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Improving Environmental Public Services Performance to Meet Needs

nvironmental (EPH) programs can • Voluntary Accreditation for Public substantially enhance public E Health Departments – The Public goals to improve performance and quality of Health Accreditation Board (PHAB) is a services. They also can contribute to and benefit nonprofit founded in 2007. from collaborations to improve public health efforts PHAB’s goal is to advance public health throughout the department. This document performance by providing a national framework of standards for tribal, state, • describes public health and EPH performance local, and territorial health departments. improvement initiatives and resources, PHAB is the national organization charged • explains how EPH performance improvement with administering the public health activities can be incorporated into public health accreditation program. Prerequisites department efforts, and of accreditation include a community • shows how performance improvement health assessment, resources can be used to support a strong role improvement plan, and health department for EPH in improving community health. strategic plan.

Activities to improve public health performance • National Public Health Improvement have been elevated to new levels in recent years. Initiative – This CDC initiative provides Surveys conducted by the Association of State and support to health departments for Territorial Health Officials (ASTHO) and National Association of and Health Officials accelerating public health accreditation (NACCHO) indicate performance improvement is readiness activities, implementing a priority for many state and local health agencies. performance and improvement Improving the effectiveness and efficiency of public practices and systems, and health services is at the root of this activity. Public implementing and sharing practice-based health departments are encouraged to identify gaps evidence. in providing essential services and incorporating community needs to better inform priorities and • Patient Protection and Affordable Care make decisions. Public health performance has Act – This requires nonprofit hospitals been improved and supported by developing to conduct a community health needs guidance and resources and has been encouraged assessment every 3 years to maintain their through initiatives and funding opportunities. nonprofit status. They also must involve at National initiatives supporting and encouraging this least one representative with public health wave of improvement include the following: expertise and develop an implementation plan to meet identified needs. Improving Public Health Performance

Improving public health performance has been an Standards Program (NPHPSP), a public evolving process, fueled by the 1988 release of the assessment framework based on the essential services. Institute of ’s report The Future of Public Health. To complement assessment of public health system The report identified three core functions: assessment, services, community health assessment and strategic development, and assurance (Figure 1). planning emerged as key mechanisms for describing and meeting health needs. In response, CDC In 1994, the U.S. Department of Health and and NACCHO released Mobilizing for Action through Services coordinated the Public Health Functions Project, Planning and Partnerships to promote a community- with national representation, to describe public health driven, strategic-planning process for improving services. This collaborative project produced a statement community health. called “Public Health in America” that identified 10 Essential Public Health Services. While resources to improve public health performance were developed and released, work was under way to In 2002, the Centers for Control and Prevention develop guidance and tools specific to EPH (Figure 2). (CDC) released the National Public Health Performance By 2002, the 10 Essential Public Health Services were

Page 3 EnvPHPS describes the optimal performance and Improving Public Health capacity for EPH systems and programs and provides Performance (continued) program-assessment tools. The purpose of these standards is to help make EPH programs and systems adapted to fit EPH by creating the 10 Essential EPH more effective. The standards are used to assess Services (text box). Subsequently, CDC released the and improve how programs and systems provide Environmental Public Health Performance Standards with the 10 Essential EPH Services. These (EnvPHPS) in 2008 to improve the EPH service delivery 10 services identify the actions necessary to protect and system. These standards complement NPHPSP while improve EPH. specifically representing EPH.

In 2000, NACCHO and CDC released the Protocol for Assessing Community Excellence in (PACE EH) to address community environmental health needs. PACE EH guides communities and local health officials in assessing community-based environmental health. It uses community collaboration and principles to help the public and other stakeholders identify local environmental health issues, set priorities for action, target most at , and address identified issues. PACE EH helps implement the 10 Essential EPH Services.

