Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
APPENDIX B ORGANIZATIONAL SYSTEMS AND RELATIONSHIP SUBCOMMITTEE REPORT
The public health system is defined as that "community of interest" comprised of state and local professionals from the public, private and voluntary sectors who protect the public's health by preventing disease and promoting health. In a broad sense, the Organizational Systems and Relationships Subcommittee sought to assess the ability of the public health infrastructure, including governmental agencies and their community partners, to fulfill this role at the state and local levels. It did not seek a "best practices" model per se although its review included assessing the conditions or attributes that contribute to best practices and high performance. The Subcommittee was specifically concerned with identifying those assets that are critical to the successful function of public health organizations. In addition, the Subcommittee wanted to better understand and document the determinants of and barriers to quality and effectiveness for the public health delivery systems.
- Jo Ivey Boufford, MD, Professor, Wagner School of Public Service, New York University
- Joan Ellison, RN, MPH, Co-Chair, Chairman Work Group, Public Health Council member; Public Health Director, Livingston County
- Paul Halverson, Dr. Ph, Co-Chair, Senior Scientist and Director, Division of Public Health Systems Development and Research, Centers for Disease Control and Prevention
- Karen Hein, MD, President, William T. Grant Foundation Peter Levin, Sc. D., Dean, NY School of Public Health Benjamin Mojica, MD, MPH, Vice President, New York City Health and Hospitals Corporation
- Ana Olivera, Executive Director, Gay Men's Health Crisis, Inc.
- Isaac Weisfuse, MD, MPH, Deputy Commissioner, NYC Department of Health and Mental Hygiene
- To evaluate the key factors that contribute to operational effectiveness;
- To identify gaps in local or state resources;
- To identify the extent to which State and Local Health Departments (LHDs) are engaging partners and communities;
- To identify emerging or critical needs;
- To document barriers to success;
- To acknowledge new initiatives and opportunities for improved performance; and, if appropriate,
- To seek out best practice attributes that might be replicated elsewhere.
The Organizational Systems and Relationship Subcommittee reviewed prior reports on the organizational structure and authority of public health, its private and public partnerships and its leadership challenges. These included:
- Background information of the public health systems in NYS and agencies;
- Information on state funding for LHDs; and
- Updates on community health partnerships.
The Subcommittee directed particular attention to issues of resource adequacy, work force competence and system robustness, all of which contribute to a successful, well-integrated public health delivery system. In particular, the Subcommittee considered what barriers constrain performance, what organizational strengths hallmark success and what recommendations for improvement can be offered.
To organize their assessment, the Subcommittee framed their review based on the National Public Health Performance Standards Program/New York (NPHPSP) recently completed by the Centers for Disease Control and Prevention (CDC). This study asked all New York State counties to complete a self-assessment on performance within the 10 Public Health Essential Services. The CDC analyzed the data for each essential service, producing individual county and state average scores.
In choosing the CDC's NPHPSP evaluation, the Subcommittee concentrated on four essential public health services which in Version 5b and 5c had average local public health assessment scores below the Overall New York Average Score (N= 64). The Subcommittee chose one more essential public health service (# 2: Plan for Emergencies) to satisfy efforts being undertaken in the critical area of emergency preparedness.. (Please see Section VII in the full report for more information on the NPHPSP self-assessment by New York State Local Health Departments.) The five areas of essential service focus for this subcommittee were:
- Essential Service # 1: Monitor Health Status to Identify Community Health Problems - (average LPH Scores of 48 and 52)
As seen in Figure 1, counties had low scores for Monitoring Health Status as compared to the overall State average for all ten essential services of 64. Use of current technology was identified as a problem area.
- Essential Service # 4: Mobilize Community Partnerships to Identify and Solve Health Problems - (average LPH Scores of 59 and 56)
Results for EPHS 4: Mobilize Community Partnerships fall just below the average for all essential services. Similar scores were given for Constituency Development (60, 52) and Community Partnerships (59, 60). 56
- Essential Service # 5: Develop Policies and Plans that Support Individual and Community Health - (average LPH Scores of 54 and 59)
Local health department responses for EPHS 5: Develop Policies and Plans show similar scores across the focus subcategories. All scores were slightly below the overall state average.
- Essential Service # 9: Evaluate Effectiveness, Accessibility, and Quality of Personal and Population-Based Health Services - (average LPH Scores of 48 and 42)
As seen in Figure 4, counties had low scores for EPHS 9: Evaluate Effectiveness. Evaluation of local public health systems was identified as especially problematic (35, 24).
- Essential Service # 2.2, 2.3: Plan For, Investigate and Respond to Public Health Emergencies: Investigate Emergencies and Laboratory Support - (average LPH Scores of 80 and 92; 87and 86)
County responses for both Investigating Emergencies and Laboratory Support were well above the overall state average for all essential services.
