PUBLIC HEALTHIMPROVEMENT PLAN

Always

working

for a

safer

and

healthier

Washington

2 0 0 4

A VISION FOR WASHINGTON’SPUBLIC HEALTH SYSTEMWashington State’s public health partners envision a public health system thatpromotes good health and provides improved protection from illness and injuryfor people in Washington State.

To help realize that goal, the public health system is committed to:• Focusing our resources effectively, defining and monitoring outcomesoutcomesoutcomesoutcomesoutcomes for key public health

issues and trends, and emphasizing evidence-based strategies.

• Maintaining a results-based accountabilityaccountabilityaccountabilityaccountabilityaccountability system, with meaningful performance measuresand program evaluation.

• Using a method of fundingfundingfundingfundingfunding across the public health system that is stable, sufficient, andequitable.

• Using standard technologytechnologytechnologytechnologytechnology across the public health system.

• Maintaining a workforceworkforceworkforceworkforceworkforce that is well-trained for current public health challenges and hasaccess to continuous professional development.

• Facilitating discussions about health care accessaccessaccessaccessaccess and delivery issues from the perspective ofcommunity systems, where the experiences of patients, providers, purchasers, and payers areconsidered important components.

• Applying communicationcommunicationcommunicationcommunicationcommunication strategies that are effective and foster greater public involvement inachieving public health goals.

• Establishing new coalitions and alliances—among stakeholders, policy makers, and leaders—that support the mission of public health.

The 2004 Public Health Improvement Plan summarizes the work of many people who havejoined efforts in committees and work groups. More detailed, full reports are available.

To obtain copies of this report, or copies of committee reports, please contact:

Joan Brewster, DirectorPublic Health Systems Planning andDevelopmentWashington State Department of Health101 Israel Road SETumwater, WA 98507

Phone: (360) 236-4062Fax: (360) 586-7424E-mail: joan.brewster@doh.wa.gov

1

PHIP 2004:

TRANSFORMING PUBLIC HEALTHIN CHALLENGING TIMES

December 2004

DOH Pub 802-021 12/2004

101 Israel Road SETumwater, WA 98507

2

ACKNOWLEDGMENTS

Washington State Department of Health2004 Public Health Improvement Plan Development TeamJoan Brewster, Director, Public Health Systems Planning and Development

Marie Flake, Local Health Liaison

Simana Dimitrova, Administrative Assistant

Kay Koth, Health Services Consultant

Editorial Design/Consultant TeamAlice Porter, Editor

Alessandro Leveque, Designer

Clarice Keegan, Desktop Publisher

Kay Koth, Copy Editor

Project PartnersThe 2004 Public Health Improvement Plan is produced by the Washington StateDepartment of Health in accordance with RCW 43.70.520. Partners in itsdevelopment are:

Washington State Department of Health

Northwest Center for Public Health Practice, University of Washington School of Public Health andCommunity Medicine

Washington Health Foundation

Washington State Board of Health

Washington State Association of Local Public Health Officials (WSALPHO)

PHIP on-line:www.doh.wa.gov/phip

3

Dear Friends of Public Health:

It is a pleasure to introduce the 2004 Public Health Improvement Plan, Transforming Public Healthin Challenging Times. This work is the product of a truly remarkable partnership among manypeople who are always working to create a safer and healthier place for all of us in WashingtonState. They include local public health officials, state health officials, the School of Public Health atthe University of Washington, and the Washington Health Foundation.

The Public Health Improvement Plan (PHIP) was established in legislation in 1993 and is to bepresented to the legislature every two years. The legislation called for the public health system tomeet standards and analyze what it will take to meet those standards, in terms of budget andstaffing. In 1995, legislation called for assessment of the public health system and identification ofwhat is needed for “the public health system to fulfill its responsibilities in improving healthoutcomes.”

These requirements are the underpinnings of a continuous effort to improve the health of people inevery community throughout our state. The cooperative effort of our PHIP Partnership has created astronger public health network, despite a critical shortage of resources. Through the PHIP, thepublic health partners have set a clear vision for a healthier future and created a strategic plan tobring it about. Along the way, we have developed a health report card, set performance standardsfor state and local public health jurisdictions, estimated the costs of achieving those standards andevaluated what must be done to respond to challenging issues in our workforce, with information-technology, and with access to health services in our communities.

Our state is fortunate to have a workforce of dedicated public health professionals who work toprotect and improve the health of people everywhere in Washington. I extend my thanks to every-one who has a hand in making this partnership work. I look forward to seeing the recommenda-tions in this report fulfilled, as we realize our hopes for safer and healthier Washington.

Sincerely,

Mary C. SeleckySecretary of Health

December 30, 2004

4

PHIP STEERING COMMITTEETorney SmithSpokane Regional Health DistrictArt Starry*Thurston County Public Health and Social ServicesDepartmentGreg SternWhatcom County Health DepartmentCorinne StorySkagit County Public Health DepartmentMaryann WelchGrays Harbor County Public Healthand Social Services Department

Department of HealthJanice Adair, Division of Environmental HealthJoan Brewster, Public Health Systems Planning andDevelopmentTim Church, Communications OfficeKatherine Deuel, Human ResourcesJohn Erickson, Public Health Emergency Preparedness andResponseMarie Flake, Public Health Systems Planning andDevelopmentMaxine Hayes, Health OfficerPatty Hayes, Division of Community and Family HealthLaurie Jinkins, Division of Health Systems QualityAssuranceHeidi Keller, Office of Health PromotionMary Looker, Office of Community and Rural HealthDonna Russell, Public Health Systems Planning andDevelopmentRita Schmidt, Division of Community and Family HealthLois Speelman, Office of Financial ServicesChris Townley, Policy, Legislative, and ConstituentRelationsJude Van Buren, Division of Epidemiology, HealthStatistics and Public Health LaboratoriesFrank Westrum, Chief Information Technology OfficerBill White, Deputy SecretaryJack Williams,* Office of the Secretary

State Board of HealthCraig McLaughlin, Executive Director

University of WashingtonMark OberleSchool of Public Health and Community MedicineJack ThompsonNorthwest Center for Public Health Practice

Washington Health FoundationGreg Vigdor, President and Chief Executive Officer

Mary Selecky, Co-chairWashington State Department of HealthSecretary of HealthLarry Jecha, Co-chairBenton-Franklin Health District

Washington State Association of LocalPublic Health Officials (WSALPHO)Jean Baldwin*Jefferson County Health and Human ServicesSherri BartlettLincoln County Health DepartmentPeter BrowningSkagit County Public Health DepartmentJanet Charles*Clark County Health DepartmentScott DanielsKitsap County Health DistrictJanet DavisWhatcom County Health DepartmentEd DzedzyLincoln County Health DepartmentDave EatonWalla Walla County Health DepartmentLarry FayPublic Health—Seattle & King CountyEdmund GrayNortheast Tri-County Health DistrictSue GrinnellCowlitz County Health DepartmentWard HindsSnohomish Health DistrictGordon KellyYakima Health DistrictVicki KirkpatrickWSALPHOKay Koontz*Clark County Health DepartmentTom LockeClallam County Department of Healthand Human ServicesTim McDonaldIsland County Health DepartmentJulie Miller*Thurston County Public Healthand Social Services DepartmentRick MocklerSnohomish Health DistrictSuzanne PlemmonsKitsap County Health DistrictDebbie RileyMason County Department of Health ServicesTerry RundellKlickitat County Health Department

*Has completed term

5

TABLE OF CONTENTS

Acknowledgments ................................................................................................................... 2PHIP Steering Committee ...................................................................................................... 4Transforming Public Health in Challenging Times................................................................. 7Summary of PHIP Recommendations for 2005-07 .............................................................. 13Key Health Indicators: Information that Works .................................................................... 15Public Health Standards: Steps to Improve Health ............................................................... 19Financing Public Health: Investment that Works for Better Health Solutions ...................... 25Information Technology: Reliable Information for Better Health ......................................... 31Workforce Development: A Statewide Network of Public Health Professionals .................... 35Access to Critical Health Services: Helping People Get Needed Services ............................... 41Effective Communication: Improving Understanding of Public Health ................................ 45

AppendicesAppendix 1: PHIP Committees ............................................................................................ 51Appendix 2: List of Key Health Indicators ............................................................................ 57Appendix 3: Sample Report Card—Grading Rationale ......................................................... 60Appendix 4: Crosswalk of Core Functions and 10 Essential Services to Standards ................ 62Appendix 5: Environmental Health Standards ...................................................................... 64Appendix 6: List of Services to ‘Cost’ the Standards .............................................................. 67Appendix 7: PHIP Laws ....................................................................................................... 69Appendix 8: Developing Estimates of Cost to Meet Washington’s Public Health Standards .. 71Appendix 9: Summary of Proposed Funding Methodology and Allocation Principles ........... 77Appendix 10: Evolving Roles to Support Information Technology for Public Health ........... 79Appendix 11: PHIP System-level Competencies ................................................................... 81Appendix 12: Improving Access to Care in Whatcom County .............................................. 83

6

Always working for a safer and healthier Washington

7

We live in times that have conditioned us tothink seriously about what it takes to be healthyand safe.

Our communities are becoming more crowded,more closely linked through travel, trade, andtechnology. As globalization increases, we facethe threats posed by both new and re-emergingdiseases that have greater opportunity thanever before to make their way around the world.As growing populations demand more re-sources, the quality of our air, water, and foodis increasingly threatened. And since Septem-ber 11, 2001, we have recognized and preparedfor new threats to our safety, such as thoseposed by bioterrorism.

It seems the world moves faster and everythingis more complicated—even a trip to the grocerystore is not as simple as it appears to be (seebox, page 8).

For each of these new challenges, the publichealth system plays a vital role in protectingpeople from harm while taking steps to reducethe health impacts felt in our changing world.The public health system is a network of agen-cies that are “always working for a safer andhealthier Washington.” This work engagesgovernment agencies—at the state and in 35local public health departments and districts—and a public health workforce of several thou-sand people, who work with thousands moreresearchers, scientists, health care providers,and other community partners.

In this sixth biennial report of Washington’sPublic Health Improvement Partnership (PHIP),we focus on the activities that are underway tokeep our state’s public health system perform-ing to the best of its ability. In many respects,the activities associated with the PHIP since itsinception in 1994, as an ongoing requirement ofthe Washington Legislature (RCW 43.70.520),have shaped the public health system today.The PHIP has moved us from a loosely associ-ated group of government agencies focused onspecific programs and clinical services to aclosely integrated and coordinated system.Each local agency continues to serve the needsof its own community, but through the PHIP,Washington’s public health leaders also work inconcert to set a vision for the future, to focus onpublic health priorities, and to direct dwindlingresources to where they are most criticallyneeded to improve and protect health.

Remarkably, this transformation has occurredduring the course of a long slide in funding forpublic health, one that continues to undermineplanning and weaken the infrastructure. Duringthis time, the state and national economy haveslumped into recession. The dedicated fundingsources that once sustained public health workhave nearly disappeared. Since September 11,2001, new resources have come into the stateto combat bioterrorism, but they cannot supportthe improvements—in surveillance, technology,and workforce expansion—that today’s morecomplex public health environment demands.

TRANSFORMING PUBLIC HEALTHIN CHALLENGING TIMES

The PHIP has moved us from a loosely

associated group of agencies focused on specific

programs and clinical services to a closely

integrated and coordinated system.

8

The need for vigilanceThe year 2003 closed with the nation’s atten-tion riveted on Washington State: A case of“mad cow” disease had been linked to a farm inour state—a case that had potentially profoundimplications for public health and instantimpact on agriculture. Within minutes, thepositive test result set off a national responsethat linked Washington’s health and agricul-tural communities with the nation’s top scien-tists and policy makers. In the days and weeksthat followed, new protocols were adopted for

monitoring cows, and the entire industrygeared up for increased testing and tracking ofanimals.

Maintaining vigilance is the key to protectingthe public’s health. BSE—or mad cow—diseaseis an emerging threat, but as the box on page 9points out, we cannot afford to turn our backson old threats. They will re-emerge if left unat-tended. Public health measures such as immu-nizations and tracking and treating communi-cable disease are just as vital today as theywere at the turn of the century in 1900.

Keeping Our Food Supply Safe to EatIn the 1950s, your typical neighborhood grocery store carried about 300 different food items,many of them produced locally. Today, a supermarket routinely carries about 30,000 various fooditems from around the world, reflecting both the scale of corporate farming and the reach of theglobal economy. Interestingly enough, with this wide variety of foods available for home prepara-tion, people eat out more, sustaining a restaurant industry that does more than $300 billionworth of business a year. And hot foods, ready to serve, are commonplace at neighborhoodgrocery stores.

This evolution of the food supply, food service industry, and customer behavior has put extraordi-nary pressures on public health food safety programs, which must adapt to new causes of food-borne disease outbreaks and the illnesses they cause. In Washington State, 1.5 million food-borne illnesses occur each year, including 6,500 hospitalizations and nearly 100 deaths. Thisyear, the state Department of Health Division of Environmental Health worked with the StateBoard of Health to revise the state’s food service rules. The new rules incorporate the latestscientific information about safe food handling from the federal Food and Drug Administration’sModel Food Code (see http://www.doh.wa.gov/ehp/sf/food.htm).

In the past decade, the primary cause of food-borne illness was holding food at an impropertemperature—most often food allowed to coolin too large a container or not cooked thor-oughly. This was the cause of the well-knowncase in our state in 1993 linked to fast-foodhamburgers that contained the bacteriumE.coli 0157:H7. In response, rules and trainingfocused on temperature control. Today, themost common cause of food-borne illness isinadequate hand-washing by food servicepersonnel. The new rules will prohibit bare-hand contact with foods that are ready-to-eat,continue to stress the importance of handwashing, and more clearly define when an illworker must be restricted from the kitchen.

9

Public health agencies are stretched to theirlimits trying to keep older problems at bay and,at the same time, prepare for emerging threats.Over the past year, local and state public healthworkers have devoted time and special exper-tise to develop detailed plans to respond toSARS, West Nile Virus, bioterrorism, and avianflu. They did not happen in our state—but any ofthem could happen, at just about any time, and

the public health community must be ready torespond quickly to reduce the amount of dis-ease and the number of deaths that wouldresult.

PHIP: vision to actionThe PHIP is a consortium of the state Depart-ment of Health, the State Board of Health, the

TB: Fighting an Old Public Health BattleTwo global trends—the ease of travel and an increase in congregate living—are driving up thenumbers of people affected by old scourges that were once thought to have been conquered bypublic health and medical interventions.

One such scourge is tuberculosis, with which a third of the world’s population is now infected. TBwas once the leading cause of death in the United States, but its incidence dropped steeply forfour decades with improvement in living conditions and development of drug therapy in the 1940s.With the rise in immigration, homelessness, and immune-suppressing conditions such as HIV, TBhas re-emerged since the late 1980s with a vengeance among homeless and immigrant popula-tions and also among other risk groups such as the very young and the elderly.

Washington, which experiences more than 250 new TB cases in a year, is one of about a dozenstates with TB rates above the national average. King County, which has experienced severaloutbreaks since 2000—some among homeless, foreign-born men—reported its highest number ofcases (156) in 30 years (2003). Another significant outbreak occurred in Yakima County in 2003,this time concentrated among the native-born.

People can feel well enough even with active TB infection to work and attend school, but theybegin to feel ill when they take the powerful drugs to treat it. For this reason, many patientsdiscontinue the months-long treatment, a situation that forces public health agencies to imple-ment costly and time-consuming directly observed therapy.

A root cause of the new wave of TB outbreaks is poverty and the rising number of uninsured inWashington and throughout the country. Lack of access to health services can delay diagnosis.And many of the poor who are at greatest riskof contracting TB have no convenient orreliable place to go for treatment.

Accessing care does not guarantee detectionof TB infection, however. Patients wereroutinely treated in sanitariums, the last ofwhich closed in Washington during the late1960s. Since then, generations of health careproviders rarely encountered a case. Thepublic health system is working with provid-ers to recognize the new face of the disease.

See http://www.doh.wa.gov/cfh/tb.

10

Promoting Tested Weapons Against Chronic DiseasePublic health programs may not have eliminated the threat of infectious diseases, but they haveremoved them as leading causes of death. Today, more Americans die from chronic diseases suchas heart disease, cancer, and stroke—and public health systems are eager to identify the mosteffective population-based approaches to reducing the rates of premature deaths associated withthem.

Washington is the only state to receive two “Steps to a Healthier US” grants, as part of a federalinitiative to identify strategies to prevent chronic disease—in some cases, right at the neighbor-hood level. The grants, which the U.S. Centers for Disease Control and Prevention awardedseparately to the state Department of Health and Public Health—Seattle & King County, imple-ment integrated, scientifically based strategies to drive down rates of obesity, diabetes, andasthma as well as their complications. This work has engaged hundreds of community partners,including schools, work sites, and health care providers.

The state grant will focus more than $16 million in federal funds over five years in four communi-ties: the contiguous area of Chelan, Douglas, and Okanogan counties; the Confederated ColvilleTribes; Thurston County; and Clark County. Working with schools, work sites, health care settings,and the communities-at-large, the Steps program seeks to identify and implement sustainableinterventions that improve access to healthy foods and opportunities for physical activity andreduce exposure to tobacco smoke and other asthmatriggers. Entire communities—from children eatingschool lunches to local political leadership—arebrought into these efforts. “We hope to see some realbehavioral change,” explains state Steps ManagerLauren Jenks, “not just among community members butamong policy makers, too.”

The local grant supports interventions in South Seattleand South King County, including programs to encour-age students to become more physically active bybiking to school and training community health workersto help families remove asthma triggers from the home.

Washington State Association of Local PublicHealth Officials (WSALPHO), the University ofWashington School of Public Health and Com-munity Medicine, and the Washington HealthFoundation. Each partner is essential tostrengthening the performance of Washington’spublic health system and positioning it toaddress emerging issues effectively.

The future vision that guides this work (seeinside cover) is complemented by a specificworkplan that addresses seven broad goals.Each goal is supported by an active committeeof professionals drawn from many fields. Themembers represent a wide spectrum of publichealth agencies: large and small, east and

west, practice and academic communities.Bringing talented people to the table on astatewide basis, the PHIP has become a conduitfor innovation, for exchanging ideas, and formaking commitments for action. The partner-ship has become an expected way of doingbusiness in public health. It is collaborative,inclusive, and creative.

The work of each committee is carried out overtwo years and is summarized in this report, thePublic Health Improvement Plan. The purposeof each committee is stated briefly below. Theirrecent accomplishments, and their complemen-tary goals and written objectives for 2005-07,are shown on pages 12 and 13-14.

11

PHIP Committees:

• Use science-based strategies to signalimportant public health issues and trends(Key Health Indicators Committee).

• Make both state and local public healthagencies accountable for meetingestablished performance measures(Standards Committee).

• Identify and describe stable, sufficient,and equitable funding needed to carry outpublic health services (FinanceCommittee).

• Link information systems and provideefficient tools for sharing information(Information Technology Committee).

• Maintain a well-trained workforce that hastimely access to professional development(Workforce Development Committee).

• Explore community actions that promotehealth care access (Access to CriticalHealth Services Committee).

• Foster greater public understanding andinvolvement in achieving public healthgoals (Communications Committee).

Washington’s public health officials believe thatwe can create a healthier future, where commu-

nities as a whole, and the families and individu-als within them, are as healthy as they can be.This means more than an absence of illness—itmeans a robust level of well-being and a goodquality of life for all.

The work of the PHIP helps us all pull togetheron efforts that will improve public healthpractice in every community. Using a ReportCard, applying performance measures, andsponsoring workforce development are all waysto strengthen the network of agencies dedi-cated to better health.

In addition, active work is underway to translatepublic health ideals into everyday living. Pro-grams such as “Steps to a Healthier US” (seebox, page 10) can lead us to a healthier future.We have great opportunities ahead in the areaof combating chronic disease, but we will makethose gains only through concerted effort and astrong public health system.

