specific health outcomes might be to hold them accountable for working with others in the community to respond to problems.

ASSESSING COMMUNITY PUBLIC HEALTH PRACTICE3

Federal, state, and local public health agencies have special responsibilities for protecting and improving community health. The Future of Public Health (IOM, 1988) defined their core functions as assessment of health status and health needs, policy development, and assurance that necessary health services are available. Healthy People 2000: National Health Promotion and Disease Prevention Objectives USDHHS, 1991) included as objective 8.14 that 90 percent of the population be served by local health departments that are effectively carrying out the core functions of public health. When this objective was published, no data were available on the performance of local health departments. Work is now underway to develop measures of effective public health performance that can be used to assess progress toward this Healthy People 2000 objective and that states and communities can use in their own efforts to monitor and improve public health practice. The workshop included a presentation on some of these efforts.

Developing Performance Measures for Public Health Practice

The workshop presentation focused on activities based at the University of Illinois at Chicago (see Turnock et al., 1994a, 1994b, 1995) and also drew on collaborative work with the University of North Carolina, where a related project is underway (see Miller et al., 1994a, 1994b). The work at the University of Illinois at Chicago has focused on developing a measurement tool for the Healthy People 2000 objective on the performance of local health departments. In contrast, the project at the University of North Carolina has as its primary purpose the development of self-assessment tools for local health departments. These efforts, and a third project at the University of South Florida (see Studnicki et al., 1994), have been encouraged by the Public Health Practice Program Office of the Centers for Disease Control and Prevention (CDC). An important principle behind the projects is the need to be able to measure public health performance in order to improve it.

The efforts to measure the performance of local public health departments have focused on the area of process—public health practice—rather than on inputs, outputs (e.g., specific programs or services), or health outcomes. A set

3  

This section is based on a presentation by Bernard Turnock.



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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary specific health outcomes might be to hold them accountable for working with others in the community to respond to problems. ASSESSING COMMUNITY PUBLIC HEALTH PRACTICE3 Federal, state, and local public health agencies have special responsibilities for protecting and improving community health. The Future of Public Health (IOM, 1988) defined their core functions as assessment of health status and health needs, policy development, and assurance that necessary health services are available. Healthy People 2000: National Health Promotion and Disease Prevention Objectives USDHHS, 1991) included as objective 8.14 that 90 percent of the population be served by local health departments that are effectively carrying out the core functions of public health. When this objective was published, no data were available on the performance of local health departments. Work is now underway to develop measures of effective public health performance that can be used to assess progress toward this Healthy People 2000 objective and that states and communities can use in their own efforts to monitor and improve public health practice. The workshop included a presentation on some of these efforts. Developing Performance Measures for Public Health Practice The workshop presentation focused on activities based at the University of Illinois at Chicago (see Turnock et al., 1994a, 1994b, 1995) and also drew on collaborative work with the University of North Carolina, where a related project is underway (see Miller et al., 1994a, 1994b). The work at the University of Illinois at Chicago has focused on developing a measurement tool for the Healthy People 2000 objective on the performance of local health departments. In contrast, the project at the University of North Carolina has as its primary purpose the development of self-assessment tools for local health departments. These efforts, and a third project at the University of South Florida (see Studnicki et al., 1994), have been encouraged by the Public Health Practice Program Office of the Centers for Disease Control and Prevention (CDC). An important principle behind the projects is the need to be able to measure public health performance in order to improve it. The efforts to measure the performance of local public health departments have focused on the area of process—public health practice—rather than on inputs, outputs (e.g., specific programs or services), or health outcomes. A set 3   This section is based on a presentation by Bernard Turnock.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary TABLE 1 Ten Basic Practices in the Core Functions of Public Health Assessment Practices Assess the health needs of the community. Investigate the occurrence of health effects and health hazards in the community. Analyze the determinants of identified health needs. Policy Development Practices Advocate for public health, build constituencies, and identify resources in the community. Set priorities among health needs. Develop plans and policies to address priority health needs. Assurance Practices Manage resources and develop organizational structures. Implement programs. Evaluate programs and provide quality assurance. Inform and educate the public. SOURCE: Adapted from Roper et al., 1992, and Turnock et al., 1994b. of 10 practices have been linked to the core public health functions of assessment, policy development, and assurance (see Table 1). Using sources such as APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991) and Healthy Communities 2000: Model Standards (American Public Health Association et al., 1991), the University of Illinois at Chicago project selected an initial set of public health practice indicators and sent them to a panel of local health officials for review. After revisions, the indicators were sent to a national sample of local health departments for comments on issues such as whether the indicators were important descriptors of local public health practice and whether proposed measures were appropriate. A more detailed study in five states looked at potential sources of data and factors that might affect access to data or willingness to share data. The most recent step has been to develop and test a merged set of 20 indicators that bring together the results of the work at the University of Illinois at Chicago and the University of North Carolina. (See Table 2.) The indicators reflect standards for both performance and capacity to perform. For example, for assessment practices the selected indicators include whether there is a community health needs assessment process and whether adequate laboratory facilities are available to meet diagnostic and surveillance needs. For some purposes, broadly framed indicators might be broken into more specific components (e.g., does the needs assessment include morbidity information).