Subcommittee Interview Survey Instrument
The Subcommittee developed a set of questions related to these essential service categories and interviewed representatives of 5 local health departments. The questions were e-mailed in advance of scheduled telephone interviews. The participating counties were chosen to reflect a reasonable cross section of New York State: 2 urban counties, 2 rural counties and 1 suburban county. Only the suburban county was a less than full service county, that is, they do not directly deliver environmental health services. The other 4 counties are full health departments. Three counties participated in the call as teams of two or three professionals. Two interviews were conducted with only one respondent. One county submitted written answers to the questions and then participated in a follow up telephone interview to expand or clarify the answers. A listing of the questions is presented as an Attachment to this report.
In many circumstances, the size and character of a county (rural versus urban, full versus partial service) may impact how effectively a local health department carries out its responsibilities. Certain organizational needs appeared in varying degrees across all county responses however, striking themes that were common to all. Among the determinants of a successful public health system was strong leadership, good communication skills that can build and sustain partnerships and evidence based decisions on policy development and resource allocation. To consider needs, however, there were concerns/gaps noted in the following areas:
- Leadership and Communication
- Leadership is key for public health effectiveness, particularly in settings where the knowledge and understanding of public health may not be current or where other concerns distract. So too is persuasive communication. Not all participants felt they possessed the requisite skill set to successfully meet opposing viewpoints or overcome competing agendas in their local communities;
- Success in building and sustaining coalitions was sited by all interviewees as critical to effective public health system performance no matter the county size, character or funding. Crisis events were mobilizing and demonstrated the benefits of synergy and effective action when concerns were commonly held. Keeping a community coalition committed for the longer term was still a challenge however. Regional networks were emerging as hopeful organizational structures for collective action;
- County governments, legislatures and boards of health can facilitate or impede LHD efforts with support for or resistance to new policy and program initiatives. Plans to respond to bioterrorism were embraced uniformly, for example, and met with no resistance. On the other hand, efforts to restrict or proscribe the sale or use of tobacco can often meet with opposition.
- Regional Networks and Partnerships
- All responders acknowledged that emerging regional networks (rural or otherwise), partnerships with local academic institutions or other collaborations were critical to amassing the necessary resources to meet new challenges. Moreover, all counties commented positively on their BT grant experience. They believe this inclusive approach to plan and execute public health initiatives is an emerging process model to be used more broadly by public health to secure community wide commitment;
- All responders acknowledged that regional networks (rural or otherwise), partnerships with local academic institutions or other collaborations were critical to amassing the necessary resources to meet new challenges; moreover, all counties commented positively on their BT grant experience. They believe this process is an emerging model to be used more broadly by public health to secure community wide commitment;
- Evaluation and Outcome Analysis
In spite of an acknowledged absence of expertise in evaluation methods to provide evidence-based outcome analysis, many counties interviewed recognize how central data interpretation is to effective system management. Counties understand that policies are informed by data analysis. They appreciate the degree to which priorities could be better set if data validated management choices. Importantly they know the advantages good information can bring to coalition building. While all counties want to demonstrate service efficacy, it can be a challenge to communicate objective benefits. Specifically they cited the need for:
- The development of policies and priorities that flow from objective analyses of program performance; this is particularly necessary in the face of competing needs and finite resources. All too often, they are instead shaped or informed by anecdotal information rather than careful data interpretation;
- Expertise in epidemiological analysis, surveillance monitoring, data analysis and evaluation methods for public health professionals and counties. Specific data related gaps include:
- An absence of standardized outcome indicators uniformly set for all federal, state and local programs;
- No sub-county, geo-coded (zip code level) data with which to track progress in areas where interventions were applied;
- Too few standardized conventions and definitions that would facilitate linkage across multiple databases;
- A perceived low value ascribed to data analysis on the part of some public health professionals in the field.
- The larger, better funded counties are making progress in quantifying the benefit of public health services through outcome measurements and evidence based assessments; they are doing this with local partners better equipped to undertake such assessments such as universities, medical schools and schools of public health. Some enjoy a county level leadership that recognizes the importance of good data analysis to support decisions and compel appropriate action.
In consideration of these findings, the Organizational Systems and Relationship Subcommittee makes the following recommendations:
Essential Public Health Service # 1 and 2.2, 2.3
- Innovative means must be sought to motivate different organizations in a community to work together to achieve their common public health goals. Incentives should be considered which promote partnerships, inspire leadership, build a common purpose and create synergistic organizations.