Washington’s public health system is poised toaccomplish its goals. The ability to do so,however, will depend on resources needed tokeep the public health system stable and well-prepared in every community.

Influencing the NationThe Institute of Medicine has published two sentinel reports on the status of public health in theUnited States, in 1988 and in 2002. In both volumes, national leaders point out the serious risksof allowing our public health system to erode. The work plan of the Public Health ImprovementPartnership responds to many of the recommendations and warnings of these reports, demon-strating for others what actions can reduce those risks.

Washington’s Public Health Improvement Partnership is highly regarded by public health profes-sionals throughout the country, and many of the specific projects outlined have been adapted foruse elsewhere. Examples include our Report Card, standards, workforce study, and communica-tions work. (For more information see http://www.iom.edu/Object.File/Master/4/165/0.pdf.)

12

CHARTING OUR PROGRESSThe Public Health Improvement Partnership carries out its work according to a specific work plan.Checked items have been completed or are nearly complete by December 2004. Remaining itemswill be worked on during January through June 2005.

Committee/Objective or Project

Key Health Indicators Committee✓ Maintain Report Card with data and grading.✓ Develop Key Health Indicators Action Guide for the web.■ Improve data systems and use of systems for the Report Card.

Standards Committee✓ Implement measurement schedule; prepare for measurement.✓ Test Administrative Capacities.■ Set system-wide priorities for future work and training.

Finance Committee✓ Study the cost of achieving the standards.✓ Develop funding allocation principles and communications.■ Publish a white paper on public health funding.

Information Technology Committee✓ Maintain and share results of an IT survey.✓ Continue VISTA development and use.✓ Coordinate and prioritize IT work statewide.■ Develop IT minimum standards for security, planning, and data.

Workforce Development Committee✓ Enumerate the public health workforce.✓ Acquire a Learning Management System.✓ Develop a regional learning network.✓ Maintain leadership development.■ Develop training based on standards findings.

Access to Critical Health Services Committee✓ Establish a committee on access from a public health viewpoint.✓ Gather information on local efforts to expand access.■ Promote exemplary practices on access and seek support.

Communications Committee✓ Prepare materials and trainings for the public health Identity Campaign.■ Conduct a statewide education campaign.■ Conduct a mid-course evaluation of campaign materials.

13

Key Health Indicators1. Adopt the Report Card.2. Publish the Report Card every two years in

a hard copy summary and web-basedformat, with links to additional informationand interventions.

3. Commit resources to develop andimplement a process to set targets.

Public Health Standards1. Adopt and apply the revised

administrative standards as part of theStandards for Public Health in WashingtonState.

2. Analyze the 2005 results of the system-wide measurement of the Standards forPublic Health in Washington State inconjunction with program requirements toidentify or reinforce priorities for system-wide improvements.

3. Identify and test methods to incorporatethe use of the standards throughout thework of public health as described in thelegislation that requires the PHIP anddevelopment of the standards (seeAppendix 7).

4. Adopt a contract monitoring system thatuses the standards as a framework.

Financing Public Health1. Increase public health funding by $400

million to close the funding gaps identifiedin the Finance Committee’s cost model.

2. Expand the Finance Committee to includebroader representation by state and localstakeholders to help identify opportunitiesto articulate the importance of fullyfunding our public health system, toexplore viable state funding options, andto get this information to decision-makers.

3. Implement the work of the FundingAllocations Subcommittee to make certainthat allocation formulas are clear and allfunding for programs is easily tracked on awebsite.

Information Technology1. Develop a shared administrative structure

for maintaining and enhancing evolvingapplications and development of a cost-sharing model for all public health ITsystems in Washington.

2. Identify top-priority areas where better useof technology could improve public healthpractice.

3. Evaluate and recommend standards forhardware, software, servers, security,distance learning, and data collection andtransfer.

4. Leverage financial investments intechnology most effectively.

5. Review and evaluate applications toidentify opportunities for efficiencies.

6. Implement on-going training into ITplanning.

Workforce Development1. Implement recruitment and retention

efforts at the agency and system level.2. Identify and develop a new generation of

managers and leaders to maintain andimprove the performance of public healthagencies and the overall public healthsystem.

3. Build on the success of the first EverybodyCounts report.

4. Promote access for public health workersto training, technology, and tools neededto support learning.

SUMMARY OF PHIPRECOMMENDATIONS FOR 2005-07

14

5. Use system-level competencies as theframework for assessing learning needs,and evaluate learning strategies thatincorporate return on investment.

6. Evaluate the usefulness of certificationand credentialing and other incentives atvarious levels of the public healthworkforce.

Access to Critical Health Services1. Collect and analyze community success

stories.2. Communicate lessons learned.3. Promote integration and availability of

data across programs.4. Look for additional resources to build on

this work.5. Develop long-term policy with respect to

critical health services.

Effective Communication1. Conduct advanced workforce training to

strengthen understanding of publichealth.

2. Adopt a set of communication strategiesthat will achieve broader understanding ofpublic health goals.

3. Collect and tell public health “stories” thatillustrate how public health affectseveryone who lives in or visitsWashington.

4. Conduct a statewide media event toincrease public understanding.

15

KEY HEALTH INDICATORS:INFORMATION THAT WORKS

A common framework for healthHow healthy are we? What makes us so? Howcan we improve and protect our health? Andhow can we protect ourselves from myriadthreats to our well-being? All health policyaddresses these questions, and the answersencompass no less than all of the systems—public and private—that affect our healthstatus. Capturing the answers in a frameworkthat policy makers can use has engaged the KeyHealth Indicators Committee for the past fiveyears.

Why is it so important to have a commonframework? By focusing on the key determi-nants of health, we can turn our attention andresources to the aspects of health protectionand promotion that promise the greatest gainsin well-being for everyone.

Most people think about “health” in a verylimited way. They think of doctor visits orhospitals. Sometimes they think about howthey feel or how easily they can move about indaily life. The Key Indicators Committee takes adeeper look at health, focusing on the “determi-nants of health” and measuring those that havethe greatest impact on our health. The contribu-tion of medical care is important, and it isessential when a person becomes ill. But otherfactors have a much greater impact on ouroverall health, including personal behaviors,such as smoking and physical activity and thesocial and physical environments in which we

live. The graph on page 17 shows the relativeweight of these factors.

A Report Card to measure healthTo track our health in Washington, the commit-tee has developed a Report Card using the keydeterminants of health. Like all report cards,this one will carry grades—about our overallhealth, our environment, our social and eco-nomic health, our health care system, ourcommunities, our families, and our individualbehaviors. The focus will be on modifiablefactors in each category. The committee hasalso added indicators to measure behavioramong our youth, to learn more about ouryounger children’s readiness to learn, and toassess how our families are doing—becausethese are key components of health for children(see box, page 17).

The committee developed grading criteria thatconsider how well Washington is doing com-pared with the United States as a whole,whether an indicator is improving or worseningover time, and whether significant disparitiesexist among racial or ethnic groups.

The Report Card is intended to inform andstimulate state and community discussion, aswell as policy development and action, byproviding solid information that will lead tobetter-targeted actions, and ultimately, betterhealth outcomes. It is intended to focusstrategic investments in health throughout the

To track our health in Washington, the

committee has developed a Report

Card using the key determinants of

health.

16

state. Good decisions begin with good informa-tion.

The Report Card is designed to be simple anddirect. To present more detailed information,the Department of Health will present theReport Card on a website beginning in 2005.The site will present the information thatsupports each grade, providing communitieswith meaningful data to inform communitydiscussion and action in six broad areas:

• How healthy are we overall?• How safe and supportive are our

surroundings?• How safe and supportive are our

communities?• How supportive is our health care system?• How safe and supportive are our families?• How healthy are our behaviors?

To maintain the Report Card, state epidemiolo-gists will conduct ongoing data collection forthe 52 indicators of health status (see Appendix2 for the list). The Key Health Indicators Com-mittee will assign grades every two years basedon established grading components: compari-sons, trends, and health disparities. The com-mittee also intends to add one more componentthat will evaluate how well we are doing inmeeting our goals. This will require the develop-

What Are Health Disparities?And why are they important to track?

Healthy People 2010, national objectives that set the prevention agenda for the United States,identified eliminating health disparities in the United States as one of its primary goals. This stemsfrom a basic value: all people deserve the same opportunity to experience good health and qualityof life (http://www.healthypeople.gov/).

A disparity in health occurs when one group of individuals experiences significantly greater—orworse—health than another group. Very often, health disparities exist among racial and ethnicgroups. They may be the result of unequal access to medical care, or differences in income oreducation, or other factors. Identifying disparities is a first step toward understanding exactlywhich disparities exist, what contributes to them, and what can be done to eliminate them.

In developing Washington’s Report Card on Health, we have put special emphasis on measuringdisparities among racial and ethnic groups. This is a difficult task, and it requires analyses of manytypes of data, in varied formats (see Appendix 3). With a goal toward eliminating disparities, thisinformation will help us focus resources on public health efforts that help “close the gap.”

ment of Washington State targets for each ofthe indicators.

Among the challenges the committee hasencountered so far is the lack of county-leveldata, which are needed if the Report Card is tobe used throughout the state. The committee isconsidering presenting regional or multi-countydata for some of the sub-indicators. Meanwhile,the committee has added questions to theBehavioral Risk Factor Surveillance System(BRFSS) survey to provide county-level data onunmet health care needs for adults and chil-dren.

Availability of data remains a challenge for thecommittee, particularly in such areas as thesafety of water systems and air quality. Forexample, at this time, the state is measuringthe quality of only the large, “Group A” watersystems, which means that the quality of the“Group B” systems, which serve 15 or fewerhouseholds, is not included in the data mix.

Making evidenced-based investmentsin healthThe committee recognizes that grades will notimprove without interventions. In the future, itwill provide links on the Report Card website tointerventions for improving health outcomes.

17

There is much we can do individually andcollectively to improve our health. Identifyingbest practice interventions that have beenproven to be effective will assist state and localorganizations in finding an approach that isright for their population. The on-line formatwill make it easy to refine and update theinformation. But as with much of the indicatorswork, the committee is learning what isn’tavailable—including interventions for all theareas tracked by our health indicators.

It will take time to collect the data called for inour Report Card and to develop ways to make iteasily accessible to people who must makedecisions about health policy, expenditures,and programs. While the concept soundssimple, it has not been done before. As theReport Card is finalized, communities will beable, systematically, to use science-based,timely information about their own health, andthey will be able to link it to the best available

Environment5%

Social circumstances15%

Medical10%

Behavior40%

Genetics30%

Factors That Influence Our Health

Source: Health Affairs

information about what really works to keepthem healthy. For more information on defini-tions and data sources for the Report Card, seehttp://www.doh.wa.gov/phip/PHIP2004/ReferenceLinks.htm.

Indicators TrendComparedto U.S.

Disparities Final

1. How Healthy Are We Overall?

Expected years of healthy life at age 20 A C C B

Percent of adults who report 14 or moredays of poor mental health in the pastmonth

B C C C

Washington has relatively fewer obese adults and overweight 10th graderscompared to the U.S. Nonetheless, in 2003 about 20% of adults reportedheights and weights indicating obesity. About 10% of 10th graders wereoverweight in 2002. Washington’s rates are moving in the wrong directionand we have moderate levels of disparities.

Overall ObesityGrade

How good is ourgeneral physicaland mental health?

General HealthGrade

Although Washington compares favorably to the U.S. on healthy lifeexpectancy and mental health, we have not seen improvement since 1993and there are moderate levels of disparities.

C

Are we a healthyweight?

Percent of adults whoare obese

B F C C

Percent of 10th graders who are overweight B N/A C C

C

Category

Report Card SampleThis is a short sample page from the PHIP Report Card. The full Report Card will be publishedseparately and can be viewed at http://www.doh.wa.gov/phip/indicators/draftreportcard.htm.

18

Recommendations for 2005-071. Adopt the Report Card.

Developing a Report Card is no easy task.This one is the result of thoughtful collabo-ration by public health professionalsthroughout Washington. It has had consid-erable scrutiny and is drawn from the bestavailable science. It focuses our attentionon the underlying determinants of health—a focus that provides the best opportunityto improve health over time. This ReportCard should be adopted and used bypolicy makers in many venues.

2. Publish the Report Card every two years ina hard copy summary and web-basedformat, with links to additional informationand interventions.

Maintaining the Report Card should be acore activity of the public health system.

By making information about actual healthtrends readily available, we will have theknowledge needed to direct resourcestoward greatest needs and toward healthinterventions that show the greatestsuccess. This will require funding forongoing collection, analysis, and dissemi-nation.

3. Commit resources to develop andimplement a process to set targets.

Setting realistic numerical targets forhealth indicators, based on the bestavailable science, will let us measureprogress over time. Numerical measureswill provide a clear picture of whether weare meeting our goals. Setting targets is asignificant undertaking and will require agreat deal of time and analysis on the partof people who contribute to this effort.

19

The Standards Committee is composed ofpeople who work in all aspects of publichealth—from clinical services to policy. Theycome from all areas of the state and representpublic health practice at both the state andlocal level.

When the Standards Committee in 1999 beganits work to develop a performance measure-ment system for Washington’s public healthsystem, it could not know that the next fiveyears would bring a series of challenges thatwould render the system increasingly fragile—and the standards even more valuable. Thestandards have identified system values—whatis most important in public health—and di-rected quality improvement efforts during anonslaught of insufficient funding and newthreats that have characterized the years sincethey were first published in 2001. The standardscan be viewed at http://www.doh.wa.gov/Standards.

The standards set a level of expectation for thestate’s public health system, both as a wholeand as a network of individual state and localagencies. They are structured to follow the corepublic health functions as defined by thefederal Institute of Medicine and the 10 essen-tial services defined by the National PublicHealth Steering Committee (see Appendix 4 fora “crosswalk” of these guidelines). The stan-dards address five general topic areas:

PUBLIC HEALTH STANDARDS:STEPS TO IMPROVE HEALTH

• Understanding key health issues• Protecting people from disease• Assuring a safe and healthy environment• Promoting healthy living, and• Helping people get the services they need.

The standards are not a statement of new work.Instead, they both describe work that is occur-ring and set expectations for the quality of thatwork. Until now, “public health” was viewed asa collection of individual, specialty programs,each with a separate means of support. Theseare sometimes referred to as “silos” in anorganization: isolated programs where effortsare not integrated. Funding often drives thatmind-set, with the creation of dedicated orspecial program funds. Funding for basic publichealth services has been largely ignored andhas eroded. Measuring public health perfor-mance against the standards accommodatescurrent programs—because they each fit in oneof the five areas. Measurement also points outweaknesses where capacity to deliver basicpublic health services is missing.

More than 300 public health professionals weretrained on use of the standards and how toprepare for an evaluation. In 2002, the stan-dards were used to conduct a baseline assess-ment, which revealed system strengths andweaknesses. Implementing the standards is aprocess that has involved collaboration throughdebate, development, training, testing, andrefining expectations.

The standards both describe work

that is occurring and set

expectations for the quality of

that work.

20

National leaders and public health profession-als in many other states have learned fromWashington’s experience. Our standards andthe collaborative process of development havebeen adapted by other states. This work isfrequently cited as a model for intergovernmen-tal collaboration and as an example of how tomake publicly funded programs accountable(see box, below).

A baseline studyIn 2002, the state Department of Health andevery local health jurisdiction participated in abaseline evaluation of the public health systemto see how well the system performs againstthe standards. The results of the 2001 study canbe viewed at http://www.doh.wa.gov/phip/Standards.

The baseline study findings revealed that evenwhere the system performs relatively well, thereis much work to do. For example, the area of“understanding health issues” is the work thathealth departments must do to know whensignificant health problems emerge and to helpcommunities identify priorities for intervention.Performance was relatively strong compared toother areas of the standards. But state officesmet the expectation about three-fourths of thetime, and local offices, just over half the time. Ingeneral, the scores reflect a lack of basiccapacity—particularly dedicated staff time andtechnical tools needed for health assessment.(The section on Key Health Indicators in thisreport, beginning on page 15, discusses someof the types of information needed.)

Other States Are Measuring Public Health PerformanceSome other states have developed performance measurement processes for public health.Many of them have used the work in Washington as a guide. By exchanging information andideas, states are working together and with national partners to improve public health practice.

Washington’s process places emphasis on mutual accountability and collaboration. Similarly, inFlorida, state and local public health officials participate in a joint conference for each localdepartment every three years. Theycompare progress on communityhealth indicators and make mutualcommitments about what eachentity, state and local, can do toimprove the health of people and toassure agency efficiency.

At right is a self-assessment modeldeveloped through the nationalTurning Point project for use bypublic health agencies. It showshow standards and measurementcan be used to assure that everyagency has the necessary skills,accountability, and communica-tions capacity to perform the workof protecting the public’s health(see http://www.turningpointprogram.org).

Source: Turning Point PerformanceManagement Collaborative

PerformanceManagement

System

PerformanceStandards • Identify relevant standards • Select indicators • Set goals and targets • Communicate expectations

QualityImprovement

Process • Use data for decisions to improve policies, programs, and outcomes • Manage changes • Create a learning organization

Reporting ofProgress • Analyze data • Feed data back to managers, staff, policy makers, and constituents • Develop a regular reporting cycle

PerformanceMeasurement

• Refine indicators and define measures • Develop data systems • Collect data

21

Both the state and local agencies showedweaker results in the areas of “helping peopleget the services they need” and in environmen-tal health measures, meeting the standardsonly half the time or less. In both areas, limitedresources and dependence on fees or reim-bursements result in programs that cannotattain the level of service and follow-throughthat is expected to meet the standards. Forexample, in the area of access to services, mosthealth departments are able to refer an indi-vidual client to a needed service—if it existslocally. But the standards envision somethingmore substantial: the ability systematically toknow exactly what services are available, whatservices are lacking, and to work with communi-ties to fill health service gaps, either within thecommunity itself or from a neighboring one.This broader, community-based work is onlyrarely supported with funding.

Putting the standards to workOne of the initial goals of the Standards Com-mittee was to tie system performance, as

measured by the standards, to funding andstate contracts as specified in RCW 43.70.580.....This is still a goal of the Standards Committeeand will be part of its work plan for the comingyear. While some standards require morefunding to implement them fully, others simplyrequire improved documentation and focus onthoughtful planning and systematic approachesto public health problems.

In June 2004, the Standards Committee askedunits within the Department of Health and mostof the state’s local public health jurisdictionshow they were using the standards. A strongmajority of system managers—82%—reportedthat they had used them to guide performanceimprovement. Nearly three-fourths (74%) of thelocal agencies have used the standards toarticulate their work to their local boards ofhealth (see box, above).

Working with the Workforce DevelopmentCommittee, the Standards Committee used thebaseline assessment findings to direct strate-gies and training to improve the results for thenext assessment. The committees are focusing

Assessing their ‘Standard’ of PerformanceIn 2002, every public health agency in Washington—state and local—participated in a baselineassessment of how well they were meeting standards for their performance. The framework ofthe standards and the specific measurement data for each health jurisdiction and program isnow used to improve public health practice. Following is what some of local health departmentmanagers had to say about the experience:

“Each year we complete an annual work plan. This year, we are revising our departmental reportfrom the current program-based format to a standards-based format. The plan will have fivesections and will describe work planned in each of the standard areas to help us meet communityneeds.”

“Many of the standards have been incorporated into our department’s planning and budgetingprocess. This process ranges from strategic directions through goals, objectives, and down totask level.”

“The standards baseline assessment identified the need for improved coordination betweenenvironmental health and infectious disease…. A regular debriefing and improved identificationis now established between the two program areas.”

“The department identified key issues for each specific standards topic and developed workplans for each, as part of the 2004 budget development process. The board of health and countycommissioners approved the plans and funding directed for each of these.”

22

this work in three areas: community collabora-tion, creating and using a strategic plan, andprogram evaluation. Focused attention in theseareas promises to improve performance system-wide across all five topic areas.