Page 4 10 Essential Environmental Public Health Services

Monitor environmental and health status to identify and solve community environmental public health problems

Diagnose and investigate environmental public health problems and health in the community

Inform, educate, and empower people about environmental public health issues

Mobilize community partnerships and actions to identify and solve environmental health problems

Develop and plans that support and community environmental public health efforts

Enforce and regulations that protect environmental public health and ensure safety

Link people to needed environmental public health services and assure the provision of environmental public health services when otherwise unavailable

Assure a competent environmental public health workforce

Evaluate effectiveness, accessibility, and quality of personal and population-based environmental public health services

Research for new insights and innovative solutions to environmental public health problems

Page 5 Performance Improvement: Using Assessment Results

Each assessment process produces individual results. Assessment results can complement each other and Return on Investment: combining them in an action plan helps to reflect department and community needs. Developing and Florida Department of implementing action plans to address identified gaps Health in Indian River and needs ensures findings result in meaningful change. Because prioritizing actions is necessary, the PACE EH The small community of West Wabasso implemented PACE EH. With a median income of $6,250 process has a built-in prioritization tool. The tool can be (2000 Census), West Wabasso has a demographic and modified for other assessment processes. Conducting socioeconomic makeup that is drastically different assessments will enable programs to identify from the surrounding Indian River county, one of the wealthiest counties in Florida.

• concerns or service gaps that can be further prioritized if desired, The PACE EH steering committee garnered media attention and gained support from county decision • possible solutions to the priority problems based makers for project activities that responded to on discussions during the assessment, and the community’s concerns. In addition, the health • a stakeholder group (whether department or department staff successfully transitioned project community-based) that can help implement coordination to the community. A community group

solutions. that grew out of the process conducted a visioning process to make long-term plans. Because of the sur- vey and strong partnerships inspired by PACE EH, sev- Return on Investment eral community-identified improvements were realized Gathering data and obtaining assessment results does in West Wabasso. Those improvements include not guarantee impact. Rather, the process and outcome • installation of 44 streetlights throughout the must yield a return on investment (illustrate how the community, data and results can produce benefits). Acquiring meaningful results, using those results, and, most • replacement of 10 septic systems most in need importantly, leveraging resources can ensure successful of repair, implementation of action plans and produce tangible • assistance from a youth ministry program that results. brings youth volunteers to build or repair houses in the community, Partnerships formed during the data gathering and assessment processes often leave community partners • connection of homes in West Wabasso to county with a newfound sense of empowerment. This added water ($850,000 Community Development Block benefit stems from their active involvement and direct Grant), and engagement with improving health status within their • improvements to local parks. community. To date, an initial investment of $30,000 by the Florida Department of Health for the PACE EH Coor- dinator’s salary has yielded more than $1.3 million in Read about how West community improvements. The value of a community Wabasso, Florida, empowered to improve its health and is contributed to broader immeasurable, and this qualitative measure is of value public health goals and when computing return on investment. processes.

Page 6 Performance Improvement: Using Assessment Results

Contributing to Broader Public PHAB’s voluntary accreditation process presents a significant performance improvement opportunity to Health Goals and Processes integrate EPH assessment results. Health departments EPH assessment results can be integrated with seeking accreditation must submit a community health broader public health department improvement efforts. assessment, community health improvement plan, and strategic plan. These documents drive voluntary Getting involved in those broader assessment and accreditation; they also ensure that EPH concerns are action-planning activities can help build and nurture included and that environmental health approaches partnerships (Figure 3). Relationships can lead to greater to addressing broader problems are recognized and understanding of how EPH is helping achieve broader supported. public health goals and can prove the importance of EPH approaches to other public health department programs. There are areas of alignment among EnvPHPS, PACE In turn, this may lead to other opportunities such as EH, and PHAB standards. Information from PACE EH or enhanced support for EPH programs. EnvPHPS assessment processes can support health

