Public health performance management: opportunities for environmental public health.

Today, profound changes are occurring in public health. Many of those changes are driven by the demand for greater efficiency and effectiveness. In response, opportunities are arising to help meet this demand. For example, the Affordable Care Act of 2010 includes among many other provisions the Prevention and Public Health Fund. That fund supports the National Public Health Improvement Initiative (NPHII) with the objective to ensure public health goals are met efficiently and effectively. During its first year, the NPHII helped build health department capacity in performance management by providing $42.5 million to 76 state, tribal, local, and territorial health departments (Centers for Disease Control and Prevention [CDC], 2010). In addition, surveys by the Association of State and Territorial Health Officials (ASTHO, 2011) and the National Association of County and City Health Officials (NACCHO, 2010) indicate that performance management and quality improvement are priorities for a large number of state and local health agencies. Environmental public health programs are an important part of those performance and quality improvement goals. Environmental public health programs can contribute to and benefit from collaborations within agency-wide public health improvement efforts.

One important way environmental public health departments can assess and improve their own programs or systems is by using the Environmental Public Health Performance Standards (EnvPHPS). The EnvPHPS provides a set of standards that describes optimal performance and capacity with which environmental public health programs and systems can fulfill the 10 Essential Environmental Public Health Services (see sidebar). The EnvPHPS allow for in-depth analysis of services and reveal areas for quality improvement (CDC, 2011). In this way, the EnvPHPS can be utilized to increase the efficiency and effectiveness of environmental public health services. A real-world example can best show how the EnvPHPS can help initiate performance management and quality improvement activities in local-level environmental public health.

Performance Management and Quality Improvement in Indian River County

In July 2011, the Indian River County Health Department, Environmental Health Department (IRCHD EHD) in Vero Beach, Florida, began its own performance management and quality improvement process. The process included five other Florida local environmental public health departments that facilitated EnvPHPS assessments for their respective environmental health systems. The assessments involved a wide range of participants from both public and private agencies and from specific areas such as environmental quality, laboratories, and civic organizations. Florida Department of Health NPHII funds supported the EnvPHPS assessments. Because of environmental health staff involvement in collaborative planning, a portion of the state's funds was utilized to support options for environmental health-focused quality improvement activities through use of the EnvPHPS or the Protocol for Assessing Community Excellence in Environmental Health (PACE EH).

IRCHD EHD chose to conduct an EnvPHPS assessment because it allowed a systems-based approach that considered the public and private entities, individuals, and associations that contribute to the delivery of environmental public health services. The assessment results revealed that among the 10 Essential Environmental Public Health Services, the most significant gaps were in #9: evaluate effectiveness, accessibility, and quality of personal and population-based environmental public health services and #10: research for new insights and innovative solutions to environmental public health problems. Following gap analysis, IRCHD EHD developed an action plan that identified specific areas for improvement. Here are several areas in which IRCHD EHD plans to implement quality improvement projects:

* coordinate data sharing among agencies with program overlap,

* develop relationships with higher learning and research institutions,

* share research findings from studies to which the department contributed, and

* foster increased collaboration of partners and understanding of roles and responsibilities. The EnvPHPS assessment gave IRCHD

EHD the opportunity to evaluate the quality of its services against national standards. It also provided a starting point for discussing service gaps and necessary improvements. IRCHD EHD will now use quality improvement frameworks to develop and implement projects that improve program and service quality, build capacity, and increase effectiveness and efficiency. Additionally, the EnvPHPS assessment and quality improvement activities produced benefits beyond simply identifying gaps. The EnvPHPS helped to build relationships and unite environmental public health system stakeholders and partners. Cheryl Dunn, IRCHD EHD manager, stated, "I was surprised by the assessment results that blew away my idea of how environmental health staff and other community partners perceived our system. Therefore, the assessment opened an avenue for discussion, education, and quality improvement."

As performance management in public health continues to gain momentum, more opportunities for environmental public health will arise. These opportunities provide openings to improve public health systems, environmental public health services, and ultimately community health status. Visit www.cdc.gov/nceh/ehs/envphps/ for more information about the EnvPHPS and quality improvement, including a new tool kit to help programs prepare for, conduct, and follow up on an EnvPHPS assessment.

10 Essential Environmental Public Health Services

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

2. Diagnose and investigate environmental public health problems and health hazards in the community.

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

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

5. develop policies and plans that support individual and community environmental public health efforts.

6. enforce laws and regulations that protect environmental public health and ensure safety.

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

8. Assure a competent environmental public health workforce.

9. evaluate effectiveness, accessibility, and quality of personal and population-based environmental public health services.

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

Editor's Note: NEHA strives to provide up-to-date and relevant information on environmental health and to build partnerships in the profession. In pursuit of these goals, we feature a column from the Environmental Health Services Branch (EHSB) of the Centers for Disease Control and Prevention (CDC) in every issue of the (Journal.

In this column, EHSB and guest authors from across CDC will highlight a variety of concerns, opportunities, challenges, and successes that we all share in environmental public health. EHSB's objective is to strengthen the role of state, local, and national environmental health programs and professionals to anticipate, identify, and respond to adverse environmental exposures and the consequences of these exposures for human health. The services being developed through EHSB include access to topical, relevant, and scientific information; consultation; and assistance to environmental health specialists, sanitarians, and environmental health professionals and practitioners.

The conclusions in this article are those of the author(s) and do not necessarily represent the views of the CDC.

LCDR Justin Gerding is an environmental health officer in the CDC Environmental Health Services Branch. Julianne Price is the Florida Department of Health's Statewide Protocol for Assessing Community Excellence in Environmental Health (PACE EH) coordinator and an environmental specialist at the Indian River County Department's Division of Environmental Health.

References

Association of State and Territorial Health Officials. (2011). Profile of state public health (vol. 2). Retrieved from http://www. astho.org/uploadedFiles/_Publications/ Files/Survey_Research/ASTHO_State_ Profiles_Single%5B1%5D%20lo%20res.pdf

Centers for Disease Control and Prevention. (2010). National public health improvement initiative factsheet. Retrieved from http://www.cdc.gov/stltpublichealth/docs/ NPHII%20Fact%20Sheet_NM.pdf

Centers for Disease Control and Prevention. (2011). Environmental public health performance standards: Improving service in communities factsheet. Retrieved from http:// www.cdc.gov/nceh/ehs/Docs/Factsheets/ EnvPHPerformanceStandards_factsheet.pdf

National Association of County and City Health Officials. (2010). 2010 national profile of local health departments. Retrieved from http://www.naccho.org/topics/infrastructure/profile/resources/2010report/ index.cfm

LCDR Justin Gerding, MPH, REHS 

Julianne Price, RS

Corresponding Author: LCDR Justin Gerding, Environmental Health Officer, Environmental Health Services Branch, Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC, 4770 Buford Highway, N.E., M.S. F-60, Atlanta, GA 30341. E-mail: [e-mail].