In addition, the Standards Committee hasworked with the state’s environmental healthdirectors to refine the measures used in thearea of “assuring a safe and healthy environ-ment for people.” With clearer measures,performance on those standards is expected toimprove system-wide (see Appendix 5).

Assuring administrative effectivenessA major piece of the Standards Committee workduring the past two years has been to developadministrative standards, which cover thetopics of leadership and governance, humanresources, fiscal management, and informationtechnology. These were tested during 2004 infive counties and the Department of Health. Theadministrative standards clarify infrastructureand capacity issues, and while they are the laststandards to be developed, they are critical tothe work of public health professionals. Theadministrative standards will be used in con-junction with the other public health standardsto assess whether a state or local entity hasadequate systems in place. They will be field-tested in 2005 as part of the overall systemassessment.

“Costing” the standardsOver the past two years, the Standards Commit-tee has worked with the Finance Committee toestimate the cost of implementing the stan-dards fully across the state. For the local publichealth agencies, this has involved creating a

common list of system program areas and thenestimating the cost of providing each service ina manner that would meet the standardsstatewide (see Appendix 8). For the stateDepartment of Health, the process has involvedidentifying the current costs of meeting thestandards to at least a 95% level. The findingsfrom these two calculations will reveal thefunding shortfall for meeting the standardsacross the system (see the chapter on theFinance Committee’s work, page 25). That sumwill express in stark terms what the standardsprocess has already revealed: the systemcurrently lacks the resources to meet theexpected level of performance.

Improving public health over timeIn 2005, the evaluation process will be repeatedto measure improvement in the interveningyears and to see where focused attention isneeded for future system improvement efforts.The criteria for determining whether a standardis met will require more than one example ofperformance for each measure, so more indi-vidual programs will be represented. In thisway, the public health system as a whole ismoving to a continuous quality improvementcycle.

While some improvements have already beenmade, the participating agencies face a host ofnew responsibilities since the 2002 baselinemeasurement, such as the threat of new com-municable diseases and the responsibility toimplement mandated programs to protectagainst bioterrorism. The next assessment willlikely reveal how these pressures have helpedor undermined public health system perfor-mance.

23

Recommendations for 2005-071. Adopt and apply the revised

administrative standards as part of theStandards for Public Health in WashingtonState.

The Standards for Public Health in Wash-ington State address five topic areasimportant to public health protection andhealth promotion. In addition, everyagency must have basic administrativeservices in place in order to be effectiveand reliable. These basic capacities are animportant part of performance—andshould be measured.

2. Analyze the 2005 results of the system-wide measurement of the Standards forPublic Health in Washington State inconjunction with program requirements toidentify or reinforce priorities for system-wide improvements.

Using the goal for the standards, “Whatevery citizen has a right to expect,” theSteering Committee will identify one ormore focus areas to concentrate efforts forimprovement. Data from the 2005 evalua-tion will help to identify an area for im-provement. The selection process couldinvolve voting across state and localagencies so that the focus area representsthe most important areas needing system-wide response.

3. Identify and test methods to incorporatethe use of the standards throughout thework of public health as described in thelegislation that requires the PHIP anddevelopment of the standards (seeAppendix 7).

Performance and standards should belinked through careful restrictions. Theresources needed to meet the standardsare not available, and no agency should bepenalized for that. Instead, the connectionbetween funding and standards shouldfocus on identifying gaps, outliningstrategies for improvement, sharing bestpractices, participating fully in the measur-ing process, and timely reporting. Meetingthe standards fully will require signifi-cantly greater resources.

4. Adopt a contract monitoring system thatuses the standards as a framework.

The emphasis should be on the wholepublic health system and its purpose, notsimply individual programs. The monitor-ing system should reflect the mutualaccountability of state and local govern-ment to ensure that public health servicesare provided.

Performance measurement and qualityimprovement must be supported throughchanges to contract development, award-ing, and monitoring; through funding andreporting requirements; and throughtraining and recognition awards.

24

Always working for a safer and healthier Washington

25

Financing is the Achilles Heel of our publichealth system—the enduring problem thatmakes it vulnerable. Public health programsrely on a complicated mix of federal, state andlocal funds. No single entity has overall respon-sibility to assure that the resources needed toprotect the health of people are available orsufficient. There is no established level offunding and no stable revenue source to ensurethat basic protection will remain in place whenfunding erodes at any level of government.

In 2002, the Finance Committee cited four keyproblems that must be overcome to assure anadequate level of protection in Washington:

• Public health is historically, persistentlyunder-funded.

• Funding for core services is eroding,making the system very fragile.

• Investments vary widely from one countyto the next, so protection is inconsistent.

• Categorical restrictions hamper efforts torespond to community needs.

No real progress has been made toward allevi-ating these problems during the past two years.The Finance Committee has accomplished someexcellent work in this period, but the rootcauses for what ails public health lies beyondthe committee’s reach.

In 2004, the United Health Foundation pub-lished America’s Health: State Health Rankings.

The report placed Washington at 44th—near thebottom—for spending on public health. Whenmany health factors were combined, our overallhealth ranking dropped from 11th in 2003 to15th in 2004. Regarding the drop, the reportsaid: “This indicates that the state may notimprove its relative healthiness in the nearfuture unless the risk factors are more aggres-sively addressed.”

Continued erosion of core servicesand growing disparitiesSpending for core public health activities—forbasic services—has experienced the mostpressure. Historically, Washington’s countiesand their city partners paid for core publichealth services such as water protection, foodsafety, and communicable disease preventionand control. State and federal funding wereadded to provide special programs. But overtime, the categorical restrictions that came withstate and federal funds created lopsided situa-tions where special services—but not basicservices—would be funded. Today, as countyfunds shrink, our ability to maintain core publichealth protection has severely eroded.

Public health services across the state arefunded in a piecemeal fashion, with everycounty setting its own spending levels. Declin-ing local revenues have forced local governmentto make hard budget cuts every year. Forexample, in the past 20 years, county spending

FINANCING PUBLIC HEALTH:INVESTMENT THAT WORKS FORBETTER HEALTH SOLUTIONS

Public health managers today are

quick to state that the system has

reached a breaking point.

26

on criminal justice programs has increased from50% to 70% of county general fund outlays,leaving little money for public health or otherlocal government services. After many years,this pattern leaves counties with uneven re-sources in disease control, environmentalhealth protection, and health education.

Washington State has not established a basiclevel of funding for local public health protec-tion. There is no minimum amount per citizen

from the state or local government, nor a broadcommitment to systemic investments in protec-tion. The inconsistency in public health fundingacross the state is reflected in the amount oflocal contributions for public health per person,which ranges from $4.50 per year in somecounties to $71.69 per year in others. It alsoshows up in basic staffing levels: 15 ofWashington’s local public health jurisdictionshave fewer than 6 employees per 10,000population. The range is from 1.8 to 29.

A Successful Public Health Investment: Tobacco PreventionAnyone who doubts that spending on public health programs can save both lives and moneyshould look at Washington’s progress in battling the nation’s No. 1 cause of preventable death:tobacco.

Since expansion of the state’s Tobacco Prevention and Control Program in 2000, financed byresources from the national tobacco settlement and the state excise tax on cigarettes, thenumber of smokers in Washington has dropped by 12%—115,000 fewer people who suffer fromthe health, behavioral, and economic consequences of tobacco use. Washington’s adult smokingrate of 19.7% is among the “lowest 10” of all the states and below the national median of 22%.

Since inception of the expanded program, Washington has invested about $90 million in tobaccoprevention and control. This work has saved an estimated 38,000 lives from early tobacco-related deaths as well as $1.4 billion in future medical costs.

The program’s four categories of activities—preventing youth from beginning to use tobacco,helping youth and adults quit, reducing exposure to secondhand smoke, and reducing tobaccouse in high-risk groups—engages thousands of people throughout the state every day. Morethan 44,000 Washington residents have already called the state’s “Tobacco Quit Line” (800-877-270-STOP). A media campaign warns children and youth, ages 8-18 years, of the dangers ofsmoking and exposure to secondhand smoke—on television and radio, in print, in conveniencestores, and in recreation centers.

Considerable work in tobacco prevention is left to do. With nearly 1 in 5 of all adults still smoking,the state can expect tobacco-related diseases to kill 8,000 people every year. About 20,000children and youth in Washing-ton will begin smoking thisyear. Ten percent of pregnantwomen in the state still smokeduring their last trimester. AndWashington’s $29 millionannual investment in tobaccoprevention is up against the$300 million the tobaccoindustry spends in the stateevery year to encouragepeople to smoke.

27

Prevention by the NumbersIt is impossible to put a dollar value on “health.” But it is possible to calculate the economicimpact of preventable health problems. Healthy People 2010, the set of national objectives thatrepresent the U.S. “prevention agenda,” includes an analysis of the how public health preventionactivities save costs associated with unhealthy environments and behaviors. Among the costs thatcould be mitigated with prevention:

• 50,000 premature deaths and $40-50 billion in annual medical costs resulting from humanexposure to outdoor air pollutants from all sources

• $3 billion each year in hospitalizations and from $20-40 billion a year in lost productivityassociated with illness from microorganisms in food

• $55,000 to $155,000 or more per person in lifetime costs associated with HIV• As much as $6,300 for first-year medical costs for every case of Lyme disease that isn’t caught

in the early stage• 55,000 cases, 11,000 hospitalizations, 120 deaths, and $100 million in direct medical costs

associated with a measles resurgence in the United States during 1989-91• $224 billion in annual costs related to preventable injuries• $6,200 in average hospital costs for each low-birthweight birth, compared to $1,900 for a

normal, healthy delivery• $200 billion a year for medical expenses and lost productivity associated with poor nutrition• $6 billion in medical expenditures and lost productivity related to asthma• 430,000 deaths a year and $50 billion in direct medical costs associated with tobacco use

Health impacts of declining resourcesWashington’s public health workers haveshouldered the burden in lean times and shownthat they can do more with less. But the size ofour public health workforce has remainedbasically static during the past 10 years, whilethe workload has been growing. Public healthmanagers today are quick to state that thesystem has reached a breaking point. Unrea-sonable workloads and staff burn-out are directoutcomes. The health impacts will come later,as a faltering system must contend with com-plex problems. These include the re-emergenceof resistant strains of diseases such as tubercu-losis, syphilis, and staph; the emergence ofglobal infections such as SARS; the specter ofcatastrophic events such as mad cow disease,and the additional responsibility of becomingone of the first responders to acts ofbioterrorism.

The cost of lost opportunities is even greater,though difficult to see. With the workforcepared down and constantly responding tourgent situations, investments in prevention getpushed aside, despite their promising poten-

tial. Washington’s special efforts in tobaccohave reaped huge rewards (see box, previouspage). We could lessen the toll of later, highmedical care costs if similar investments weremade in early childhood screening, physicalactivity, nutrition, environmental health protec-tion, and early intervention for mental healthand substance abuse.

Today, less that 1% of the nation’s $1.5 trillionhealth tab is directed toward public healthmeasures, despite the fact that they are provento be effective and offer greater return oninvestment than medical care (see box, above).What is needed is a formal national and state-wide “prevention agenda” that demandsincreased prevention investments for everypublic dollar spent on medical care.

Estimating costs of adequatepublic health protectionWhat should we be spending on public health inWashington? With publication of the Standardsfor Public Health in Washington State in 2001,the Finance Committee and the Standards

28

Spending Too Much on Health Care—but Not Enough on Health?U.S. spending on health has reached $1.5 trillion annually. But the way we spend this moneydoes not logically follow the factors that we know determine our health.

For example, a Priorities of Government group considering health expenditures in WashingtonState has adopted a set of recommended priority strategies that is based on the determinants ofhealth (see page 17). But it saw major discrepancies between these priorities and where statehealth dollars actually go. Some examples:

• Our behavior accounts for about 40% of how healthy we are, but state spending to supporthealthy behavior is only about 2.5% of the overall health budget.

• Our surroundings—environment and social circumstances—account for about 20% of ourhealth, but we spend about 2.8% of our health budget in these areas.

• Medical care contributes only about 10% to our overall health, but it consumes about 95% ofWashington’s state health budget.

Medical care is essential, and seeing that all who need it have access is a core function of publichealth. But medical costs are rising far faster than either government, payers, or consumers canafford. If we invested more in preventive measures, we might be able to reduce spending onhealth care to affordable levels.

Source: Projected expenditures, 2005-07 biennial budget, based on Washington State Depart-ment of Health Priorities of Government Health Committee

Committee were able to join forces to determinethe cost of providing the services that allWashington residents have a right to expectfrom their public health system. In effect, thetwo committees have worked to “cost” thestandards at about a 95 percent performancelevel—a level the committee members consid-ered to be realistic.

The joint committee created three “cost mod-els” that capture the specific responsibilities ofstate, local, and metropolitan public healthjurisdictions. Each of these models is based onclearly defined assumptions. To guide thiswork, the Finance Committee developed a list ofessential public health activities—those neces-sary to the public’s health and that should beprovided by public health agencies if there is noone else in the community to do it—and orga-nized the services according to the standardsframework (see Appendix 6).

To meet the standards for public health state-wide, the committee estimates it would takeadditional investments of $400 million peryear—with most of that, $385 million, spent at

the local level. While this amount is roughlydouble what we now spend at the local level, itremains only a few cents on the dollar for whatis spent every day for medical care servicesafter people have become ill with an infectiousdisease, a chronic condition, or a mentalillness.

Based on reports from the U.S. Department ofHealth and Human Services and reports onpublic health spending in Washington State:

• Medical care spending is roughly $4,370per capita, per year.

• Public health spending is roughly $98 percapita, per year.

• If fully funded to meet the standards,public health spending would be $163 percapita, per year.

The cost estimate work creates a rationalframework for funding public health, but alone,it does not achieve the goal of a “stable andsufficient” financing system for public healththat the first PHIP called for in 1994. Meetingthat goal will require a collective effort among

29

state and local elected officials, public healthagencies, and their community partners toprovide needed resources and to identify newfunding sources. In recognition of thisnecessary next step, the Finance Committee willdraft a white paper on public health financingthat describes our current system’s strengthsand weaknesses and encourages policy makersto explore potential new funding sources.

Improving the way we manage fundingAlthough the Finance Committee cannot changenational investment strategy, it has elected towork on some issues that will improve quality inour state’s system. The committee has identi-

fied ways to spend the system’s limited dollarsmore efficiently by examining the complex flowof categorical funds from the federal govern-ment to the state and on to local public healthjurisdictions. It has developed templates thatwill provide a standardized process for allocat-ing funds and established criteria for reviewingand updating funding allocation formulas. Thecommittee also drafted principles for fundingallocations, so that available funds will bedistributed in an equitable and predictablemanner (see Appendix 9). This work will helpstate and local health officials make reasonabledecisions about how best to allocate limitedresources.

30

Recommendations for 2005-071. Increase public health funding by $400

million to close the funding gaps identifiedin the Finance Committee’s cost model.

Stable and sufficient sources of fundingare essential to maintaining a soundpublic health system. All residents needand expect a predictable level of publichealth protection.

2. Expand the Finance Committee to includebroader representation by state and localstakeholders, to help identifyopportunities to articulate the importanceof fully funding our public health system,to explore viable state funding options,and to get this information to decision-makers.

Active involvement by concerned citizensand policy makers is critical to solving thechronic funding instability that plaguespublic health. The Steering Committee will

look to a specially organized group tostudy alternative financing strategies andseek solutions that will work, statewide.

3. Implement the work of the FundingAllocations Subcommittee to make certainthat allocation formulas are clear and allfunding for programs is easily tracked on awebsite.

Given scarce resources, every dollar inpublic health needs to be used efficiently.The Finance Committee will continue towork to improve funding practices toachieve a common understanding ofallocation principles and how they areused. Additional work will be pursued onstatewide program evaluation and onclarifying data needs so that requiredprogram reports are as simple as possible,yet support accountability measures,program evaluation, and where feasible,needed research.

31

As more applications are developed, it

will be increasingly important to have

a central forum for planning and

coordinating IT work.

INFORMATION TECHNOLOGY:RELIABLE INFORMATION FORBETTER HEALTHThe Information Technology Committee ensuresthat Washington’s public health professionalshave access to information and technologywhen and where they need it—from the simpleextension of e-mail systems onto handhelddevices to installation of complex securityfunctions so that data are protected. The goal isto employ appropriate and effective technology,in the background, to make the work of assur-ing the public’s health easier, more efficient,and more effective.

Rapid changes and growingexpectations for “e-government”People expect government agencies to adopttechnology-based ways of doing business whenit translates to faster and better service. Forexample, public health agencies used to rely ona paper-based system for birth certificates,making obtaining birth records a somewhatslow process. Today, birth certificates areissued from an electronic system that linkshospitals, all local health jurisdictions, and thestate vital records office. Obtaining records isquick and can be done from any county in thestate, regardless of where the original certifi-cate was issued. Next, death certificates willbecome part of an electronic system. In bothcases, developing these systems takes time,and a significant initial investment must bemade to acquire new technology. But theupdated systems are more efficient and providetools for long-term cost savings.

Change has always been a part of the informa-tion technology (IT) field, but the rate at whichthis change occurs has increased dramaticallyin recent years, and public health agencies arechallenged to keep pace. Most phone systemsare complex computers, and most workers usea personal computer during their workday.Many factors combine to put pressure on publichealth to adopt new technology including newfederal laws on medical record handling,changes in computer operating systems, andthe adoption of new technology by partners.

Across all service areas, there is a need toadopt new technology: keeping track of data forclient records or evaluation, using handheldcomputers in the field to save time transferringinformation later, adopting new analytical toolsto support decision-making. All of this trans-lates to a new demand within public health; ITtools have become a critical part of our infra-structure and will require resources as we adaptto the new “electronic” world.

The need for system-wide coordinationMost local health jurisdictions rely on countygovernments to provide their basic IT infrastruc-ture, and each county government has its ownprocess for procuring equipment, software, andsupport. Yet there is increasing need for stateand local public health offices to share informa-tion quickly, and reliable interconnectivitybetween these systems is required. As the

32

public health system evolves, it will be impor-tant to move from “home grown” systems thatevolved without common standards to a moresophisticated approach that will allow integra-tion of information management within largesystems.

The Information Technology Committee hasprovided an initial forum to coordinate acrossdisparate IT environments, so that public healthagencies can work as members of a sharedsystem. The committee approaches IT planningfor public health in terms of designing intercon-necting pieces that are based on “commonarchitecture” or design standards. It has helpedset priorities among many emerging informa-tion-technology applications.

The committee is also working with a growingcircle of partners who are essential to publichealth, including clinical laboratories, hospi-tals, and funeral homes. Some of the applica-tions under development will connect theseentities to public health agencies, on a continu-ous basis, 24 hours a day, seven days a week.

As more applications are developed, it will beincreasingly important to have a central forumfor planning and coordinating IT work. TheInformation Technology Committee, or an entityestablished as an outgrowth of this effort, canplay a crucial role in guiding coordination inareas such as funding, maintenance, andoversight, as well as such routine operationaltasks as authorizing access, maintainingsecurity, and training individuals in the use ofapplications. The impact of this work will be toreduce duplication, assure “interconnectivity”so health departments can share information asneeded, and reduce expenditures over time,perhaps through joint purchasing power.

New roles emerge, along withtechnologyAs information technology becomes a promi-nent part of public health practice, it has adirect effect on the workforce. Some jobs areperformed differently with technology, so newskills are needed. Sometimes, whole new rolesemerge as a result of adopting new technology.For example, making training accessible state-wide requires someone with specialized skills

to manage distance learning technology such assatellite transmission, on-line courses, andweb-conferencing. With many aspects of publichealth practice adopting technology tools, newworker roles are emerging to handle a broadarray of IT needs, from basic computer supportto training in the use of various applications.

Technology is also changing the way agenciesrelate to one another. The committee is consid-ering the essential roles and activities that mustbe performed in every public health agency sothat information is secure—yet can flow easily.This requires agreements about how data willbe handled, who will authorize access to data,where data will reside, and how data will bekept up-to-date (see Appendix 10).