Page 7 Performance Improvement: Using Assessment Results

Contributing to Broader Public Contributing to Broader Health Goals and Processes Public Health Goals and (continued) department fulfillment of certain PHAB standards. Table 1 Processes: Walton County, highlights the alignment among PHAB domains, EnvPHPS Florida standards, and PACE EH activities. The Walton County Health Department’s Division Environmental factors can influence broader public of EH (environmental health) and a stakeholder health goals such as reducing . For example, group (the EH Council) worked with sidewalks and safe, accessible parks are enhancements departments, schools, community , built into the environment to encourage physical activity. and local government using the EnvPHPS to Identifying areas of alignment between community environmental health concerns and broader public health assess environmental health capacity and needs. goals can reveal approaches that address both. Activities Meanwhile, the health department developed to improve performance help identify community the County Health Improvement Plan (CHIP), a environmental concerns and potential beneficial prerequisite for accreditation. The CHIP cohort strategies. These activities also help communities align used Mobilizing for Action through Planning and with broader efforts to improve public health goals and Partnerships, while the council members used PACE strengthen environmental health’s role in improving the EH to assess and develop action plans. public’s health. Early in the CHIP process, the Division of EH realized they should be active in the county’s health improvement planning initiatives. CHIP stakeholders learned that many root causes for chronic diseases link directly to environmental factors. They composed specific strategies to address both the community’s EH concerns and the environmental causes of chronic . For example, CHIP stakeholders created a “garden in a bucket” initiative to encourage families to plant small container vegetable gardens and prepare and enjoy nutritious meals together. The National Association of County and City Health Read about how Walton County, Officials recently designated this program, now Florida, contributed to broader public implemented in all of Walton County’s schools, as a health goals and processes. promising practice.

Page 8 Get Involved!

Environmental public health approaches can improve • Improve performance management leadership the odds of achieving public health goals. Using among environmental health professionals— specific EPH tools promotes involvement and provides involvement in performance management is an helpful information to align with broader public health essential workforce development opportunity and performance initiatives such as strategic planning. can heighten understanding of the importance of Ensuring a role for EPH in broader public health performance initiatives has several primary benefits, environmental health. including helping Involvement in broader public health performance improvement efforts can help EPH programs realize • Highlight environmental components of chronic these benefits. and infectious disease—addressing environmental causes of larger public health goals is often critical to achieving them. Explore the “Resources and Informa- tion to Improve Environmental Public • Address environmental concerns of community Health Performance” and “Examples members and other stakeholders—integrating of Funding Sources to Support community priorities into broader planning efforts Assessment and Implementation” on the next page. can generate additional partners and resources.

Page 9 Resources and Information to Examples of Funding Sources Improve Environmental Public to Support Assessment and Health Performance Implementation

• Environmental Public Health Performance Standards • Community Transformation Grants: http://www.cdc. (EnvPHPS): http://www.cdc.gov/nceh/ehs/envphps/ gov/communitytransformation/ Protocol for Assessing Community Excellence in • Small Communities: http://www.cdc.gov/ Environmental Health (PACE EH): http://www. communitytransformation/small-communities/ naccho.org/topics/environmental/PACE-EH/ index.htm • Essential Environmental Public Health Services • Kresge Foundation (nonprofits only): http://kresge. Evaluation Framework: http://www.wvdhhr.org/ org/programs/health envhealth/index.htm • HHS Prevention Fund: http://www.hhs.gov/open/ • National Public Health Performance Standards recordsandreports/prevention/index.html Program (NPHPSP): http://www.cdc.gov/nphpsp/ • Robert Wood Johnson Foundation: http://www.rwjf. • Public Health Accreditation Board (PHAB): org/en/grants/calls-for-proposals.html http://www.phaboard.org/ • National Public Health Improvement Initiative: http:// www.cdc.gov/stltpublichealth/nphii/ • Mobilizing for Action through Planning and Partnerships: http://www.naccho.org/topics/ /Mapp/index.cfm • National Association of County and City Health Officials (NACCHO) Accreditation Preparation and Quality Improvement: http://www.naccho.org/ topics/infrastructure/accreditation/ • Association of State and Territorial Health Officials Accreditation (ASTHO) and Performance: http:// www.astho.org/programs/accreditation-and- performance/