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary TABLE 2 Performance Indicators for Local Public Health Practice Assessment For the jurisdiction served by your local public health agency, is there a community health needs assessment process that systematically describes the prevailing health status and needs of the community? In the past three years in your jurisdiction, has the local public health agency surveyed the population for behavioral risk factors? For the jurisdiction served by your local public health agency, are timely investigations of adverse health events, including communicable disease outbreaks and environmental health hazards, conducted on an ongoing basis? Are the necessary laboratory services available to the local public health agency to support investigations of adverse health events and meet routine diagnostic and surveillance needs? For the jurisdiction served by your local public health agency, has an analysis been completed of the determinants and contributing factors of priority health needs, adequacy of existing health resources, and the population groups most impacted? In the past three years in your jurisdiction, has the local public health agency conducted an analysis of age-specific participation in preventive and screening services? Policy Development For the jurisdiction served by your local public health agency, is there a network of support and communication relationships which includes health-related organizations, the media, and the general public? In the past year in your jurisdiction, has there been a formal attempt by the local public health agency at informing elected officials about the potential public health impact of actions under their consideration? For the jurisdiction served by your local public health agency, has there been a prioritization of the community health needs which have been identified from a community needs assessment? In the past three years in your jurisdiction, has the local public health agency implemented community health initiatives consistent with established priorities? For the jurisdiction served by your local public health agency, has a community health action plan been developed with community participation to address priority community health needs? During the past three years in your jurisdiction, has the local public health agency developed plans to allocate resources in a manner consistent with the community health action plan? Assurance For the jurisdiction served by your local public health agency, have resources been deployed as necessary to address the priority health needs identified in the community health needs assessment? In the past three years in your jurisdiction, has the local public health agency conducted an organizational self-assessment?

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary For the jurisdiction served by your local public health agency, are age-specific priority health needs effectively addressed through the provision of or linkage to appropriate services? In the past three years in your jurisdiction, has there been an instance in which the local public health agency has failed to implement a mandated program or service? For the jurisdiction served by your local public health agency, have there been regular evaluations of the effect that public health services have on community health status? In the past three years in your jurisdiction, has the local public health agency used professionally recognized process and outcome measures to monitor programs and to redirect resources as appropriate? For the jurisdiction served by your local public health agency, is the public regularly provided with information about current health status, health care needs, positive health behaviors, and health care policy issues? In the past year in your jurisdiction, has the local public health agency provided reports to the media on a regular basis? SOURCE: Unpublished material provided by B. Turnock, University ofIllinois at Chicago, and A. Miller, University of North Carolina,May 1995. Using Public Health Performance Measurement The information that monitoring public health performance provides has various applications. At the national level, the measurement tools being developed provide a way to monitor progress toward the Healthy People 2000 objective of having 90 percent of the population served by local health departments effectively carrying out core public health functions. States and communities can use this kind of information to identify practice areas that need attention and to track changes in performance and the circumstances associated with those changes. The assessment framework can also provide guidance for education and training for the public health workforce. An additional application, which has been adopted in Illinois, is using performance indicators in the certification of local health departments. National Surveillance Responses from the University of Illinois at Chicago's national survey of a sample of local health departments indicated that, on average, those health departments performed about 50 percent of the activities associated with the 10 public health practices (see Table 1). Overall, health departments performed more of the practices related to the assurance function than those related to

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary assessment or policy development. In addition, performance of these practices was more extensive in larger health departments than in smaller departments. No attempt was made to compare performance in specific programmatic areas such as environmental health or maternal and child health. From the survey responses estimates were made that, in terms of the Healthy People 2000 objective, about 20–30 percent of health departments, serving about 40 percent of the population of the United States, had an “effective” level of performance. Effectiveness was defined in two ways: (1) performing 7 of the 10 public health practices listed in Table 1 or (2) from among those 10 practices, performing at least 2 of the assessment practices, 2 of the policy development practices, and 3 of the assurance practices. Application in Illinois In 1992 and 1994, the performance of local Illinois health departments was assessed using a set of 26 measures of public health practice (see Turnock et al., 1995). Between 1992 and 1994, the percentage of practices performed rose from an average of 55 percent to an average of 85 percent. Several changes contributed to the improved performance. Local health departments reported that the most influential was the state's requirement that they conduct assessments based on NACCHO 's APEXPH model (NACHO, 1991) or on an Illinois version called IPLAN (Illinois Plan for Local Assessment of Needs). Reports from the local health departments indicated that the Illinois Public Health Leadership Institute had its greatest impact on policy development activities. Changes in the state certification requirements, including the IPLAN process, had a broad impact across all areas of public health practice. They shifted attention away from a standard set of programmatic tasks to assessing and responding to local health needs, which is more consistent with the core functions and public health practices that are reflected in the 26 performance measures. Implementation of the requirement for community health assessment was based on a collaboration between the state and the local health departments. For most local health departments, community health needs assessment was a new and unfamiliar task for which they had few resources and little training. The state health department provided resources in the form of orientation and training programs. It also developed a data system that could give local health departments access to essential information and provided the training and equipment needed to use the data system.