Information systems that areimproving public health todayWhile technology comes with challenges, it alsobrings tremendous benefits that can improvethe quality of public health services.Washington’s innovative public healthworkforce has some very valuable applicationsdeveloped or in development. Some examplesare detailed below.

• The Public Health Issue ManagementPublic Health Issue ManagementPublic Health Issue ManagementPublic Health Issue ManagementPublic Health Issue ManagementSystem (PHIMS)System (PHIMS)System (PHIMS)System (PHIMS)System (PHIMS), a secure, web-basedapplication for local health jurisdictionsand Department of Health staff to use toinvestigate and report communicabledisease, is in production in severalcounties. Local health jurisdictions will usethe new PHIMS to investigate and reportdisease occurrence to the stateDepartment of Health, which can send theinformation on to the federal public healthagency, the U.S. Centers for DiseaseControl and Prevention (CDC). PHIMS willbring faster disease outbreak investigationand quicker treatment, which should resultin reduced spread of disease in thecommunity.

PHIMS will make it faster and easier tomaintain accurate records during adisease event, and comparableinformation can be shared across countieswhen needed. It can summarize and

33

provide data for charts showing the trendin a disease outbreak. Without PHIMS,every jurisdiction has to create andmaintain its own records and carry out itsown analysis—all of which can be verytime-consuming.

• The Washington Secure ElectronicWashington Secure ElectronicWashington Secure ElectronicWashington Secure ElectronicWashington Secure ElectronicCommunication and Urgent ResponseCommunication and Urgent ResponseCommunication and Urgent ResponseCommunication and Urgent ResponseCommunication and Urgent ResponseSystem (WaSECURES)System (WaSECURES)System (WaSECURES)System (WaSECURES)System (WaSECURES) is a secure web-based tool providing urgentcommunication for public healthemergency response partners. Manypublic health partners now send suchmessages via e-mail listservs, with no wayto verify whether the intended recipientshave received them. In the WaSECURESapplication, an emergency notification istyped into the system and converted toaudible voice. The notification can then besent via e-mail, pager, or phone.

WaSECURES will be very important if wehave a natural disaster, terrorism event, orother catastrophic health event where theentire system must mobilize quickly. Whendanger is high and time is short, publichealth expertise will be needed quickly.Through WaSECURES, Washington’s publichealth leaders will be able to respond afterhours as well as during the regular workweek.

• Speed is often very important inresponding to a public health concern,whether to rule out a problem such asrabies or SARS—or to confirm a problemand initiate appropriate action. The PublicPublicPublicPublicPublicHealth Reporting of Electronic DataHealth Reporting of Electronic DataHealth Reporting of Electronic DataHealth Reporting of Electronic DataHealth Reporting of Electronic Data(PHRED) (PHRED) (PHRED) (PHRED) (PHRED) system is a secure, web-basedapplication that hospitals and laboratorieswill use to transmit laboratory reportselectronically. The system will pass theselaboratory results to the appropriate localor state agencies. This reporting includesboth infectious and non-infectiousconditions. The results of using PHRED willmean some people can start treatmentsooner, reducing disease in thecommunity, and public health officials willhave added ability to track diseasepatterns.

• VISTAVISTAVISTAVISTAVISTA is a standardized tool that helpscollect, analyze, interpret, and shareinformation for community healthassessment. This web-based, menu-drivensoftware package—now used across thestate’s public health system—allows userswith diverse computer skills to access andanalyze population-based health data.New features include integration of 2000Census data and sub-county populationestimates (see http://www.doh.wa.gov/OS/Vista/HOMEPAGE.HTM).

• “EDITH”“EDITH”“EDITH”“EDITH”“EDITH” is an Electronic Data Transfer Hubthat provides a secure, reliable, Internet-based system for the electronicinterchange of public health information.Initially, it will focus on handlinginformation about laboratory-notifiableconditions, as defined in WAC 246-101.

• The Electronic Death Registration SystemThe Electronic Death Registration SystemThe Electronic Death Registration SystemThe Electronic Death Registration SystemThe Electronic Death Registration System(EDRS)(EDRS)(EDRS)(EDRS)(EDRS) is a secure, web-based applicationthat will enable the professionalsparticipating in death registration to filedeath records with local and stateregistrars electronically. It will allowdecedent demographics and cause-of-death information to be registeredelectronically by multiple participants.

• EpiQMSEpiQMSEpiQMSEpiQMSEpiQMS is a tool for analysis of health datathat may include a geographic informationsystem (GIS) function.

• Epi-XEpi-XEpi-XEpi-XEpi-X is a secure, web-basedcommunication system provided by theCDC to state epidemiologists and variousother public health officials.

• The Pre-Event Vaccination System (PVS)The Pre-Event Vaccination System (PVS)The Pre-Event Vaccination System (PVS)The Pre-Event Vaccination System (PVS)The Pre-Event Vaccination System (PVS) isa web-based system that supports thesecure exchange of data about those beingvaccinated against smallpox. The statesand CDC will continue to use thisinformation to ascertain progress inpreparedness activities, to assist in themonitoring of adverse events, and to trackpersonnel who are protected byvaccination and able to participate insmallpox response efforts.

34

Recommendations for 2005-071. Develop a shared administrative structure

for maintaining and enhancing evolvingapplications and development of a cost-sharing model for all public health ITsystems in Washington.

Work has progressed on IT systems thatwill serve both governmental and non-governmental agencies at both the stateand local level. A shared administrativestructure is needed for the ongoing main-tenance and improvement of these appli-cations, as well as for considering cost-sharing models and a variety of fundingsources.

2. Identify top-priority areas where better useof technology could improve public healthpractice.

Using prior analyses of business needsand new information, the committeeshould consider which programs andactivities would benefit most from newtechnology applications. Some specificexamples might be home visits or restau-rant inspections or system-wide applica-tions for documenting client services.

3. Evaluate and recommend standards forhardware, software, servers, security,distance learning, and data collection andtransfer.

With the goal of seamless integration, acommon look and feel, a common point ofentry and security, the IT system standardsare essential to assure that the public

health system remains connected and ableto share information quickly and confiden-tially. The committee should also explorethe ideas of role-based standards: defin-ing what is expected of a person based onjob function as well as the roles andresponsibilities of various agencies in theinformation chain.

4. Leverage financial investments intechnology most effectively.

The committee and partners shouldexplore ways to calculate the maximumbenefit of the new technologies, includinga cooperative model with shared resourcesand group purchases.

5. Review and evaluate applications toidentify opportunities for efficiencies.

The committee should seek ways toimprove the ability to analyze, aggregate,and use existing data by implementingstandards, avoiding duplication, usingcommon data elements and definitions,and developing interface applicationswhere needed. It should also explore waysto develop a common look and feel foraccessing a variety of data sets.

6. Implement on-going training into ITplanning.

Computer applications will be effectiveonly when accompanied by training. Thecommittee should consider ways to de-velop and implement “informatics compe-tencies” as well as an IT resource center.

35

WORKFORCE DEVELOPMENT: ASTATEWIDE NETWORK OF PUBLICHEALTH PROFESSIONALSFor Washington’s public health system to be“always working,” it needs appropriatelytrained and skilled workers. And once on thejob, these workers need ongoing support—joborientation, mentoring, and distance learningopportunities—to keep working effectively.Finding and keeping public health workers, andgiving them the professional development theyneed, are the two parallel interests of theWorkforce Development Committee.

Findings from the 2002 baseline measurementof the Standards for Public Health in Washing-ton State underscored what many public healthpractitioners experience first hand: training andemployee development are too often casualtiesof funding losses and workload demands.Training records were not routinely kept, train-ing needs were cited in a broad range of spe-cific and general topics, and there was a gen-eral lack of training about basic public health.

In the continually changing health fields,training is essential throughout a worker’scareer, and it has a direct impact on individualand agency performance.

Getting to know the workforceDuring 2003, we conducted our first-evercensus of Washington’s public healthworkforce, Everybody Counts (see next page).The report gave us a first detailed look at whoworks in public health, what educationalbackgrounds they brought to their jobs, how

long they have worked, and how long theyexpect to stay in public health. Significantly,more than 1 of every 6 of the state’s mostexperienced public health employees—thosewho have worked for the system for two de-cades or more—expect to leave the publichealth field within five years. This findingshows why workforce planning, particularly inthe areas of recruitment and retention of skilledworkers, is a committee priority.

The multidisciplinary nature of public healthand geographic dispersion of the workforceprovides some formidable challenges toworkforce development activities. Workforcedevelopment programs must address the needsof workers as diverse as veterinarians, mid-wives, nutritionists, and wastewater treatmentsystems inspectors. And learning opportunitiesmust be available in rural towns as well as inlarge cities.

A full report about Washington’s public healthworkforce can be viewed at http://www.doh.wa.gov/phip/communications/tools/survey/everybodycounts/.

Washington State provides leadership to thesix-state Northwest Regional Workforce Devel-opment Network, which is coordinated by theUW Northwest Center for Public Health Practice.Through the network, leaders from throughoutthe Northwest collaborate on development oftraining needs assessments, training plans,and learning opportunities. In the coming year,

Training and employee development

are too often casualties of funding

losses and workload demands.

36

the network will be working both on examina-tion of approaches to worker certification anddevelopment of mentoring programs.

Developing managers and leadersMarket conditions present a considerablechallenge to recruiting and keeping strongpublic health managers. Often, public healthjurisdictions cannot pay the salaries needed tocompete effectively with the private sector for

the most skilled managers. Finding new manag-ers within the public health system would helpaddress this challenge, but Washington lacksany formal or informal system for developingmanagement skills among people with strongpublic health experience.

The Workforce Development Committee isstudying a variety of learning strategies todevelop public health managers and leaders.These include both formal education methods

Mapping the Workforce: Everybody Counts!About 5,400 people work for Washington’s governmental public health system—the state Depart-ment of Health and the 35 local public health jurisdictions. We now know about many of the charac-teristics of these workers, because we counted them in November 2003 in the state’s first-evercensus of our state’s public health workforce, Everybody Counts (http://www.doh.wa.gov/phip/communications/tools/survey/everybodycounts/).

We now know several of the demographic characteristics of these workers:

• 74% are female• 88% are white• 40% are younger than 45 and 22% are

55 or older

We know about their educational backgrounds:

• 9% hold associate degrees.• 38% have bachelor’s degrees.• 22% have earned master’s degrees.• 2% hold professional degrees.• 2% hold doctoral degrees.

We know the fields in which Washington’s publichealth workers are most likely to hold degrees:

• 16% in nursing• 12% in business administration, public administration, policy, public affairs, and law• 11% in chemistry and biology• 8% in psychology, counseling, and social work

And we know something about current workers’ plans for staying in the public health field, asshown in the chart above.

Everybody Counts is a first step to understanding Washington’s public health workforce. TheWorkforce Development Committee has recommended conducting the census every 3-5 years andexpanding its reach to include those who work as the system’s non-governmental, communitypartners. The first count has already revealed important policy issues to guide workforce develop-ment activities. These include increasing worker diversity to reflect the composition of the popula-tion it serves, preparing for retirement transitions, and forecasting educational and training needs.

Not sure42%

<5 more years7%

5-9 years11%

10 years or more39%

Years Expected to Work in Public Health

37

as well as less traditional instructional venuessuch as short, web-based interactive modulesand mentoring, peer consultation, and appren-ticeship programs. To retain the most skilledworkers, the committee is exploring ways tomake compensation competitive with theprivate sector and to offer more versatile,rewarding, and challenging career tracks.

The Northwest Public Health Leadership Insti-tute is an example of one promising strategy(http://healthlinks.washington.edu/nwcphp/nwphli). This is a partnership between the UWNorthwest Center for Public Health Practice andthe states of Alaska, Idaho, Montana, Oregon,and Washington that began in 2003. This year-long experience builds participants’ collabora-tive leadership skills through on-site anddistance learning opportunities. Participantsare guided by practice-based faculty, includingscholars from such diverse backgrounds asgovernment public health, community healthcenters, community hospitals, community-based organizations, and social service and lawenforcement agencies. Participants developleadership skills while working on innovative

approaches to public health problems at thecommunity level. Central to this work is theassumption that many sectors of the communitymust engage in the process of promotinghealth, so participants include leaders frompolitics, business, and the non-profit sectors aswell as government public health agencies.

Planning to meet workforce needsTo meet the needs of the public health system,workforce development activities must supportgoals of both the public health system andindividual agencies. Standards for PublicHealth in Washington State provide one way toapproach this, by helping organize workforcedevelopment efforts toward areas where overallperformance in the system needs to bestrengthened.

Using the standards baseline findings, theWorkforce Development Committee has begunto develop model training plans in three areasthat have been selected as most important forthe workforce, including:

Agencystrategic

plan

Evaluation

Communityhealth

assessment

Programevaluation

Implementation

Implementation

Workforceassessment

Workforceplanning

This is how a public health agency mightapproach its regular planning cycle.

Planning for workforce development is an important component of the planningcycle. The Workforce Development Committee pictures it like this:

Who makes up the workforce?Education and skills?Assessing individual compentecyAssessing organizational competency, overall

Organizational development planIndividual development plan for workersAgency plans for recruitment

Measure changes in performanceConsider the impact of workforce development efforts and the return on investsments made

Making needed information or “content” availableCreating a system to deliver informationCreating a culture to support continuous learningAdopting incentives for learning

Linking Public Health Planning and Workforce Development

38

• Increasing skills for communitycollaboration,

• Creating and using a strategic plan, and• Conducting program evaluation.

For each area, the training plan will show therelated standards and administrative capacitiesrequired in this area. Then, the model plan setsforth desired individual competencies andlearning strategies (various ways to increaseskills), and it names the types of worker forwhom this is most important. Once fully devel-oped, the training plans can be used by indi-viduals seeking to improve their own perfor-mance and by administrators seeking to im-prove performance agency-wide (see http://www.doh.wa.gov/phip/PHIP2004/ReferenceLinks.htm for a sample of a drafttraining plan).

In selecting an approach to the training planwork, the Workforce Development Committeehas placed emphasis on some key beliefs:

First, performance improvement is the goal—not “training.” Training, alone, does not alwaysresult in better skill or improved job perfor-mance. Instead, the committee has put itsattention to a wide range of strategies thatpromise to result in improved performanceamong workers.

Second, expected competencies need to bedefined and related to job function or employeerole. To be a successful worker, and to assessyour workforce as a manager, it is important tohave a clear understanding of the skills andknowledge required for each job.

Third, workforce planning should be done aspart of an agency’s strategic planning cycle. Asagency planning focuses on future goals, it isimperative to have a formal way to assess andplan for the changing needs of workers. Thisrelationship is shown on page 37.

Competencies as a foundationThe 2002 PHIP included a general list of pro-posed public health competencies coveringnine areas. These describe areas where publichealth workers need to have skills, such ascommunication, systems thinking, and leader-

ship (see Appendix 11). These competenciesrepresent the general system-level knowledgeand skills that are needed to achieve theStandards for Public Health in WashingtonState. The level of competency people actuallyneed to do their jobs well varies by position orrole, so the committee is currently detailingcompetencies for individual public healthworkers. In time, these can be used to evaluateindividual training needs and target specificperformance areas.

New training tools and approachesHistorically, formal classroom training has beenthe most common method for delivering train-ing to public health workers. But new technol-ogy has provided creative formats to makelearning more accessible and more timely.Several new learning tools are now being usedby Washington’s public health workers, includ-ing:

• Learning management system: Learning management system: Learning management system: Learning management system: Learning management system: During2005, public health workers will be able toaccess training using a web-based systemthat will allow people to register for in-person and on-line courses and tomaintain training records. In time, thissystem will be able to link training tospecific competencies. The LMS is a tool tohelp manage different types of learning, tohelp individuals set training goals, and toassist with workforce planning (see box,page 39).

• On-line orientationOn-line orientationOn-line orientationOn-line orientationOn-line orientation: An expanded on-lineorientation for new public health leadersoffers additional learning resourcematerials based on specific public healthroles (http://www.doh.wa.gov/pho/default.htm).

• Web conferencing: Web conferencing: Web conferencing: Web conferencing: Web conferencing: The Northwest Centerfor Public Health Practice has made thisnew resource available to the northweststates. This is a tool that uses both theinternet and phone to make trainingaccessible from the desk, withoutrequiring travel. It provides criticallearning and information on current issuesto public health practitioners in diverse

39

locations, across a six-state region. Anexample of one training series beingdelivered with this tool is Hot Topics inPreparedness, which are monthly, hour-long forums on such topics as preparingfor SARS and a possible flu pandemic.These forums are archived so that they canbe viewed and heard on-line at the mostconvenient time for individual workers(see http://healthlinks.washington.edu/nwcphp/htip).

• A web-based information clearinghouse:A web-based information clearinghouse:A web-based information clearinghouse:A web-based information clearinghouse:A web-based information clearinghouse:AssessNow is a web-based learningresource for public health staff working incommunity health assessment throughoutWashington. It provides information, tools,resources, and a venue for dialog toimprove the practice of assessment andthe use of assessment data for publichealth decision-making. The first phase ofAssessNow can be found at http://www.doh.wa.gov/EHSPHL/AIA. Keyelements include: publications, datasources, and an assessment toolkit. Thesecond phase of this work, to be

completed during 2005, will includepassword-protected templates, worksamples, a technical assistance staffdirectory, and additional training materialson assessment methods.

• Cross-discipline training:Cross-discipline training:Cross-discipline training:Cross-discipline training:Cross-discipline training: Technologybrings unique benefits, but traditionalclassroom education is still effective formany areas of learning, especially whenthe goal is to help different disciplineswork together. For example, the trainingmodule Forensic Epidemiology: JointTraining for Law Enforcement and PublicHealth Officials on InvestigativeResponses to Bioterrorism engages lawenforcement and public health officials inworking through fact-based case scenariosinvolving biological weapons. The modulewas developed jointly by the U.S. Centersfor Disease Control and Prevention and thefederal Department of Justice. InWashington, this training module has useda “train-the-trainers” strategy toemphasize peer teaching and to createadditional capacity to sustain the trainingover time.

Tracking Skills and Readiness of the Public Health WorkforceFollowing are some of the ways that Washington’s learning management system (LMS) willimprove the delivery of training in ways that meet the diverse needs of our state’s public healthworkers.

• By providing “just in time” training for handling emergencies and new or emerging diseaseand threats

• By tracking individuals, organizations, and system-wide education/training records• By administering and managing educational programs at the local level• By identifying organizational or individual competencies• By identifying course competencies• By performing assessments to identify organizational and individual learning gaps• By delivering education/training• By developing educational content• By sharing best practices• By providing the basis for mobilizing public health workers for events or emergencies• By providing collaborative work tools

40

Recommendations for 2005-071. Pursue recruitment and retention efforts at

the agency and system level.

Coordinated statewide recruitment strate-gies could include marketing the appeal ofliving and working in Washington State;recruiting workers from such underutilizedvenues as technical schools, student andprofessional organizations; and imple-menting creative loan repayment andtuition reimbursement incentives. Reten-tion activities could include mentoring,promoting a learning culture in the field soworkers will want to stay, exploring finan-cial and non-financial incentives forcontinued learning and development, andexploring ways to extend the contributionsof retirement-eligible workers.

2. Identify and develop a new generation ofmanagers and leaders to maintain andimprove the performance of public healthagencies and the overall public healthsystem.

As today’s leaders move toward retire-ment, it is crucial to develop new onesready to take the helm in public health.The six-state leadership institute begun inthe past few years at the Northwest Centerfor Public Health Practice is an excellentstart, but long-term strategies should beestablished to ensure that we are ready toface tomorrow’s public health challenges.

3. Build on the success of the first EverybodyCounts report.

Conduct this census every 3-5 years andexpand it to include public health partnerssuch as tribal public health agencies,community-based organizations, commu-nity health clinics, and other public healthpartners.

4. Promote access for public health workersto training, technology, and tools neededto support learning.

Workers need adequate access to thetechnology (i.e., web-connected comput-ers, DVD players, telephones with head-sets or speaker phones) through whichlearning is delivered.

