Ned E. Baker Lecture: New Rules for Strengthening the Public Health System

1
Ned E. Baker LectureNew Rules for Strengthening
the Public Health System

• Leslie M. Beitsch
• Florida State University
• College of Medicine
• Center for Medicine and Public Health
• March 30, 2007

2
Landscape

• 3000 counties in the US
• 20,000 cities and towns
• 50 states
• 7 territories
• Federally recognized tribes

3
Landscape

• 3000 LHDs
• 75 have BOHs
• Home rule (Ohio), decentralization,
  centralization, city/county/district, urban,
  rural, tribal, state

4
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)

5
Climate

• Deming and variance

6
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

7
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

8
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

9
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 Isnt that why we
  came to work everyday, day after day after day?

10
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

11
A Challenge for Leadership

• We know what to do to enable our WF to perform
  better
• But what about our organizations????

12
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

13
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

14
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)

15
Research Has Found Four Barriers to Strategic
Implementation
The Vision Barrier
Only 5 of the work force understand the strategy
The People Barrier
The Management Barrier
9 of 10 companies fail to execute strategy
Only 25 of managers have incentives linked to
strategy
85 of executive teams spend less than one hour/
month discussing strategy
60 of organizations dont link budgets to
strategy
The Resource Barrier
Todays Management Systems Were Designed to Meet
The Needs of Stable Industrial Organizations That
Were Changing Incrementally You Cant Manage
Strategy With a System Designed for Tactics
16
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

17
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

18
New Rule PH systems should be accountable for
the services they provide (or fail to provide)
19
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

20
New Rule Accreditation and Standards Are Not
Just for Everyone Else

• Why is it that PH thinks it doesnt need
  standards or accreditation, but everyone else
  should have them?

21
New Rule Standards Actually Mean Something, like
a Standard
22
New RuleQuid Pro Quo Applies

• Local
• State
• Federal!!!!!!

23
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

24
Federal, State and Local Program Silos
Public Health
Law Enforcement
Emergency Management
Medical Services
Agriculture
25
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

26
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

27
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

28
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

29
How do the NPHPS Fit into the National Scene?

• PH Preparedness (CDC and HRSA CA)
• Accreditation Movement
• HP 2010/ HP 2020
• Natl PH Performance Improvement Institute (PHFs
  AARO)

30
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

31
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????

32
RWJF/CDC

• Convened natl public health stakeholders meeting
  December 04
• Consensus from gathering
• Valuable to investigate feasibility of
  establishing voluntary natl accreditation sys
• Sys defined as development of
• Set of standards
• Process for validation
• Recognition and/or incentives

33
Exploring Accreditation Project

• CDC/RWJF financed
• An APHA, ASTHO, NACCHO and NALBOH collaboration
  to
• A natl steering committee was established to
  make definitive recommendations regarding the
  feasibility and desirability of a voluntary natl
  accreditation system
• Final recommendations recently released

34
The Natl Steering Committee Utilized 4 Workgroups

• Governance and Implementation
• Consideration of overall system structure
• Single point of entry
• Network of states meeting natl 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?

35
The Natl Steering Committee Utilized 4 Workgroups

• Financing and Incentives
• How is system to be financed?
• Appropriate incentives (avoiding unintended
  consequences)
• Study business case for natl accreditation sys
• Research and Evaluation
• Establish research agenda to promote
  evidence-based approach to accreditation
  methodology
• Evaluate NACCHO/ASTHO collaborative process

36
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

37
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

38
Four components of a performance management
system
Source Turning Point Performance Management
Collaborative, From Silos to Systems Performance
Management in Public Health (in press).
39

• In a performance
• management
• system...
• 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.
40
Baldrige Criteria For Organizational Performance
Excellence
5 Human Resource Focus
2 Strategic Planning
7 Business Results
1 Leadership
3 Customer Market Focus
4 Information and Analysis
41
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

42
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!

43
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

44
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

45
The Relationship Between Accreditation and QI
46
Public Health Agency Accreditation System
Implementation (Simplified)
July 21, 2006
Inputs
Strategies
Outputs
Short-Term Outcomes
Long-Term Outcomes

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

Research and Evaluation of Accreditation

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

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

PH Agencies meet Accreditation Standards and are
Accredited

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

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

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

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

PH Agencies Buy-into Accreditation and receive
technical Assistance for pursuing Accreditation
Increased public recognition of public health
role and value
PH agencies are better ability to communicate
work and results to public

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

More visibility of the work of PH agencies
Create incentives for participation
47
Achieving 9 HP 2010 Goals

• Would save 2 million lives by decades 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?

48
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

49
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

50
New Rule PH must build vocal constituencies

• NIH vs. CDC
• HIV/AIDS and MCHBG vs. PHBG

51
New RulePH 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

52
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

53
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

54
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 DONT SAY THE WORDS FAMILY PLANNING OR
  ENVIRONMENTAL HEALTH, NO ONE ELSE WILL

55
(No Transcript)
56
New Rule Think boldly

• Adopt what Celestial Seasonings implores
• Edmund Spencer
• Dante

57
Questions/Comments/Diatribes

• Leslie M. Beitsch
• Director, Center for Medicine and Pub Hlth
• Florida State University College of Medicine
• 1115 W. Call St
• Tallahassee, FL 32306
• (O) 850-645-1830
• les.beitsch_at_med.fsu.edu