- The New York State Department of Health (NYSDOH) and its academic partners should creatively use and make available to counties expert resources organized by and available in the disciplines of disease surveillance, epidemiological analysis, behavioral science, environmental health, social marketing, community organizing and public health administration. This need is particularly acute for counties that lack the resources to purchase or leverage such services independently.
- NYSDOH should continue its commitment to improve and provide continuous technical assistance and training on specific Information Technology (IT) networks. These would include such systems as the Health Provider Network (HPN), the Health Information Network (HIN) and the Health Alert Network (HAN) for local health department (LHD) personnel and their community partners (local hospitals) for whom the HPN delivers particular benefit.
Essential Public Health Service # 4 and # 5
- To the degree possible, the pooling of government and other community assets must be effected, whether through regional collaborations, academic partnerships or through addressing governance and statutory issues which may present barriers to optimizing organizational capacity. Successful initiatives cited by all county interviewees came as a result of strong collaborative efforts that transcended traditional silo organizational approaches.
- Training should be developed to teach State and LHD professionals how to develop and sustain community partnerships. Based on these strategies and best practices, local health leaders must increasingly use coalitions and partnerships to execute their programs. Getting things done through regional, cooperative approaches such as those used to undertake bioterrorism planning is key. This model ( BT Grant) serves as a useful process for other community partnerships in the future.
- Training needs to expand to include targeted skills building for public health directors on leadership, coalition building, and notably on the art of effective communication, particularly to an increasingly culturally diverse community.
Essential Public Health Service # 9
- Allocating resources to the populations of highest need with interventions that demonstrate the greatest benefit will increase as a strategy as the population becomes more diverse and presents with additional needs. Evaluation and outcome analysis must be a key determinant in public health policy and program development.
- There must be greater commitment to the ongoing evaluation of programs and services throughout the public health system (local and state level) to provide (1.) for accountability and (2.) the basis for continuing improvement in system effectiveness and/or efficiency;
- There must be training on the new science of informatics and on data analysis techniques in order to support smart use of resources, set policy and determine priorities; alternatively, to properly document and communicate the consequences when resources are reduced or eliminated;
- There must be a more effective outreach to LHD professionals to support their use of self appraisal and other evaluation applications and to strengthen the capacity at the LHD to undertake such disciplines with consistency;
- There must be standardization of public health program outcome indicators (federal, state and local) so that effectiveness can be measured and benefits communicated when useful and appropriate; conversely so that shifts in policy direction or service delivery can be made.
Attachment I: Telephone Interview Questions
Essential Public Health Service # 1: Monitor Health Status to Identify Community Health Problems
- How would you describe the strengths of your department that allowed you to achieve this level of success?
- If you had a wish list for training, related to ES# 1, what would that include?
- How frequently is the community health assessment conducted?
- How does the county generate a community health assessment?
- Were past community health assessments or current ones done by the department or did you engage community partners?
- Do you have an existing community partnership/coalition?
- How does the county disseminate the information in the community health profile to the community?
- How does the county use the community health profile in planning for public health and other services?
- Can you point to an outcome you are especially pleased with that illustrates yourproficiency in ES# 1?
Essential Public Health Service # 4: Mobilize Community Partnerships to Identify and Solve Health Problems
- How would you describe the strengths of your department that allowed you to achieve this level of success?
- What are the barriers facing staff when carrying out ES# 4?
- If you had a wish list for training, related to ES# 4, what would that include?
- How did you mobilize partners to solve health problems? 5. Can you point to an outcome that illustrates your proficiency in ES# 4?
Essential Public Health Service # 5: Develop Policies and Plans that Support Individual and Community Health Efforts
- How do policies and plans that support individual and community health efforts come to exist?
- What is the local governing structure?
- What barriers might you have encountered that you feel hindered your progress?
- Can you point to an outcome you are especially pleased with that illustrates your proficiency in ES# 5?
Essential Public Health Service # 9: - Evaluate Effectiveness, Accessibility, and Quality of Personal and Population-Based Health Services
- Describe the barriers facing staff when carrying out ES# 9?
- If you had a wish list for training, related to ES# 9, what would that include?
- How does the country establish criteria for evaluation of personal and population-based health services?
- Can you point to an outcome you are especially pleased with that illustrates your proficiency in ES# 9?
Essential Public Health Services # 2.2, 2.3: Plan For, Investigate and Respond to Public Health Emergencies: Investigate Emergencies and Laboratory Support
- What enhanced or prevented your ability to monitor for rapid detection and do a hazard assessment?
- How would you describe the strengths of your department that allowed you to achieve this level of success at the time of the CDC National Performance Standards survey?
- Describe barriers facing staff when carrying out ES # 2.2, 2.3?
- If you had a wish list for training, related to ES # 2.2, 2.3, what would that include?
- What has changed?