5. Use system-level competencies as theframework for assessing learning needsand evaluate learning strategies thatincorporate return on investment.

To support the mission of public healtheffectively, a system-wide perspectiveshould be used in designing curriculumand in evaluating and measuring perfor-mance—for both individual public healthworkers and their agencies. Investments intraining and performance improvementshould be evaluated to show they yielddesired results.

6. Evaluate the usefulness of certificationand credentialing and other incentives atvarious levels of the public healthworkforce.

Credentialing may be one way to formalizethe workforce development and planningthat is needed throughout the field ofpublic health. Careful assessment of thebenefits and costs should be done.

41

ACCESS TO CRITICAL HEALTHSERVICES: HELPING PEOPLE GETNEEDED SERVICES

The State Board of Health reached a

clear determination that access to

needed health services requires much

more than personal medical care.

Access to health services is a high-profile publicpolicy issue at the local, state, and federallevel. As health care costs continue to escalate,and a growing share of Washington residentslose private and public health care coverage,the state’s public health system role in assuringaccess to critical health services—a core publichealth function and one of Washington’sStandards for Public Health—becomes increas-ingly important.

But achieving this ambitious goal, even in thebest of times, requires a series of steps anddecisions to determine which services are trulyessential, identify gaps in these services, andengage community partners in closing thesegaps. Making substantial progress in theseareas while local resources shrink and safetynets fray is all the more daunting. Innovativeleadership, community mobilization, andregional and statewide collaborations arerequired to deal with a problem of this scopeand magnitude.

The Washington State Board of Health (SBOH)took the first steps in addressing this publichealth standard by asking the question, “Ac-cess to what?” Its answer, published in 2001,was to define critical health services as “safe,evidence-based health care services that have apredictable benefit to the health status of thecommunity at large.”

The SBOH then developed a Menu of CriticalHealth Services, which lists the health care

services and health conditions or risks forwhich appropriate services—screening, educa-tion and counseling, or interventions—shouldbe available in every community. The menuaddresses eight areas: general access; healthrisk behaviors; communicable and infectiousdiseases; pregnancy and maternal, infant, andchild health and development; behavioralhealth and mental health services; cancerservices; chronic conditions and diseasemanagement; and oral health.

Using an evidence-based methodology, theSBOH reached a clear determination that accessto needed health services requires much morethan personal medical care. Improvement ofcommunity health status requires a broad rangeof complementary health services that are oftenoverlooked and unappreciated in the continuingdebate over access to health services. TheSBOH saw the broadening of this vision of whatit takes to have a healthy community as aunique mission for the public health system ingeneral and the PHIP access standard in par-ticular (see http://www.doh.wa.gov/phip/Access/default.htm).

With the menu established, the SBOH turned tothe task of measuring access to health servicesand identifying access gaps at the communitylevel. Early on, it determined that reliable localdata about access to the critical services simplydo not exist.

42

The Access Committee, joined by a new partner,the Washington Health Foundation, has em-barked on several activities designed to im-prove health services access issues at thecommunity level. The committee has begun towork closely with local health jurisdictions,provider groups, and other community partnersto understand better the successful accessprojects that are underway throughout thestate. The committee hopes that a systematicreview of these success stories will identifyinnovative strategies, essential communitypartners, and the types of technical assistancethat are needed to support local access projectsamong Washington’s diverse communities.

Following are some of the efforts underwayacross the state to address access issues:

• The Washington Health Foundation’sHealthiest State in the Nation CampaignHealthiest State in the Nation CampaignHealthiest State in the Nation CampaignHealthiest State in the Nation CampaignHealthiest State in the Nation Campaignbuilds upon a series of 2003 communityforums regarding health system change,which found that “fairness” was the

important public value for our healthsystem. Washington State is currentlyranked as 15 under the United HealthFoundation’s annual state ranking report.The Washington Health Foundationcampaign is intended to educate andengage the public on the many changesand actions that are necessary to make usnumber 1. In addition, the foundation haschosen to focus on access to care for thestate’s most vulnerable populations as oneof its major contributions to the overallcampaign.

• The Healthy Communities Access ProgramHealthy Communities Access ProgramHealthy Communities Access ProgramHealthy Communities Access ProgramHealthy Communities Access Program,a project of the U.S. Health Resources andServices Administration, supports thework of communities to provide “safetynet” services for the uninsured andunderinsured. The goal is to reorganizehealth care delivery systems to coordinatemore sharing of uncompensated careamong local health care providers. Fiveprojects have received funding to do this

The Whatcom Alliance Access ProjectThis collaboration of the Whatcom County Health Department, health care providers, communitygroups, local businesses, and consumers works to increase health services access. Its keycomponents are:

Outreach—• Developing a user-friendly website and health outreach materials• Establishing a network of trained volunteers to ensure Medicaid enrollment• Placing professional outreach workers strategically in venues such as hospital emergency

departments

Systems re-design, care coordination and case management—• Improving care management and clinical staff productivity by implementing open access

scheduling at participating community clinics• Improving clinical outcomes for low-income, underserved patients

Develop a system of managed, donated specialty care—• Establishing a specialist recruitment program for donated services• Establishing a shared database that can be used by community clinics to ensure that all

qualifying patients have equal access to needed specialty care

Long-term system capacity building—• Establishing a community-based physician recruitment and retention program• Creating a public-private partnership to sustain community-based access initiatives

43

work in Washington. In Spokane, forexample, the project has developed aprovider network that will take uninsuredpatients on a rotation basis, and itsupports a referral system from theemergency room to primary care. Partnersin this effort include local healthdepartments, public hospitals, communityhealth centers, universities, and stategovernments.

• Communities ConnectCommunities ConnectCommunities ConnectCommunities ConnectCommunities Connect is a statewidecollaboration of concerned communitymembers and leaders who are workingtogether to improve access to care. Thiswork fosters grassroots efforts to promotehealth system change, supportsinformation-sharing on solutions to healthcare problems, provides technicalassistance to communities, and developsshared objectives for local, state, andfederal policy.

• Clark County’s Community Choices 2010 Community Choices 2010 Community Choices 2010 Community Choices 2010 Community Choices 2010brings together local partners to assessregularly demographic and health datawith the overall purpose of buildingawareness and support for thecommunity’s health. This work has focusedon several health issues, such oral health,adult smoking, teen pregnancy, and theuninsured. A community report cardprovides information in 33 indicator areas,including new categories of socialconnectedness, educational health(readiness to learn), and violence andinjury (domestic violence).

Community-based work on access has engagedother Washington counties, including Benton-Franklin, Clallam, Jefferson, Kittitas, Thurston,Spokane, and Whatcom (see page 42 and

Appendix 12). The focus of this work changesover time, as new health issues or diseasesemerge. Among the issues addressed so far arematernity care access, oral health, mentalhealth, and provider shortages. Recognizingthat other county efforts are underway, thecommittee will collect and describe examples ofsuccessful projects throughout the state.

One of the greatest challenges the AccessCommittee faces is finding ways to work withhealth system elements that are outside of thepublic health system, such as reimbursementthrough Medicare and Medicaid. Or, transporta-tion, which must be accessible and available forlow income populations—especially in rural andsparsely populated areas—for access to healthservices to be possible. Work to ensure accessto care must also recognize the presence ofhealth disparities across ethnic and racialgroups in the state, as discussed in the KeyIndicators work in Chapter 1. Finally, health careworkforce issues are also critical: we need anadequate supply of health professionals, and asa group, they need to be representative ofdiverse populations.

In addition, the committee has learned there isno one-size-fits-all solution to improving accessto critical health services. Each of Washington’s35 local public health jurisdictions has adifferent level of involvement with access-related issues, reflecting unique communityresources, opportunities, and circumstances.Achieving greater access to critical healthservices in Washington’s communities willdepend on a host of local variables, includingprovider recruitment and retention,engagement of community leaders, addressinghealth workforce shortages, and the manydemographic characteristics that affect demandfor care.

44

Recommendations for 2005-071. Collect and analyze community success

stories.

Using a common set of data elements andcharacteristics, collect and share modelsof community-based and statewide effortsto address critical health service access.

Many local health jurisdictions havestories to tell of their involvement in theircommunities on projects that focus onaccess. A Resource Guide of Models orPractices will be compiled and madeavailable via web and hard copy. Dataabout health services should reflect abroad understanding of health, includingunderlying determinants of health.

2. Communicate lessons learned.

Find opportunities and forums to presentfindings and discuss the access standardswork. Linking this work with PHIP commu-nications efforts has great potential toexpand the audience for public health’smessages concerning community healthimprovement. The media covers healthcare access issues on a routine basis.Engaging the media to expand their focusto services other than personal medicalcare will stimulate needed debate on thetrue determinants of health and wise useof limited health care resources. Confer-ences such as the Joint Public HealthConference, Healthy Communities, theWashington Rural Health Association andothers are places to share models of workto improve access.

3. Promote integration of and availability ofdata across programs.

Several Department of Health programs,other state programs, and private founda-tions collect data. The data collected onthe key indicators for the state Report Cardon health need to be integrated with these

data systems. Analysis may be done at thelocal or state level and shared with otheragencies or with local health departments.These data are often used to support grantfunding. The website AssessNow.infoprovides an opportunity to present dataand analysis as well as studies on-line,making them accessible to local healthjurisdictions and others (see http://www.AssessNow.info).

4. Look for additional resources to build onthis work.

Help find resources to pilot, expand, orsustain models of implementing accessstandards at both the state and local level.Often, grant funds are available at thefederal, state, and local level as well asthrough private foundations and charitableorganizations. Some of the state’s morenotable access projects are based oncreative local partnerships sustained bydonated resources of community partners.

5. Develop long-term policy with respect tocritical health services.

Among the elements of this work will be toexplore further the central organizing rolethat local health jurisdictions can play inassuring community-based access tocritical health services, with particularattention to population-based and clinicalpreventive services. It will be necessary toprioritize and focus efforts on services thatare evidence-based and offer the greatestcommunity benefit. The work of the SBOHcan be built on to collect data aboutcritical services. The committee will alsobegin to identify high-priority and feasiblesurveillance systems for use in determin-ing access gaps at both state and locallevels. These services can then be linkedto existing quality improvement and safetyefforts in the health care delivery sector.

45

EFFECTIVE COMMUNICATION:IMPROVING UNDERSTANDINGOF PUBLIC HEALTH

People value what public health agencies

do, but they don’t often understand the

context in which they do it.

Most of the work that has engaged the Commu-nications Committee during the past four yearsaddresses a simple quandary: People valuewhat public health agencies do, but they don’toften understand the context in which they doit. They appreciate that public entities protectthem from dangers they cannot control—suchas communicable disease, unsafe food andwater, and other environmental hazards. Butthey are unlikely to recognize the necessity ofmaintaining a complex government system,supported by research and regulatory infra-structure, to do the job.

To secure this vital connection—between widelyvalued public health services and the agenciesthat provide them—the Communications Com-mittee during the past two years has overseendevelopment of a range of focused activitiesdesigned to clarify and reinforce the coremission of the state’s public health system:Always working for a safer and healthier Wash-ington.

During the past two years, these activities haveincluded a web-based public health communi-cations “toolkit,” including resources for publichealth employees to use when they interactwith people in their communities, on the web,and through the news media. These toolsinclude fact sheets, a brochure, and publicservice advertisements that can be customizedfor use in a variety of settings. The website

(http://www.doh.wa.gov/phip/communica-tions/tools) also provides straightforwardlanguage that public health professionals canuse to explain succinctly the essential workthey do in ways that people understand andvalue.

Training is provided for public health workers,at all levels of work, so they can describe clearlythe benefits of public health services. An “e-newsletter” informs public health workersabout the availability of new communicationtools and how to use them.

Communication strategies should increase theconsistency, frequency, and impact of mes-sages reinforcing the credibility and account-ability of the state public health system.

This effort builds largely on research conductedin 2001, which revealed broad support for thework of public health but also exposed a con-tinuing identity problem for Washington’sgovernmental health system: Few state resi-dents think of public health when asked aboutgovernment health programs. Instead, theyassociate public health with medical servicesand programs for low-income people. Yet whenasked, they place high value on public healthservices, such those described in Appendix 6.

Over the next two years, the CommunicationsCommittee will direct its efforts to providing

Continued on page 47

46

When They Know What It Is, They Support ItAs part of the initial research into communications strategies, the Communications Committeeasked Washington residents what came to mind when they were asked about “public health.” Theirresponses revealed a generally poor understanding. But once people were informed of the servicespublic health provided, they indicated strong support and enthusiasm. Among typical responseswere:

“If public health doesn’t do it, who will?”

“It made me think of Hanford. I expect someone to be responsible for our health and safety andissues like that.”

Among people who have worked with public health agencies directly, such as elected officials, wefound both solid understanding and strong support:

“Public health is not an optional program. It’s a fundamental issue of government, no matter whatyour politics.”

“Investigation of communicable disease is undervalued because there are so few of them. Butthere are so few of them because the investigation work is well done.”

“Public health is data-based and can document health outcomes. No other government enterpriseis as clearly focused on demonstrable outcomes.”

Creating a Visible PresencePublic health workers are active throughout theircommunities on a daily basis. But the business of“prevention” is often hard to see, so the Communi-cations Committee is exploring ways to give publichealth a visible presence. Public health employeesare encouraged to wear articles of clothing that carrythe “brand” of Washington’s public health system.They have found them to be remarkably effective atraising the profile of their work, as one employeeattests:

“We use the vests and hats throughout all ourprograms: environmental health, communicabledisease, to name just two. They were very helpfulduring our flood effort last winter. When you are oneof several agencies at the emergency operationscenter, walking around a flooded area, givingtetanus shots, etc., it is important for people toknow that it’s us out there doing public healthwork.”

—Corinne Story, Environmental Health Director,Skagit County Public Health Department

47

public health leaders with advanced communi-cations training so they become familiar withbetter ways to communicate the value of publichealth and become more available to andaccountable with their communities and thenews media. A new approach will be to share

some of the stories generated across Washing-ton State every day, to illustrate both theroutine and creative ways the state publichealth workforce works to keep residentshealthy and safe.

Continued from page 45

48

Recommendations for 2005-071. Conduct advanced workforce training to

strengthen understanding of publichealth.

The committee will conduct a round ofadvanced communications training todevelop workforce skills in communicatingthe value and benefit of public healththrough the media, community organiza-tions, and service groups. They will beginthe series with top management in publichealth agencies.

2. Adopt a set of communication strategiesthat will achieve broader understanding ofpublic health goals.

The public will gain a greater understand-ing of public health services if all agenciesput forward a clear and consistent mes-sage about what public health does, how itserves and protects people, and how itinforms them about how they can partici-pate in public health efforts.

3. Collect and tell public health “stories” thatillustrate how public health affectseveryone who lives in or visitsWashington.

Stories provide the most effective way tocommunicate a memorable message.Public health workers have many interest-ing, even dramatic, stories to tell thatillustrate how public health is “alwaysworking for a safer and healthier commu-nity.” Collecting and sharing writtenstories will be helpful in achieving abroader public understanding.

4. Conduct a statewide media event toincrease public understanding.

Beginning with the series of five communi-cations workshops from January throughMarch 2005, the committee will organizestatewide participation in a coordinatedpublic health “event” to engage the mediain increasing public understanding ofpublic health services and the agenciesthat deliver them. This event could takeplace during Public Health Week, in earlyApril.

49

APPENDICESAppendix 1: PHIP Committees

Appendix 2: List of Key Health Indicators

Appendix 3: Sample Report Card—GradingRationale

Appendix 4: Crosswalk of Core Functions and10 Essential Services to Standards

Appendix 5: Environmental Health Standards

Appendix 6: List of Services to ‘Cost’ theStandards

Appendix 7: PHIP Laws

Appendix 8: Developing Estimates of Cost toMeet Washington’s Public Health Standards

Appendix 9: Summary of Proposed FundingMethodology and Allocation Principles

Appendix 10: Evolving Roles to SupportInformation Technology for Public Health

Appendix 11: PHIP System-levelCompetencies

Appendix 12: Improving Access to Care inWhatcom County

50

51

APPENDIX 1: PHIP COMMITTEES

Riley PetersWashington State Department of HealthMaternal and Child Health

Suzanne PlemmonsKitsap County Health District

Katharine SandersWashington Health Foundation

Katrina Wynkoop SimmonsWashington State Department of HealthCenter for Health Statistics

David SoletPublic Health—Seattle & King County

Christie SpiceWashington State Department of HealthEpidemiology, Health Statistics, and PublicHealth Laboratories

Art StarryThurston County Public Health and SocialServices Department

Juliet VanEenwykWashington State Department of HealthEpidemiology, Health Statistics, and PublicHealth Laboratories

Lyndia VoldSpokane Regional Health District

Staff:Donna RussellWashington State Department of HealthPublic Health Systems Planning andDevelopment

Key Health Indicators Committee

Project Leads:Ward Hinds, Co-chairSnohomish Health District

Jude Van Buren, Co-chairWashington State Department of HealthEpidemiology, Health Statistics, and PublicHealth Laboratories

Members:Barbara Andrews*Yakima Health District

Bobbie BerkowitzTurning Point

Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Maxine HayesWashington State Department of HealthHealth Officer

Josh JonesNorthwest Portland American Indian HealthBoard

Heidi KellerWashington State Department of HealthOffice of Health Promotion

Carrie McLachlanIsland County Health Department

*Has completed term

52

Public Health Standards Committee

Project LeadsTorney Smith, Co-chairSpokane Regional Health District

Bill White, Co-chairWashington State Department of HealthDeputy Secretary

Jack Williams*, former Co-chairWashington State Department of Health

MembersJanice AdairWashington State Department of HealthDivision of Environmental Health

Tony BarrettLewis County Public Health

Sherri BartlettLincoln County Health Department

Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Charlene Crow-Shambach*Snohomish Health District

Lou Anne Cummings*Walla Walla County Health Department

Janet DavisWhatcom County Health Department

Larry Fay*Public Health—Seattle & King County

Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Jan Fleming*Washington State Department of HealthMaternal and Child Health

Maxine HayesWashington State Department of HealthHealth Officer

Jan HaywoodWashington State Department of HealthDivision of Environmental Health

Vicki KirkpatrickWashington State Association of Local PublicHealth Officials

Steve KutzMason County Department of Health Services

Claudia LewisWashington State Department of HealthDivision of Community and Family Health

Mary LookerWashington State Department of HealthHealth Systems Quality Assurance

Marc MarquisChelan-Douglas Health District

Craig McLaughlinWashington State Board of Health

Rick MocklerSnohomish Health District

Maggie Moran*Public Health—Seattle & King County

Nancy ReidWashington State Department of HealthChild and Adolescent Health

Don SlomaWashington Health Foundation

Christie SpiceWashington State Department of HealthEpidemiology, Health Statistics, and PublicHealth Laboratories

Kim ThorburnSpokane Regional Health District

Lincoln WeaverWashington State Department of HealthCommunity Wellness and Prevention

Jane WrightKittitas County Health Department

*Has completed term

53

Staff:Rita SchmidtWashington State Department of HealthDivision of Community and Family Health

Consultants:Marlene MasonBarbara MauerMCPP Healthcare Consulting

Bruce BrownPacific Rim Resources

Public Health Finance Committee

Project Leads:Tim McDonald, Co-chairIsland County Health Department

Lois Speelman, Co-chairWashington State Department of HealthOffice of Financial Services

Members:Jean BaldwinJefferson County Health and Human Services

Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Janet Charles*Clark County Health Department

Nancy CherryPublic Health—Seattle & King County

Elaine CroteauKitsap County Health District

Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Patty HayesWashington State Department of HealthDivision of Community and Family Health

Tom JaenickeWashington State Department of HealthDivision of Community and Family Health

Larry JechaBenton-Franklin Health District

Vicki KirkpatrickWashington State Association of Local PublicHealth Officials

John ManningSan Juan County Department of Health andCommunity Services

Craig McLaughlinWashington State Board of Health

Rick McNeelyWashington State Department of HealthDivision of Community and Family Health

