010 Goals• Would save 2 million lives by decade’s

end• Reductions in cancers, vascular disease,

and injury• What are the fulcrums, leverage points to

enable these?• How do we relate these ideas to the

ESPH? To accreditation?

Remember the 10 Great PH Achievements?

• PH has an extraordinary track record

• Accreditation offers an opportunity and a framework

• Envision extraordinary results, beginning with very concrete steps

New Rule: Build Partnerships, But Accept Credit (and Fault)

• Old Rule:– There is no limit to what can be accomplished

if others receive the credit

• Old Rule amended:– There is no limit to what can be accomplished

if others receive some of the credit

New Rule: PH must build vocal constituencies

• NIH vs. CDC

• HIV/AIDS and MCHBG vs. PHBG

New Rule:PH Whining is now extinct

• Although PH has developed whining into a high art form, it has not served us well

• Others look to “can do” partners– Relegating PH to the sidelines

New Rule: PH is A &W

• 101st anniversary of Jacobsen vs. Mass

• Preparedness remains at the forefront

• We have occasional hurricanes

• State Medicaid programs are broke

New Rule: Opportunities Abound

• Silver lining in the cloud of each new disaster or calamity

• But PH has been invisible in Katrina and Rita

• We must invite ourselves to the table, even we have to bring our own chairs…

New Rule: All PH Staff Are Empowered with the Courage to

Speak Out• Esp. important when there is a vacuum in

leadership (at any level of tripartite system)

• IF YOU DON’T SAY THE WORDS “FAMILY PLANNING” OR “ENVIRONMENTAL HEALTH,” NO ONE ELSE WILL…

New Rule: Think boldly

• Adopt what Celestial Seasonings implores

– Edmund Spencer

– Dante

Questions/Comments/Diatribes

Leslie M. BeitschDirector, Center for Medicine and Pub HlthFlorida State University College of Medicine 1115 W. Call StTallahassee, FL 32306(O) 850-645-1830les.beitsch@med.fsu.edu