Page 10 Table 1. Connections between PHAB Domains Version 1.0, EnvPHPS Standards, and PACE EH

Environmental Public Health Public Health Protocol for Assessing Accreditation Performance Community Excellence in Board (PHAB) Standards Environmental Health (PACE EH) Domains (EnvPHPS)

Domain 1: Conduct Essential Service 1: PHAB cites PACE EH as an example tool for standard and disseminate Monitor environmental 1.1 (Participate in or conduct a collaborative assessments focused and health status process resulting in a comprehensive community on to identify and health assessment). status and public solve community health issues facing the environmental public Additional PACE EH activities may contribute to community health problems PHAB standards: • 1.2.3 A (Collect additional primary and secondary data on population health status).

• 1.3.1 A (Analyze and draw conclusions from public ).

• 1.3.2 L (Provide public health data to the community... ). • 1.4.1 A (Use data to recommend and inform public , processes, programs, and/or interventions).

• 1.5 (Provide public health data to the community in the form of reports on a variety of public health issues, at least annually)

Domain2: Essential Service 2: None noted. Investigate health Diagnose and problems and investigate environmental public environmental public health hazards to health problems and protect the community health hazards in the community

Table Continued C)

Page 12 Table 1. Connections between PHAB Domains Version 1.0, EnvPHPS Standards, and PACE EH

Public Health Environmental Public Protocol for Assessing Community Excellence in Accreditation Board Health Performance Environmental Health (PACE EH) (PHAB) Domains Standards (EnvPHPS)

Domain3: Essential Service 3: PACE EH activities may contribute to PHAB Inform and educate Inform, educate, and standards: about public health empower people about • 3.1.1 A (Provide information to public on issues and functions environmental public protecting their health). health • 3.1.2 A (Implement strategies to protect the population from preventable health conditions).

Domain4: Essential Service 4: The community-focused assessment component of Engage with the Mobilize community PACE EH may be supportive of this domain. community to identify partnerships and and address health actions to identify and problems solve environmental public health problems

DomainS: Essential Service 5: PHAB cites PACE EH as an example tool for Develop public health Develop policies measure 5.2 (Conduct a policies and plans and plans that process resulting in a Tribal/state/community support individual health improvement plan). and community environmental public Additional PACE EH activities may contribute to health efforts PHAB standards: • 5.1.2 A (Engage in activities that contribute to the development and/or modification of public health policy).

• 5.2.3 A (Implement elements and strategies of the health improvement plan, in partnership with others).

Domain6: Essential Service 6: PACE EH activities may contribute to PHAB standard Enforce public health Enforce laws and 6.2 (Educate and organizations on the laws regulations that protect meaning, purpose, and benefit of public health laws environmental public and how to comply). health and ensure safety

Table Continued C)

Page 13 Table 1. Connections between PHAB Domains Version 1.0, EnvPHPS Standards, and PACE EH

Public Health Environmental Public Protocol for Assessing Community Excellence in Accreditation Board Health Performance Environmental Health (PACE EH) (PHAB) Domains Standards (EnvPHPS)

Domain7: Essential Service 7: PACE EH activities may contribute to PHAB Promote strategies Link people to needed standards: to improve access to environmental public • 7.1.1 A (Convene and/or participate in a services health services and collaborative process to assess the availability assure the provision of environmental public of health care services). health services when • 7.1.2 A (Identify populations who experience otherwise unavailable barriers to health care services).

DomainS: Essential Service 8: None noted. Maintain a competent Assure a competent public health workforce environmental public health workforce

Domain9: Essential Service 9: None noted. Evaluate and continu­ Evaluate effective­ ously improve health ness, accessibility, and department processes, quality of personal programs, and inter­ and population-based ventions environmental public health services

Domain 11: None noted. Maintain administra­ tive and management capacity

Domain 12: None noted. Maintain capacity to engage the public health governing entity

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