Rick MocklerSnohomish Health District

Don SlomaWashington Health Foundation

David SwinkSpokane Regional Health District

Kathy UhlornPublic Health—Seattle & King County

Carol VillersNortheast Tri-County Health District

Staff:Donna RussellWashington State Department of HealthPublic Health Systems Planning andDevelopment

*Has completed term

54

Consultant:Marty WineBerk and Associates

Public Health Information TechnologyCommittee

Project Leads:Ed Dzedzy, Co-chairLincoln County Health Department

Frank Westrum, Co-chairWashington State Department of HealthChief Information Technology Officer

Members:Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Kathy CarsonPublic Health—Seattle & King County

Melanie DaltonKitsap County Health District

Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Jo HofmannWashington State Department of HealthEpidemiology, Health Statistics and PublicHealth Laboratories

Teresa JenningsWashington State Department of HealthCenter for Health Statistics

Bryant KarrasUniversity of WashingtonSchool of Public Health and CommunityMedicine

Sherri McDonaldThurston County Public Health and SocialServices Department

Jim Minty*Snohomish Health District

Tim MurphySnohomish Health District

Patrick O’CarrollRegional Health Administrator, Region XU.S. Department of Health and Human Services

Margaret ShieldUniversity of WashingtonNorthwest Center for Public Health Practice

Torney SmithSpokane Regional Health District

Greg Story*Chelan-Douglas Health District

Brent VeenstraPublic Health—Seattle & King County

Carol VillersNortheast Tri-County Health District

Jim WhiteWashington State Department of HealthWashington Electronic Disease SurveillanceSystem

Public Health WorkforceDevelopment Committee

Project Leads:Sue Grinnell, Co-chairCowlitz County Health Department

Jack Thompson, Co-chairUniversity of WashingtonNorthwest Center for Public Health Practice

Members:Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Kathy DeuelWashington State Department of HealthHuman Resources

*Has completed term

55

Dorothy GistWashington State Department of HealthOffice of Health Promotion

Nancy GoodloeKittitas County Health Department

Maryanne GuichardWashington State Department of HealthDivision of Environmental Health

Vic HarrisTacoma-Pierce County Health Department

Dennis KlukanYakima Health District

Debbie LeeWashington State Department of HealthDivision of Community and Family Health

Marianne Patton*Chelan-Douglas Health District

Margaret ShieldUniversity of WashingtonNorthwest Center for Public Health Practice

Corinne StorySkagit County Public Health Department

Patti SwansonThurston County Public Health and SocialServices Department

Pam WalkerClark County Health Department

Staff:Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Janice TaylorWashington State Department of HealthPublic Health Systems Planning andDevelopment

Access Committee

Project Leads:Tom Locke, Co-chairClallam County Department of Health andHuman ServicesJefferson County Health and Human Services

Greg Vigdor, Co-chairWashington Health Foundation

Jack Williams*, former Co-chairWashington State Department of Health

Members:Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Regina DelahuntWhatcom County Health Department

Marie FlakeWashington State Department of HealthPublic Health Systems Planning andDevelopment

Nancy GoodloeKittitas County Health Department

Larry JechaBenton-Franklin Health District

Sherri McDonaldThurston County Public Health and SocialServices Department

Kim ThorburnSpokane Regional Health District

StaffMary LookerWashington State Department of HealthHealth Systems Quality Assurance

*Has completed term

56

Communications Committee

Project Leads:Heidi Keller, Co-chairWashington State Department of HealthOffice of Health Promotion

Maryann Welch, Co-chairGrays Harbor County Public Health and SocialServices Department

Members:James ApaPublic Health—Seattle & King County

Laura BlaskeWashington State Department of HealthOffice of Communications

Joan BrewsterWashington State Department of HealthPublic Health Systems Planning andDevelopment

Peter BrowningSkagit County Public Health Department

Tim Church*Washington State Department of HealthOffice of Communications

Elaine EngleSpokane Regional Health District

Marie FlakeWashington State Department of Health *Has completed term

Public Health Systems Planning andDevelopment

Vicki KirkpatrickWashington State Association of Local PublicHealth Officials

Craig McLaughlinWashington State Board of Health

Sandra OwenBenton-Franklin Health District

Suzanne PateSnohomish Health District

Joanne PradoWashington State Department of HealthDivision of Environmental Health

Art StarryThurston County Public Health and SocialServices Department

Holly WeeseUniversity of WashingtonSchool of Public Health and CommunityMedicine

Judith YarrowUniversity of WashingtonHealth Policy Analysis Program

Consultants:Desautel Hege Communications

Special ThanksTo the participants who assisted with work on the PHIP committees and subcommittees:

Barbara Baker

Betty Bekemeier

Lillian Bensley

Kathy Carson

Sandy Ciske

Bob Clark

Wayne Clifford

Dan Francis

Theresa Fuller

Marcia Goldoft

Gregg Grunenfelder

Rick Gunderson

Linda Gunnels

Melinda Harmon

David Koch

Denise LaFlamme

Shelley Lankford

Scott Lindquist

Brad Massey

Ramona Nelson

Mark Nunes

Cathy O’Conner

Carol Oliver

Eric Ossiander

Carolina Padila

Richard Pedlar

Steve Rauch

Tom Rogers

Mark Rowe

Jennifer Sabel

Vince Schueler

Marianne Seifert

Marni Storey

Madeline Thompson

Lori Van De Wege

Joby Winans

Pam Woll-Hunter

57

APPENDIX 2: LIST OF KEY HEALTHINDICATORSCategory or Domain and Indicators

HOW HEALTHY ARE WE OVERALL?How good is our general physical and mental health?

Expected years of healthy life at age 20

Percent of adults who report 14 or more days of poor mental health in the past month

Are we a healthy weight?

Percent of adults who are obese

Percent of 10th-graders who are overweight

HOW SAFE AND SUPPORTIVE ARE OUR SURROUNDINGS?

Do we have illnesses commonly associated with unsafe food, unsafe water, and poor hygiene?

Rate of campylobacteriosis per 100,000 population

Rate of E.coli 0157:H7 infection per 100,000 population

Rate of giardiasis per 100,000 population

Rate of listeriosis per 100,000 population

Rate of salmonellosis per 100,000 population

Rate of shigellosis per 100,000 population

Rate of vibriosis (non-cholera) per 100,000 population

Rate of yersiniosis per 100,000 population

Do we have clean drinking water?

Percent of the population whose homes receive water from Group A public water systems incompliance with nitrate monitoring requirements

Percent of the population whose homes receive water from Group A public water systems incompliance with quality standards for nitrates

Percent of the population whose homes receive water from Group A public water systems incompliance with coliform monitoring requirements

Percent of the population whose homes receive water from Group A public water systems incompliance with quality standards for coliform bacteria

(Indicator for Group B systems under development)

Data not included in Report Card at this time

58

Category or Domain and Indicators

Do we have clean air to breathe?

Percent of population breathing air that is meeting the National Ambient Air Quality Standards

HOW SAFE AND SUPPORTIVE ARE OUR COMMUNITIES?

Do our incomes meet basic financial needs?

Percent of Washington State households with incomes less than twice the U.S. poverty level(incomes less than 200% of the U.S. poverty level)

Are we connected to our communities?

Percent of adults reporting that most people can be trusted

Percent of high school students dropping out of school

Rate of serious violent crime offenses per 100,000 population

Are we getting injured unnecessarily?

Unintentional motor vehicle deaths per 100,000 population

Unintentional poisoning deaths per 100,000 population

Unintentional drowning deaths per 100,000 population

Unintentional fall-related deaths among persons 65 years and older per 100,000 population

HOW SUPPORTIVE IS OUR HEALTH CARE SYSTEM?

Are we able to get medical care when we need it?

Percent of households unable to obtain health care or experiencing a delay or difficulty inobtaining health care

Do we have illnesses that could be prevented by immunization?

Rate of hepatitis A per 100,000 population

Rate of hepatitis B per 100,000 population

Rate of measles per 100,000 population

Rate of mumps per 100,000 population

Rate of pertussis per 100,000 population

Rate of polio per 100,000 population

Rate of rubella per 100,000 population

Rate of tetanus per 100,000 population

Data not included in Report Card at this time

59

Category or Domain and Indicators

HOW SAFE AND SUPPORTIVE ARE OUR FAMILIES?

Are we planning for and spending time with our families?

Percent of pregnancies that were intended

Percent of families that regularly read to their young children

Percent of youth who report eating dinner with their family most of the time or always

Are our families safe?

Number of offenses involving domestic violence per 1,000

Number of reports of children younger than 18 who were abused or neglected per 1,000population

HOW HEALTHY ARE OUR BEHAVIORS?

Do we smoke cigarettes?

Percent of adults reporting current cigarette smoking

Percent of 10th-graders who report smoking cigarettes in the past 30 days

Percent of women who report smoking during the last three months of pregnancy

Are we physically active?

Percent of 10th-graders who report meeting recommendations for vigorous physical activity

Percent of adults meeting recommendations for moderate or vigorous physical activity throughwork or leisure

Are we eating right?

Percent of adults who report eating fruits and vegetables five or more times per day

Percent of 10th-graders who report eating fruits and vegetables 5 or more times per day in thepast week

Percent of 10th-graders who report drinking two or more non-diet sodas yesterday

Do we abuse alcohol?

Percent of adults who report having five or more drinks on one occasion during the past 30days

Percent reporting chronic drinking in the past 30 days: women who report more than one drinkper day and men who report more than two drinks per day

Percent of 10th-graders who report drinking any alcohol in the past 30 days

Data not included in Report Card at this time

60

APPENDIX 3: SAMPLE REPORT CARD—GRADING RATIONALEBelow is a description of the rationale for each grade assigned in the example of the Report Card shown onpage 17. A more complete example of the Report Card and a description of grading criteria can be found at http://www.doh.wa.gov/phip/Indicators/DraftReportCard.htm.

How healthy arewe overall?

How good is ourgeneral physicaland mentalhealth?

Are we a healthyweight?

Indicator

Expected years of healthy life at age 20

Percent of people experiencing poor mentalhealth for 14 or more days in one month

General health grade: Although Washingtoncompares favorably to the United States onhealthy life expectancy and mental health, wehave not seen improvement since 1993, andthere are moderate levels of disparities.

Percent of adults who are obese

Percent of 10th-graders who are overweight

Obesity grade: Washington has relatively fewerobese adults and overweight 10th-graderscompared to the United States Nonetheless, in2003, about 20% of adults reported heightsand weights indicating obesity. About 10% of10th-graders were overweight in 2002.Washington’s rates are moving in the wrongdirection, and we have moderate levels ofdisparities.

Grade

A

B

B

B

Expected years of healthy life at age 20was higher in Washington than in theUnited States for 1999, 2000, and 2001.

Similar percentages of adults in Washing-ton and the U.S. reported 14 or more daysof poor mental health in 2001 and 2003. In2002, fewer adults in Washington reported14 or more days of poor mental health.

Fewer adults in Washington were obese in2001 and 2003 than in the United States.Similar proportions were obese in 2002.

For the 1998/99 and 2002/03 schoolyears, there was less obesity among 10thgraders in Washington compared to theUnited States.

Comparison to United States

61

Grade

C

C

F

There have not been signifi-cant changes in the expectedyears of healthy life from1993 to 2002.

There have not been signifi-cant changes in the percentof adults in Washingtonreporting 14 or more days ofpoor mental health from1993 to 2003.

Since 1990, the percent ofobese adults in Washingtonhas been increasing.

With only two years of data,a trend cannot be calculated.

Grade

C

C

C

C

Disparities for years of healthy life cannot be computeddirectly at this time. But there is a 103% disparity betweenAmerican Indian/Alaska Native (23%±5%) and Asian/PacificIslander (11%±4%) for having poor or fair health. There isalso a 9-year difference in life expectancy between Asian/Pacific Islander (83 years) and American Indian/AlaskaNative (74 years).

112% difference between American Indian/Alaska Native(14%±4%) and African Americans (7%±2%) for 2001-2003.This level of disparity is similar to the level in 1995-1997 and1998-2000.

There was a 179% difference between African Americans(29%±6%) and Asian/Pacific Islanders (11%±3%) for 2001-03. This is similar to the percent differences for 1995-97 and1998-2000.

There was a 115% difference between Hispanics (16%±4%)and Asian/Pacific Islanders (7%±3%) in 2002. Numbers aretoo small for race breakdowns in earlier years.

2.7

2.3

2.5

1.7

2.5

2.1

Finalgrade

averageTrend Disparities

62

APPENDIX 4: CROSSWALK OF COREFUNCTIONS AND 10 ESSENTIALSERVICES TO STANDARDSThe following matrix compares the federal framework of 10 Essential Services of Public Health with theStandards for Public Health in Washington State. Local and state health officials drafted the standardswith frequent reference to the 10 Essential Services, but they did not use the federal framework toorganize their work. Instead, they chose to develop standards in five topic areas. For each area, theysought to assure that the 10 Essential Services were addressed. Please note that the standards, asreferenced here, are abbreviated. An entire standard and its measures must be read to understand itsscope.

The 10 Essential Services are:

Assessment• Monitor health status of the community.• Diagnose and investigate health problems and hazards.• Inform and educate people about health issues.

Policy Development• Mobilize partnerships to solve community problems.• Support policies and plans to achieve health goals.

Assurance• Enforce laws and regulations to achieve health goals.• Link people to needed personal health services.• Ensure a skilled public health workforce.• Evaluate effectiveness, accessibility, and quality of health services.• Research and apply innovative solutions.

63

10 Essential Services

Topic Area/Standard Assessment Policy Assurancedev’t

Assessment

1. Assessment skills and tools in place X X X

2. Information collected, analyzed, and disseminated X X X X X X

3. Effectiveness of programs is evaluated X X X X

4. Health policy reflects assessment information X X X

5. Confidentiality and security of data protected X

Communicable disease

1. Surveillance and reporting system maintained X X X X X X

2. Response plans delineate roles X X X

3. Documented investigation and control procedures X X X X X X

4. Urgent messages communicated quickly X X X X

5. Response plans routinely evaluated X X X X

Environmental health

1. Environmental health education planned X X X X

2. Response prepared for environmental threats X X X X X X

3. Risks and events tracked and reported X X X X X

4. Enforcement actions taken for compliance X X

Prevention/health promotion

1. Policies support prevention priorities X X X X X X

2. Community involvement in setting priorities X X X

3. Access to prevention services X X X X X X

4. Prevention, early intervention provided X X X X

5. Health promotion activities provided X X X X X X

Access to critical services

1. Information on service availability X X X

2. Information shared on trends, over time X X X X

3. Plans developed to reduce specific gaps X X X X X

4. Quality and capacity monitored and reported X X X X X

Mon

itor

Inve

stig

ate

Info

rm

Mob

ilize

Polic

ies

Enfo

rce

Ser

vice

s

Wor

kfor

ce

Eval

uate

Rese

arch

64

APPENDIX 5: ENVIRONMENTAL HEALTHSTANDARDS

The Standards for Public Health in WashingtonState include one set of standards that coverenvironmental health, referred to as “Assuringa safe and healthy environment for people.”During 2004, environmental health directorsfrom several local health jurisdictions workedwith staff from the Washington State Depart-ment of Health to revise some of the measures.These revised measures will be used in the2005 standards measurement.

Standard EH1Environmental health education is a plannedcomponent of public health programs.

Local measures:EH1.1L Information is available about

environmental health, includingcompliance requirements, throughbrochures, flyers, newsletters,websites, or other mechanisms.

EH1.2L The community and stakeholders areinvolved in appropriate ways inaddressing environmental healthissues, including through presentationsor individual technical assistance.

EH1.3L Environmental health educationinformation in all forms (includingtechnical assistance) is reviewed atleast annually and updated, expandedor contracted as needed based onrevised regulations, changes incommunity needs, etc.

EH1.4L The critical components of allenvironmental health activities areidentified and used as the basis foreducation that is provided. Workshopsand other in-person trainings (includingtechnical assistance) are evaluated todetermine effectiveness.

State measures:EH1.1S Information is provided to the public

about the availability of state levelenvironmental health throughbrochures, flyers, newsletters,websites, or other mechanisms.

EH1.2S Stakeholders are involved inappropriate ways in addressingenvironmental health issues, includingthrough presentations or technicalassistance.

EH1.3S Environmental health educationinformation in all forms (includingtechnical assistance) is reviewed atleast annually, and is updated,expanded, or contracted as neededbased on revised regulations, changesin stakeholder needs, etc.

EH1.4S Environmental health education isprovided in conformance with needs ofstakeholders, as identified throughmeetings, surveys, or other assessmentmeans. Environmental health educationis assessed for effectiveness throughevaluations of participants, surveys, orother means.

EH1.5S Staff members conductingenvironmental health education haveskills (health education,communication, etc.) as evidenced byjob descriptions, resumes, or trainingdocumentation.

Standard EH2Services are available throughout the state torespond to environmental events or naturaldisasters that threaten the public’s health.

Local measures:EH2.1L Information is provided to the public on

how to contact local jurisdictions toreport environmental health threats or

65

public health emergencies 24 hours aday.

EH2.2L Environmental health threats and publichealth emergencies are included in thelocal emergency response plan. After apublic health emergency responseinvolving environmental health occurs,environmental health staff are includedin the local jurisdiction after-actiondebrief. Any changes to the responseplan affecting environmental healthresponse are documented.

EH2.3L Environmental health services that arecritical to access in different types ofemergencies are identified. Publiceducation and outreach includesinformation on how to access thesecritical services. After-action debriefincludes a review of the accessibility ofthose services, and any changesnecessary are made and documented.

EH2.4L There is a plan that details the roles andresponsibilities for local healthjurisdiction staff in a natural disaster orother public health emergency that bothstands alone and is part of the localemergency response plan. All localhealth jurisdiction staff receive annualtraining on their respective duties.

State measures:EH2.1S Information is provided to the public on

how to report environmental healththreats or public health emergencies,24 hours a day; this includes a phonenumber.

EH2.2S Environmental health threats and publichealth emergencies are included in theemergency response plan. After a publichealth emergency response involvingenvironmental health occurs,environmental health staff are includedin the after-action debrief. Any changesto the response plan affectingenvironmental health response aredocumented.

EH2.3S Written procedures are maintained anddisseminated for how to obtainconsultation and technical assistance

regarding emergency preparedness forenvironmental events or naturaldisasters that threaten the public’shealth. Procedures are in place toevaluate the effectiveness of theseemergency response plans. Plans orprocedures are revised based on eventdebriefing findings andrecommendations.

EH2.4S There is a plan that describesDepartment of Health internal roles andresponsibilities for environmentalevents or natural disasters that threatenthe health of the people. There is a clearlink between this plan and other stateand local emergency response plans.

EH2.5S Appropriate Department of Healthprogram staff are trained in riskcommunication and the DOH emergencyresponse plan, as evidenced by trainingdocumentation.

Standard EH3Both environmental health risks and environ-mental health illnesses are tracked, recorded,and reported.

Local measures:EH3.1L Environmental health data are available

for community groups and other localagencies to review.

EH3.2L Key indicators of environmental healthrisks and illnesses are identified. Asystem is in place for reporting of anysuspected environmental healthillnesses based on those indicators, andreporting is tracked to monitor trends. Asystem is in place to assure the data areshared with appropriate local, state andregional agencies.

EH3.3L Public requests, board of healthtestimony, compliance rates, and otherdata and information are used todetermine what internal or externalquality improvements may be needed. Ifneeded, a plan is developed to instituteneeded changes over time.

66

State measures:EH3.1S Coordination to develop environmental

health indicators and data standards isprovided.

EH3.2S Key indicators of environmental healthrisks and illnesses are identified. Asystem is in place for reporting of anysuspected environmental healthillnesses based on those indicators, andreporting is tracked to monitor trends. Asystem is in place to assure the data areshared with appropriate local, regional,state, and national agencies.

EH3.3S Public requests, testimony before theState Board of Health, compliance rates,and other data and information areused to determine what internal orexternal quality improvements may beneeded. If needed, a plan is developedto institute changes over time.

Standard EH4Compliance with public health regulations issought through enforcement actions.

Local measures:EH4.1L Written policies, local ordinances,

administrative codes, and enabling lawsare accessible to the public.

EH4.2LThere are written procedures to followfor enforcement actions. The proceduresspecify the type of documentationneeded to take an enforcement action,which conforms with local policies,ordinances, and state laws.

EH4.3L A selected number of enforcementactions are evaluated each year todetermine compliance with andeffectiveness of enforcementprocedures. If needed, procedures arerevised.

EH4.4L Enforcement actions are logged(tracked) from the initial report, throughthe investigation, findings, andenforcement action and are reported toother agencies as required.

EH4.5L Appropriate environmental health staffare trained on enforcement procedures.

State measures:EH4.1S Written policies, local ordinances, laws,

and administrative codes are accessibleto the public.

EH4.2S Information about best practices inenvironmental health complianceactivity is gathered and disseminated orposted to agency’s website, including,as appropriate, form templates, timeframes, interagency coordination steps,hearing procedures, citation issuanceand documentation requirements.

EH4.3S There are written procedures to followfor enforcement actions. The proceduresspecify the type of documentationneeded to take an enforcement action,which conforms with state law.

EH4.4S There is a documented process forperiodic review of enforcement actionsand a selected number of enforcementactions are evaluated each year todetermine compliance with andeffectiveness of enforcementprocedures. If needed, procedures arerevised.

EH4.5S Enforcement actions are logged(tracked) from the initial report throughthe investigation, findings, andenforcement action, and they arereported to other agencies as required.

EH4.6S Appropriate environmental health staffare trained on enforcement procedures,as evidenced by trainingdocumentation.

67

Following are the core public health activitiesand services that a mid-size health jurisdictionwould provide to meet 95% performance on theStandards for Public Health in WashingtonState.

Assuring a safe and healthyenvironment

• Food safety (inspections, education,permitting, data management includinglocal responsibilities for shellfishmonitoring)

• Water recreational facility safety(inspections, education, permitting, datamanagement)

• Hazardous materials management (druglab inspection, testing oversight, clean-upoversight)

• Solid waste management (permitting,inspection, enforcement, education)

• Water quality control: sewage (permitting,inspection, enforcement, education andoperations and management), groundwater, drinking water (permit, inspection,enforcement, education, drinking waterdata), surface water (drinking waterpermit, inspection, enforcement,education, and environmental monitoring)

• Vector/rodent control/zoonotic disease(inspection, enforcement, education, andsampling)

• Air quality monitoring (indoorinvestigations)

• Environmental laboratory services• School safety (inspection, education, and

consultation)• Environmental health community

involvement• Environmental sampling• Review of land use decisions

Protecting people from disease• Detection/case investigation: screening

(specimen collection and analysis),

APPENDIX 6: LIST OF SERVICES TO‘COST’ THE STANDARDS

testing, lab (identification and diagnosis),diagnosis (clinical and lab identification)

• Surveillance, reporting (transmission ofinformation), data analysis (monitor andinterpret), data gathering (collectinginformation and collection systems),epidemiological investigations, casefinding (identifying cases and location),contact tracing (identifying potentialexposure)

• Regional epidemiology• Laboratory (identification and diagnosis)• System intervention: immunizations

(preventive pre- or post-exposure),treatment and prophylactic treatment(dispensing, shots, application, andobservation), counseling (one-on-oneeducation and therapy), tuberculosisprogram

• Public and provider education (informinggeneral public and outbreak specific)

• Surveillance of chronic disease trends andbehavioral changes, identifying clusters,special studies to identify risk factors andfocus prevention efforts, preventionactivities focused on behavioral andenvironmental/policy interventions, andevaluation

• Outreach and prevention with high-riskpopulations

• Plans and surge capacity for response toemergency situations that threaten thehealth of people

Understanding health issues• Epidemiology (infectious and non-

infectious disease trends monitoring,collection, and analysis of data on healthrisk behaviors, health status, and criticalhealth services)

• Dissemination of assessment informationin the community to support decision-making

68

• Technical assistance, education andleadership for community-level datautilization

Evaluation of public health programresults

• Prevention is best: promoting healthyliving

• Capacity for health education and systemswork related to the following activities:engaging community agencies,organizations and constituencies toaddress and develop locally designedprograms driven by locally identifiedhealth issues, strategic planning based oncommunity needs, local data gatheringand analysis, and coalition andstakeholder-building

• Resource assessments (developassessment of resources based on specificneeds), generate resources (designmaterials, find funding, write grants),designing and providing promotionalmaterials and/or social marketingcampaigns evaluating results of efforts,and collecting and disseminatingresearch-based best practices

• Assure and support healthy pregnancy,healthy birth outcomes, early braindevelopment; includes maternal and childhealth programs, early intervention,health and safety promotion in child carecenters, children with special health careneeds, family planning, First Steps/MCM/MSS community outreach and WIC

• Evaluating results of efforts, collecting anddisseminating research-based, replicablebest practices (including about chronicillnesses and health behaviors), providerand public education

Helping people get the services theyneed

• System assurance role: bring peopletogether and provide leadership andsupport, system infrastructure, support forlocal community SWOT assessment

• Provide information and education aboutcritical public health services; createconditions that make action possible.

• Information and referral activities(maintain inventory of services, referral,resource broker)

• Create conditions that make actionpossible (standards, policy, qualityassurance, materials and supplies,information, and education)

• Safety net services (direct services asidentified through local assessment, Menuof Critical Health Services)

Administration• Leadership, planning, policy development,

and administration• Financial and management services

(accounting, budget, contracts,procurement, grants, and assetmanagement)

• Leadership and governance(communication, public relations,relationship building, program planning,and fundraising)

• Legal authority (policies, procedures, andregulations)

• Human resources (personnel, employeedevelopment and recognition,compensation and benefits management,and employee policies)

• Information systems (hardware/softwaresystems, networking, data sharing,policies)

69

APPENDIX 7: PHIP LAWS

(iii) An analysis of the costs and benefits ex-pected from adopting minimum public healthstandards for assessment, policy development,and assurances;

(b) Recommended strategies and a schedule forimproving public health programs throughoutthe state, including:

(i) Strategies for transferring personal healthcare services from the public health system,into the uniform benefits package where fea-sible; and

(ii) Timing of increased funding for public healthservices linked to specific objectives for improv-ing public health; and

(c) A recommended level of dedicated fundingfor public health services to be expressed interms of a percentage of total health serviceexpenditures in the state or a set per personamount; such recommendation shall alsoinclude methods to ensure that such fundingdoes not supplant existing federal, state, andlocal funds received by local health depart-ments, and methods of distributing fundsamong local health departments.

(4) The department shall coordinate this plan-ning process with the study activities requiredin section 258, chapter 492, Laws of 1993.

(5) By March 1, 1994, the department shallprovide initial recommendations of the publichealth services improvement plan to the legisla-ture regarding minimum public health stan-dards, and public health programs needed toaddress urgent needs, such as those cited insubsection (8) of this section.

(6) By December 1, 1994, the department shallpresent the public health services improvementplan to the legislature, with specific recommen-dations for each element of the plan to beimplemented over the period from 1995 through1997.

RCW 43.70.520Public health services improvement plan.

(1) The legislature finds that the public healthfunctions of community assessment, policydevelopment, and assurance of service deliveryare essential elements in achieving the objec-tives of health reform in Washington state. Thelegislature further finds that the population-based services provided by state and localhealth departments are cost-effective and are acritical strategy for the long-term containmentof health care costs. The legislature furtherfinds that the public health system in the statelacks the capacity to fulfill these functionsconsistent with the needs of a reformed healthcare system.

(2) The department of health shall develop, inconsultation with local health departments anddistricts, the state board of health, the healthservices commission, area Indian health ser-vice, and other state agencies, health servicesproviders, and citizens concerned about publichealth, a public health services improvementplan. The plan shall provide a detailed account-ing of deficits in the core functions of assess-ment, policy development, assurance of thecurrent public health system, how additionalpublic health funding would be used, anddescribe the benefits expected from expandedexpenditures.

(3) The plan shall include:

(a) Definition of minimum standards for publichealth protection through assessment, policydevelopment, and assurances:

(i) Enumeration of communities not meetingthose standards;

(ii) A budget and staffing plan for bringing allcommunities up to minimum standards;

70

(7) Thereafter, the department shall update thepublic health services improvement plan forpresentation to the legislature prior to thebeginning of a new biennium.

(8) Among the specific population-based publichealth activities to be considered in the publichealth services improvement plan are: Healthdata assessment and chronic and infectiousdisease surveillance; rapid response to out-breaks of communicable disease; efforts toprevent and control specific communicablediseases, such as tuberculosis and acquiredimmune deficiency syndrome; health educationto promote healthy behaviors and to reduce theprevalence of chronic disease, such as thoselinked to the use of tobacco; access to primarycare in coordination with existing communityand migrant health clinics and other not forprofit health care organizations; programs toensure children are born as healthy as possibleand they receive immunizations and adequatenutrition; efforts to prevent intentional andunintentional injury; programs to ensure thesafety of drinking water and food supplies;poison control; trauma services; and otheractivities that have the potential to improve thehealth of the population or special populationsand reduce the need for or cost of healthservices.

[1993 c 492£ 467.]

RCW 43.70.580Public health improvement plan—Funds—Performance-based contracts—Rules—Evalua-tion and report.

The primary responsibility of the public healthsystem, is to take those actions necessary toprotect, promote, and improve the health of thepopulation. In order to accomplish this, thedepartment shall:

(1) Identify, as part of the public health improve-ment plan, the key health outcomes sought forthe population and the capacity needed by thepublic health system to fulfill its responsibilitiesin improving health outcomes.

(2)(a) Distribute state funds that, in conjunctionwith local revenues, are intended to improvethe capacity of the public health system. Thedistribution methodology shall encouragesystem-wide effectiveness and efficiency andprovide local health jurisdictions with theflexibility both to determine governance struc-tures and address their unique needs.

(b) Enter into with each local health jurisdictionperformance-based contracts that establishclear measures of the degree to which the localhealth jurisdiction is attaining the capacitynecessary to improve health outcomes. Thecontracts negotiated between the local healthjurisdictions and the department of health mustidentify the specific measurable progress thatlocal health jurisdictions will make towardachieving health outcomes. A communityassessment conducted by the local healthjurisdiction according to the public healthimprovement plan, which shall include theresults of the comprehensive plan preparedaccording to RCW 70.190.130, will be used asthe basis for identifying the health outcomes.The contracts shall include provisions to en-courage collaboration among local healthjurisdictions. State funds shall be used solely toexpand and complement, but not to supplantcity and county government support for publichealth programs.

(3) Develop criteria to assess the degree towhich capacity is being achieved and ensurecompliance by public health jurisdictions.

(4) Adopt rules necessary to carry out thepurposes of chapter 43, Laws of 1995.

(5) Biennially, within the public health improve-ment plan, evaluate the effectiveness of thepublic health system, assess the degree towhich the public health system is attaining thecapacity to improve the status of the public’shealth, and report progress made by each localhealth jurisdiction toward improving healthoutcomes.

[1995 c 43£ 3.]

71

Why “cost” the standards?Standards provide:

• A clear and accountable measure ofperformance for public health agencies—alevel of protection citizens can count on.

• Information to health policy makers aboutthe operational “health” of the system aswell as the effectiveness of public healthinterventions.

• A way to evaluate on a regular basis wherepublic funds are needed, what they arebuying, and how well they are being spent.

• By estimating what it would cost toachieve the standards statewide, thestandards can be used to link state andlocal funding with meeting public healthstandards and improving health outcomes.Over time, costing the standards helps tomeet the system goal of stable andsufficient funding for public health.

General assumptions used to cost thestandards

• The standards are what the public healthsystem believes that the state and everylocal health jurisdiction must be able to doto protect and promote the health ofpeople. The cost of meeting the standardswill not rest with the measures themselvesbut with the underlying capacity it takes todemonstrate performance.

• The estimates should lead torecommendations for funding priorities inpublic health.

APPENDIX 8: DEVELOPING ESTIMATESOF COST TO MEET WASHINGTON’SPUBLIC HEALTH STANDARDS

What would it take to protect thepublic’s health according to the publichealth standards?To provide public health protection by meetingthe public health standards 95% of the time,Washington’s governmental public healthsystem would need a sustained annual invest-ment of about $400 million in addition tocurrent resources.

• This total includes an additionalinvestment of $14.5 million towardDepartment of Health (DOH) efforts toprovide public health protection. Thelarger proportion of this estimate would befocused on ensuring assessment skills andtools are in place, that programevaluations are conducted, and for healthpromotion activities.

• The total also includes $385 million abovecurrent public health capacity for 35 LHJsto meet the standards at 95% capacity.

BackgroundThe Standards for Public Health in WashingtonState describe what public health professionalsbelieve everyone has a right to expect of thegovernmental public health system. The stan-dards were developed jointly by state and localpublic health officials and field-tested overtime. A 2002 baseline measured the capabilityof the state agency and the 35 local publichealth agencies to meet the standards; thestudy shows how far the partners in the systemare from being able to perform the standardsstatewide.

Continued on page 74

72

Methodology for ‘Costing’ the Standards

LOCAL

STATE

Start with the gap• Use “Proposed Matrix” of DOH

assignments of divisionalresponsibility to meet the standards asa starting point. Focus on the gap. Focus on the gap. Focus on the gap. Focus on the gap. Focus on the gapbetween what was measured and whatbetween what was measured and whatbetween what was measured and whatbetween what was measured and whatbetween what was measured and whatit would take to improve DOHit would take to improve DOHit would take to improve DOHit would take to improve DOHit would take to improve DOHperformance to 95% of standard.performance to 95% of standard.performance to 95% of standard.performance to 95% of standard.performance to 95% of standard.

• Seek key informants to be identified bysenior management team.

Develop mid-size LHJ cost estimate• Matrix: “core” services x big ideas behind each standard, showing

relationship between service and standard.o April: Distribute matrix to 8 LHJs:

* Joint Finance-Standards Committee (Island, Jefferson, Clark,Spokane)

* Four LHJs near population 175,000 (Chelan-Douglas, Benton-Franklin, Whatcom, Thurston).

• LHJs estimate the number of professional FTEs (direct costs) needed tosuccessfully meet 95% performance of the standards for a jurisdictionserving population 175,000 (the average population of all current 35jurisdictions). This mid-size jurisdiction is the starting point and basisfor costing standards at the local level. Technology may be separatelyestimated.

• Staff will synthesize and share FTE estimates and report exceptions.• LHJ reps confirm and resolve remaining differences.• Complete mid-size LHJ cost estimate by multiplying:

o Direct FTEs by estimated salaries;

o Direct FTEs by support and management ratio for span of control;

o All FTEs by percentage overhead factor.

• Centrally add costs for tools, training, overhead, and supporting staff(management and administration) on percentage basis and by span-of-control formula.

• Sum: the cost for a mid-size LHJ to meet standards at 95%Sum: the cost for a mid-size LHJ to meet standards at 95%Sum: the cost for a mid-size LHJ to meet standards at 95%Sum: the cost for a mid-size LHJ to meet standards at 95%Sum: the cost for a mid-size LHJ to meet standards at 95%performance.performance.performance.performance.performance.

IDENTIFY “CORE”ACTIVITIESIdentify the “big idea”behind each standard

• Vital services,protection,outcomes,deliverables

• Recognize a servicecould cut acrossmultiple standardsand vice versa.

73

Scale the estimate and aggregatestatewide

• Use the cost for a mid-size LHJ as thestarting point and 2002 population.

• Use the four categories of local healthjurisdiction types (Rural-UrbanCommuting Area) outlined in thebaseline evaluation to group to classifyLHJs and establish relationship of eachLHJ to mid-size. Multiply costs byscaling factor and aggregate costsstatewide.

• Implications: LHJs with 10x populationwill have 10x cost; those with 0.1x thepopulation will have that fraction ofcost. Acknowledge that estimates mayneed to be adjusted for outliers (suchas separate estimate for Public Health—Seattle & King County).

• Sum: the cost for all LHJs to meet theSum: the cost for all LHJs to meet theSum: the cost for all LHJs to meet theSum: the cost for all LHJs to meet theSum: the cost for all LHJs to meet thestandards at 95% performance.standards at 95% performance.standards at 95% performance.standards at 95% performance.standards at 95% performance.

• Test costs by consulting LHJs thatperformed well in 2002. Interview themand see how they rate and wouldimprove the estimate.

Estimate cost for DOH to meet standards• Schedule individual meetings for key informants in four divisions: CFH,

Epi/Lab, HSQA, and EH, to develop models for meeting the standard atthe 95% level, in terms of FTEs and the major resources needed.

• Key informants review standards for all topic areas whereresponsibility has been assigned for their division.

• Program managers and/or key program staff review cost estimates fortheir division and modify.

• DOH staff estimates costs for the remaining divisions (MSD, OS, DIRM,SBOH) and applies costs to FTE estimates. Result: Cost for DOH toResult: Cost for DOH toResult: Cost for DOH toResult: Cost for DOH toResult: Cost for DOH tomeet 95% of performance.meet 95% of performance.meet 95% of performance.meet 95% of performance.meet 95% of performance.

Estimate the gap• Use the estimate for totalUse the estimate for totalUse the estimate for totalUse the estimate for totalUse the estimate for total

funds needed system-widefunds needed system-widefunds needed system-widefunds needed system-widefunds needed system-wideand subtract currentand subtract currentand subtract currentand subtract currentand subtract currentresourcesresourcesresourcesresourcesresources (2002 BARSestimate) to give theamount of additionalresources needed (the“gap”) to meet thestandards.

• Ensure the estimate allowsfor flexibility to respond topublic health priorities.

Total costs: Local gapLocal gapLocal gapLocal gapLocal gap

+++++

State gapState gapState gapState gapState gap

=====

Estimated cost toEstimated cost toEstimated cost toEstimated cost toEstimated cost tomeet standardsmeet standardsmeet standardsmeet standardsmeet standards

statewidestatewidestatewidestatewidestatewide

74

• The estimates draw on the expertise ofpublic health professionals from both theFinance Committee and the StandardsCommittee. The cost estimates incorporatethe best judgment of practicingprofessionals, applied using real-lifescenarios and costs to develop formulas.Assumptions are documented so readerscan easily track how cost figures werederived.

• Estimating costs should focus onadditional resources needed to achievepublic health performance standardsstatewide, on top of current capacity in thesystem, beginning with informationgathered in the 2000 field test and the2002 baseline study. Thus, additionalfunds needed focus on the “gap” betweencurrent performance and the performancedesired to achieve the standards.

• The estimates focus on the system as awhole; state and local needs are estimatedseparately, but the model is not designedto be applied in a district-specific orservice-specific method.

• The cost model is based on the resourcespublic health professionals believe it willtake to meet the standards, includingassumptions about known costs such assalary, benefits, rent, equipment, andvehicles.

• The model and assumptions will be usedto derive reasonable estimates of overallneed—but they will not represent the onlyway or the “right” way to organize ordeploy resources. The modeling workfocuses on current capacity only in termsof today’s current organization of LHJs andDOH, and it did not try to figure thosecosts in any re-structured system. Fromthe initial estimate, other work may bedone to estimate costs using differentapproaches that seem to offer improvedservice or that promise cost savings. Thiseffort should lead to next steps in whichways to improve our public health effortsare considered. A continued focus on

quality improvement is essential—findingways to be more effective in terms ofoutcomes and more efficient in terms ofcosts and resources.

• Core public health activities and resourcesneeded to provide them were estimated,based on the standards, rather than themany categorical programs that helpsupport basic capacity. These differencesare drawn because separating core fromcategorical activities will reveal the realcost of resources that must be in place toassure baseline public health protection.

Costing methodology: DOH• At DOH, the process to develop costs was

sponsored and led by the seniormanagement team and managers fromacross the department. Costing was basedon full-time equivalent (FTE) estimates andused formula calculations for each divisionto calculate the total costs, which includesindirect or overhead costs, supervisionand administrative support.

• These cost estimates were conducted as aseparate and parallel process from thecosting work done with LHJs, and they donot reflect anticipated state capacity thatwould be needed once LHJs are fullyfunded. The DOH estimates were based onthe size and capacity that exists withinlocal health at this time. A next step forDOH would be to use the local healthestimates as information to re-examine thestate estimates.

• Given the expectations for delivery of localpublic health services throughout thestate and current under-funding, it wouldbe expected that the estimates for localhealth would be far greater than for thestate.

• From the baseline assessment, a“proposed matrix” of DOH assignments ofresponsibility (by standards) was refined,and DOH focused on the gap betweenwhat was measured and what it would taketo improve performance in those specificareas already identified on the matrix—not

Continued from page 71

75

on all areas where the standards could beused.

• Program managers were encouraged tothink beyond the minimum level ofperformance and estimate the FTE neededfor a very good program.

• The process focused on FTEs and askedmanagers to think into the future anddevelop the most realistic estimate theycould. The costs were calculated at thestandard level and used a formula to applycosts to the new FTEs needed and add inany other extraordinary cost.

• Assumptions about making the costestimates:o Cost estimates are based on the number

of new professional staff and anyextraordinary costs (e.g., technicalequipment, software, etc.) needed tomeet the standards at 95% perfor-mance. Excluded were all administrativesupport staff. A consistent formulaspecific for each division calculated theassociated costs (support and supervi-sory staff) and overhead.

o The estimates of current FTEs werebased on what are expected to be inplace by June 6, 2005. New FTE willassume a start date of July 1, 2005.Economies of scale will be addressedthrough management review. Thetimeframe for reaching 95% perfor-mance on the standards could bephased in over five years, with a mid-point assessment (in 2007) to determineprogress toward goals and adjustcalculations as necessary.

o Estimates are at the standards level andnot at the measure level.

o For programs that currently receivegrant funding that may not be ongoingbut that allows them to accomplish thework, estimates include the number ofFTEs needed to continue the work if thegrant went away. These are grants thathave a good chance of being discontin-ued.

• Given that the DOH AdministrativeStandards have not been finalized, theywere not included in the DOH estimates.

• Detailed FTE information is not included infinal reports.

Costing methodology: local publichealth

• Assumptions and guidance for costestimation was provided by a six-membergroup of representative LHJs from thefollowing counties: Benton-Franklin, Clark,Island, Spokane, Thurston, and Whatcom.The estimate was calculated by Berk &Associates.

• Important public health protection andactivities for each standard were selectedfor costing, using a matrix of services.Members of the subgroup related thematrix to the standards and estimated thetotal number of professional FTEs neededto carry out the activity in a jurisdictionwith a population of 175,000.

• Local estimates were calculated by topicarea of the standard, then aggregated bytopic for the five areas. Not every standardmust have a cost assigned, though mostwill. Cost per measure was not estimatedand public health professionals believed itwould be a misrepresentation to do so.

• A span of control factor was applied toeach direct service FTE to estimate supportand management FTE, and an index of thecost of a mid-size LHJ to meet thestandards was set ($17.5 million)

• Next, local cost estimates were scaled forsize, to take into account different costsfor rural or urban areas. (Example: ruralareas have greater travel time and fewerappointments per day. Urban areas mayhave concentrated populations, but alsomuch higher demands for service.) For thismodel, we adapted a calculation used inthe baseline study called the Rural-UrbanCommuting Area system. At this point itwas decided that the scaling resulted in an

76

unrealistic result for Seattle-King County,and it would be estimated separately. Theremaining LHJs fell into six size categories.

• Using the estimate of the total amount itwould take to reach the standards,subtracted from that was the amount offunding already committed to meeting thepublic health standards. The result is theshortfall in LHJs to be able to fully meet thepublic health standards (“the gap”).

• The model to cost the standards seems towork relatively well, except for cases ofvery small and very large local healthdepartments; therefore, an adjustment tothe estimate was developed for PublicHealth—Seattle & King County (PHSKC)because the model resulted in a very low

total estimate for this jurisdiction to meetthe standards. In addition, the estimaterecognizes other ways to describecapacity, such as investments in contractswith community health, research,investments in partnering with the privatehealth care industry, and developingautomated records.

• All the divisions of PHSKC participated in acosting methodology similar to localhealth departments to estimate the cost tomeet the standards for a largemetropolitan health department. Theagency considered areas in 2002 baselineperformance that needed improvement,plus all activities that it engaged in tomeet the standards.

77

This summary is taken from a paper based onfinancing principles developed by the PublicHealth Improvement Partnership FinanceCommittee. The paper contains recommenda-tions for how the Washington State Departmentof Health will work with local health partners indetermining allocations of state-administeredfunds. The complete set of recommendations isavailable at http://www.doh.wa.gov/phip/documents/Financing/fundingallocation/recommendations.pdf.

Definitions:Funding methodologyFunding methodologyFunding methodologyFunding methodologyFunding methodology—The formula used tocalculate an allocation

Funding allocationFunding allocationFunding allocationFunding allocationFunding allocation—The amount of fundingdistributed as a result of a funding methodol-ogy formula

Finance system principle:Public health funding is a shared responsibilityof federal, state, and local government.

Allocation group recommendation

• Funding methodologies and allocationswill be developed jointly by theDepartment of Health and local healthjurisdictions.

• Communication is a joint responsibility.

Finance system principle:Federal, state, and local funds can be usedmost effectively when restrictions are few, whilestill maintaining accountability for public healthoutcomes.

Allocation group recommendation

• Use evidence of effective programstrategies in allocating flexible funds.

APPENDIX 9: SUMMARY OF PROPOSEDFUNDING METHODOLOGY ANDALLOCATION PRINCIPLES

• Options to consider when funds areunrestricted: population, level of effortneeded to meet requirements, legislativeintent.

Finance system principle:State and federal sources should be allocatedbased on regularly updated, well-defined/documented/communicated, measurablecharacteristics.

Allocation group recommendation

Selecting funding methodology:

• Evaluate the impact of a new fundingmethod or changing an existing one.

• Review programmatic strategies in light ofavailable dollars, allocation, andeffectiveness of strategies.

• Link the purpose of funding withmethodology. For example:o Specific population—specific target

o Capacity/broad population focus—statewide population target

• Select an approach appropriate to thesubject, i.e., incidence (rate) v. prevalence(number of people affected).

Deciding allocation amounts:• Use available assessment data at onset of

allocation review. Develop a picture ofwhat is happening with the issue beingconsidered.

Advisers:• Gather input using advisers to guide

decision-making.

78

Regular updates:• Schedule a methodology review every 10

years at a minimum or when there aremajor changes in the funding, changes indata elements of a formula, or changes infederal requirements.

• Schedule an allocation review everybiennium to include new data as available,unless there are substantial changes infunding that require immediate action.

For example: If methodology is going tochange, synchronize any changes with thebudgeting process, if possible. When thereis a difference between the funding targetand current allocation, bring all LHJs totheir targeted allocation. Adjustments infunding should be phased in over time toreach targets.

Communication:• Provide an opportunity for all affected by

the allocation to be involved and “heard,”both in the development of themethodology as well as the allocationupdates.

• Funding methodology and allocationprocess should be a participatory,transparent, and understandable process.

Finance system principle:Financial incentives should exist to encouragepartnerships that result in less costly and mostcost-effective public health service.

Allocation Group recommendation

• If funds are insufficient to be effectivewhen allocated among all local healthjurisdictions statewide, consider: Notdistributing statewide; coordinatingfunding with other programs with similargoals; leveraging funds (e.g., commonoutcomes or statement of work); reviewingflexibility or strategies; seeking morefunding; developing a regional strategy; orbuilding in program evaluation only inareas with sufficient population to bestatistically significant.

• Funds allocated for a specific programshould be used to implement thatprogram. Evaluation and reportingrequirements must be reasonable.

• Contract deliverables, program andreporting requirements must be consistentwith the allocation amount.

79

The new technologies that make informationcollection, processing, and exchange moreefficient for public health agencies also requirenew staff responsibilities. The InformationTechnology Committee has identified thefollowing roles and activities that must bepresent in every agency to keep informationsystems efficient and secure.

Technology roles for agencyadministration and management

• Assign roles for agency and clearlycommunicate expectations; provideguidance and guidelines.

• Develop a coordinated approach toapprove individuals for access to specificapplications and to approve the “rights” tobe granted each individual for eachapplication (i.e., types of rights,application administrators, supervisoraccess for monitoring program oremployee performance, user-only, etc.).Decide who in the agency—amongsupervisors, managers, and programdirectors—will approve individuals foraccess to specific applications and whowill communicate this information to thestate Department of Health.

• Decide who will go to which trainings andhow often.

• Decide and approve how much of whichtype of equipment to acquire.

• Decide and approve use policies—expectations, monitoring, andconsequences regarding security,timeliness, accuracy, accountability, andacceptable behavior regarding use.

APPENDIX 10: EVOLVING ROLES TOSUPPORT INFORMATION TECHNOLOGYFOR PUBLIC HEALTH

Technology roles that might beassigned to the IT manager

• Decide how much of which type ofequipment to acquire.

• For individuals approved for access andspecific rights to specific applications,arrange for necessary and appropriateequipment, security tools such as digitalcertificates, training, etc., andcommunicate this information to the stateDepartment of Health.

• Maintain the list of who has access, andthe specific rights granted, to whichapplications. Communicate thisinformation, as appropriate, routinely tostate Department of Health.

• Maintain a tracking system that includes 1)who has been granted access and whichtype of rights to what; 2) who has signedthe necessary paperwork, such as securityand confidentiality statements and data-sharing agreements; 3) who has beentrained in what and who is due fortraining; 4) when each digital certificateexpires or needs to be renewed, etc.Communicate this information, asappropriate, routinely to state Departmentof Health.

• Maintain current contact or profileinformation, such as accurate e-mailaddresses for each user. Manage areminder system to queue employees toupdate their own contact information andprofile. Communicate this information, asappropriate, routinely to state Departmentof Health.

• Maintain a collection of current policiesregarding data access and a current list ofwho may grant approval.

80

• Serve as information coordinator inassuring that once an employee has beenappropriately approved for access to anapplication, the agency’s applicationadministrator or technical staff make theappropriate changes.

• Assign individuals to “administer” theapplication within the agency or region—i.e., with WaSECURES and LMS, localhealth jurisdictions will administer andmanage their own use of the application.This will require significant training andfrequent (sometimes daily) work with theapplication.

• Serve as main point of contact for the localhealth jurisdiction in communications withthe state Department of Healthapplication, program, or technical staff.

• Serve as the agency technical resource forthe specific application.

• Provide general technical resource peragency policy.

Technology roles that might beassigned to human resources or qualityimprovement or assurance managers

• Develop a coordinated approach toapprove individuals for access to specificapplications and to approve the “rights” tobe granted each individual for eachapplication (i.e., types of rights,application administrators, supervisoraccess for monitoring program oremployee performance, user-only, etc.).Decide who in the agency—amongsupervisors, managers, and programdirectors—will approve individuals foraccess to specific applications and whowill communicate this information to thestate Department of Health.

• Maintain current contact or profileinformation, such as accurate e-mailaddresses for each user. Manage areminder system to queue employees toupdate their own contact information andprofile. Communicate this information, asappropriate, routinely to state Departmentof Health.

• Maintain collection of current policiesregarding data access and a current list ofwho may grant approval.

Technology roles needed at the StateDepartment of Health

• Establish a single point of contact to learnabout each application—technicalspecifications, equipment and securityrequirements, user and administratortraining, access help desk resources, typesof rights available for users, etc.

• Establish a single point of contact for localhealth jurisdictions to arrange fornecessary and appropriate equipment,security tools such as digital certificates,training, etc.

• Establish a single point of contact for localhealth jurisdictions to communicatechanges in individuals approved access.

• Coordinate an approach for maintaining atracking system and providing routinereports to local health jurisdictionleadership that includes 1) who has beengranted access and which type of rights towhat; 2) who has signed the necessarypaperwork such as security andconfidentiality statements and data-sharing agreements; 3) who has beentrained in what and who is due fortraining; and 2) when each digitalcertificates expires or needs to berenewed.

81

New coalitions and alliances• Analyze information and influence diverse

groups to participate in public healthactivities.

• Identify potential strategic partners.• Facilitate and form various work groups,

alliances, and coalitions, and usecommunity mobilization methods andtools appropriate to the local community.

• Foster trusting and effective relationshipswith diverse groups.

Communication• Manage information dissemination to

diverse entities including the public,legislators, local boards of health, and thenews media.

• Interact with the public and the mediaespecially with regard to riskcommunication.

• Balance legal and confidentiality issues forthe public benefit.

• Use the most effective, efficient, andexpedient telecommunications media forindividual public health situations.

Results-based accountability system• Develop a strategic plan that identifies

goals, objectives, and performancemeasures and has a process to monitorand evaluate achievements.

• Develop, maintain, and evaluate:* Operating infrastructure (accounting,

budget, contracts, procurement, grantscompliance, facilities, and risk manage-ment systems)

* Program and administrative writtenpolicies, procedures, and protocols

APPENDIX 11: PHIP SYSTEM-LEVELCOMPETENCIES

• Use program evaluation and costefficiency tools (cost benefit analysis,return on investment tools) to monitor andevaluate effectiveness of results andadjust as indicated.

• Evaluate resource utilization.

Information technology systems• Enable collection and access to

information on current health topics,demographics (including vital statistics),and health outcome indicators.

• Implement data collection processes thatensure technology transmissioncompatibility and systems storage.Processes should also assure access toclient treatment and case managementplans, current health topics and updates,and community demographic andinfrastructure information.

• Provide information in user-friendlyformats in a timely manner.

• Guide the collection, analysis, anddissemination of health statusinformation.

• Collect, analyze, and organize data andinformation for staff, public healthpartners, and clients.

• Use software available within the agencyto perform research, record keeping,communication (e.g., e-mail, wordprocessing programs), data analysis andinterpretation (including simplespreadsheet programs), and reportingtasks.

• Use web-based applications for searchingand retrieving information.

82

Technical and professionalcompetencies

• Create an environment that embracesworkforce development methods to buildstaff capacity through continuous learningopportunities.

• Apply workforce development principles(personnel rules, compensation, employeepolicies).

• Use commonly applied workforcedevelopment tools (needs assessment,training, learning and development plans,evaluations, etc.) and apply as needed todevelop staff.

• Identify and apply current relevantscientific and technical information.

• Apply the consultation process to differingaspects of the internal and externalconsultant roles as appropriate to thesituation and stakeholders.

• Model and encourage creativity and visionin the application of technology to improveservices and productivity.

• Improve knowledge, skills, and abilities toimprove performance in the short-termand long-term.

Public health policy, authority, andresponsibility

• Apply and practice leadership principlesand skills.

• Analyze, evaluate, and communicatepublic policy choices.

• Interpret and apply laws and regulationsthat pertain to public health authority andresponsibility.

• Apply an understanding of the value andcosts of public health services to makestrategic decisions regarding fundingchoices.

Quality improvement• Apply strategic quality improvement

methodologies that are aligned withprogram goals, stakeholder input, etc.

• Evaluate needs and develop a qualityimprovement plan.

• Foster an environment where qualityimprovement is embraced and applied aspart of everyday work.

Systems thinking• Understand the need to see

interrelationships rather than cause-effectchains; evaluate key stakeholder intereststo find commonalities that benefit thepublic health system.

• Be proactive and manage the processes ofchange.

• Promote and facilitate organizationallearning.

• Be creative and flexible in identifying andevaluating alternatives, and anticipate theconsequences of actions and responses.

• Optimize opportunities to improve thehealth status of the community.

• Demonstrate ability to address problemswith new and effective solutions.

Visionary leadership• Define key values and use these principles

to guide action.• Participate in scanning the environment,

internally and externally, for informationcritical to the agency’s mission.

• Keep the mission in focus and articulate itclearly.

• Facilitate creation of a vision of excellenceand a scenario of a preferred future.

• Allow others to be empowered to createand implement plans to enact the sharedvision.

• Coach, inspire, and motivate staff andothers to accomplish agency mission.

83

APPENDIX 12: IMPROVING ACCESS TOCARE IN WHATCOM COUNTY

The Whatcom Alliance Access Project will increase access to care and improve quality and cost effective-ness of care for uninsured and underserved people in Whatcom County. Project goals and objectivesare:

• Consumer outreach assistance and advocacy;• Coordination of care and case management for people with chronic illness, high-risk individuals,

and high utilizers;• Centralized access to specialty care for uninsured people, using managed, donated services;• System capacity-building for community health centers through advanced access scheduling and

recruitment and retention for private medical practices.

The following diagram shows key activities and the roles community entities will play.

Care Integration and System Capacity-buildingFor Uninsured and Under-insured People in Whatcom County, WA

Outreachassistance

and advocacy

Carecoordination Donated

specialty care

Service integrationsites throughoutWhatcom County • three rural school districts • opportunity council

Hospital emergencydepartment

Community clinics • Interfaith CHCs* • Sea Mar CHC • MB Family Medicine

Madrona PediatricsSpeciality clinics staffedby volunteer physicianspecialists at CHCs

Year 2: Mental healthcounselors and dentistswilling to accept reducedfee patients added tothe database

Shared data baseallowing distributionand efficient access toparticipating specialists

Enhanced shared care plan

Physician recruitment andretention program

Health access funddevelopment

System capacity-building

Open accessscheduling at CHCs

*CHC = community health center

84

THE CORE FUNCTIONS OFPUBLIC HEALTHPublic health officials focus on “what we as a society do collectively to assure the conditions inwhich people can be healthy” (Institute of Medicine, 1988). The field of public health seeks tomitigate factors that threaten people’s health and works to create conditions that improve or pro-mote good health. In this way, public health services are “population-based.” These services can beorganized into three “core functions,” as described below.

Health AssessmentHelps us determine how, where, and when health threats are occurring. It includes collection,analysis, and dissemination of information on health status, incidence of health problems andrisks, choices about health behavior, environmental health concerns, availability and quality ofservices, and the concerns of individuals.

Policy DevelopmentUsed to set a course for specific action or regulation to improve or protect health. It may involve aformal public process, as with a local board of health. Private organizations and citizen groups alsodevelop public health policy.

AssuranceMeans making sure the right things happen—that we have the health information we need, that weadhere to the policies we have chosen, and that needed services are available. Government pro-grams often play an assurance or oversight role, but they do not provide all the needed services.

SnohomishHealth District

Okanogan CountyHealth District

WallaWalla

CountyHealth

Department

Jefferson County Healthand Human Services

Northeast Tri-CountyHealth District

Benton-FranklinHealth District

Yakima HealthDistrictSkamania

CountyHealth

Department

San Juan CountyDepartment of Health

and Community Services

Chelan-DouglasHealth District

Island CountyHealth Department

Thurston CountyPublic Health and

Social ServicesDepartment

Grant CountyHealthDistrict

Kitsap CountyHealth District

SpokaneRegional

HealthDistrict

Public Health—Seattle &

King County

Whatcom CountyHealth Department

Grays HarborCounty Public

Health andSocial Services

Department

Clallam County Departmentof Health and Human Services

MasonCounty

Departmentof HealthServices

AsotinCountyHealthDistrict

WhitmanCountyHealth

Department

Columbia CountyPublic Health

District

Cowlitz CountyHealth

Department

Kittitas CountyHealth Department

Klickitat CountyHealth Department

Lewis CountyPublic Health

Lincoln CountyHealth

Department

Skagit CountyPublic HealthDepartment

Tacoma-PierceCounty Health

Department

WahkiakumCounty Department of

Health and Human Services

PacificCounty

Public Health andHuman Services

Department

Adams CountyHealth District

Garfield CountyHealth District

Clark CountyHealth Department

Washington’s 35 Local Public Health Jurisdictions

101 Israel Road SETumwater, WA 98507