State Public Health Infrastructure and

Performance: Insights from Recent ASTHO

SurveysJim Pearsol, Chief Program OfficerAssociation of State and Territorial Health

OfficialsSeptember 16, 2008

Outline

Describe performance context Describe baseline survey and results Describe branding research and results Relate to STHA performance and voluntary

national accreditation Consider next steps

Deconstructing “performance”

Performance management seeks to more closely link employee activities to organizational activities.  A performance management system supports and contributes to the creation of high-performance work and work systems by translating behavioral principles into procedures. (ASQ).

Design and use performance measures to drive and monitor organizational performance, and evaluate the results in relation a plan (ASQ).

Performance improvement is a process for achieving desired institutional and individual results. The goal of Performance Improvement is the provision of high quality, sustainable health services. Results are achieved through a process that considers the institutional context, describes desired performance, identifies gaps between desired and actual performance, identifies root causes, selects interventions to close the gaps and measures changes in performance.

Funding support

ASTHO’s Baseline Survey and Marketing Projects are supported through funding from:

Robert Wood Johnson Foundation

&

Centers for Disease Control and Prevention

ASTHO baseline survey: BackgroundSurvey Partners:

Robert Wood Johnson Foundation (RWJF)Centers for Disease Control and Prevention (CDC)Public Health Foundation (PHF)

Goal: Define the purposes, functions, roles and responsibilities of state public health agencies.

Results: 47 responses (46 states and District of Columbia, 82% response rate) (NOW 50)

Survey Purposes

Describe State and Territorial Health Agency (STHA) structure and function

Contribute to development of Accreditation Standards & Measures

Inform STHA marketing “message” to policy makers and general public

Populate a Public Health Information and Analysis System at ASTHO

Inform Public Health Systems & Services Research

Survey Subheadings

Respondent Information Activities Organization for Federal

Initiatives STHA Descriptors STHA Personnel State Organizational

Structure Agency Mission STHA Scope of Work 75 + survey questions Web survey tool

Planning and Quality Improvement

Relationship with Local Public Health Agencies

STHA Training Emergency Preparedness

Infrastructure Partnership and

Collaboration STHA Performance

Activities STHO Qualifications and

Experience

Organizational Structure & Relationship with Local Health Agencies

Structure of state health agencies:58% Free-standing independent agency

40% Under a larger agency

Organizational relationship between state healthagencies and local health departments:40% Decentralized control (local services provided through local gov’t or boards)

18% Mixed control (some local services provided by state and some by locals)

17% Shared control (local services are subject to shared authority of state and local entities)

15% Centralized control (local services provided through units of state)

10% No local health departments

Collaboration (relate to NPHPSP state tool – section on state-local collaboration)More than 83% reported collaboration on the following with local public healthagencies:

Exchanging informationWorking together on activities or projectsProviding financial resources

Over 90% reported working together on projectsor activities with:

HospitalsCommunity health centersOther health care providersRegional cancer societyEmergency respondersSchoolsCommunity based organizationsFaith communitiesUniversities

0

10

20

30

40

50

60

70

Business Health Insurers Health Centers Community-basedOrganizations

Other Health CareProviders

Increased Collaboration & Information Exchange (%)

50

60

70

80

90

100

CommunicationSystem

Epidemiology &Surveillance

Planning &Surge Capacity

Workforce &Relationships

Lab Services Legal Basis forPH Action

Stronger Infrastructure Due to Emergency Preparedness Efforts (%)

30

40

50

60

70

80

90

100

Food & SafetyEducation

EnvironmentalEpidemiology

Toxicology RadiationControl

Radon Control Private WaterSafety Supply& Indoor Air

Environmental Protection Activities (%)

Population-based Primary Prevention Services

Population-based Primary Prevention Services

State Public Health Agency # (%)

Local Public Health Agency # (%)

Tobacco control and prevention 44 (91.7) 37 (77.1) Obesity 41 (85.4) 32 (66.7) Injury control and prevention 39 (81.3) 32 (66.7) STD counseling/partner notification

38 (79.2) 37 (77.1)

HIV 37 (77.1) 38 (79.2) Diabetes 34 (70.8) 29 (60.4) Substance abuse 20 (41.7) 18 (37.5)

Enforce public health laws & regulations

Educate about laws and regulations 77% Local health departments 56% Hospitals

75% Emergency responders 50% Community-based organizations

67% Laboratories

Regulation, inspection or licensing 77% Laboratories 65% Hospice and long term care

73% Hospitals 61% Lead inspection

71% Food service establishment 54% Campgrounds/RVs

69% Swimming pools 50% Public drinking water

Other activities73% Veterinarian PH activities; 70% trauma system; and 67% Institutional Review Board

Help people receive health services

Access to health care

87% Health disparities 40% Emergency Medical Services

81% Minority health 29% SCHIP, pharmacy and substance

65% Rural health 25% Tribal health & Faith-based

46% Certifying authority for federal reimbursement

& Outreach and enrollment for medical insurance

Maternal and Child Health services67% CSHCN 27% Non-WIC nutrition counseling

48% WIC 29% School health (non-clinical)

42% Early intervention 23% EPSDT

30% Family planning/prenatal care

Scope and Source of State Health Agency Authority

Source of Authority Scope of Authority Number/Percent State Statute Gubernatorial

Order Rules/Regulation

Collect data 48 (100) 48 (100) 4 (8.3) 32 (66.7) Manage vital statistics

47 (97.7) 47 (97.7) 3 (6.3) 30 (62.5)

Declare health emergency 38 (79.3) 33 (68.8) 18 (37.5) 15 (31.3)

Conduct health planning

37 (77.1) 35 (72.9) 2 (4.2) 18 (37.5)

License health professionals

30 (62.5) 30 (62.5) 0 (0) 23 (47.9)

Issue certificates of need

27 (56.3) 26 (54.2) 1 (2.1) 20 (41.7)

Operate health facilities

22 (45.8) 21 (43.8) 2 (4.2) 13 (27.1)

Develop Public Health Policies and Plans

Developed Health Improvement Plan (HIP):56% within 3 years 22% 3 years ago21% no

56% created a state HIP using a State Health Assessment

81% plan to update HIP in next 3 years

State HIP linked to local health department HIP:25% yes 27% some 15% no

STHA has a strategic plan (73%)

Within past year, STHA adopted new public health regulation (83%)

Maintain Competent Workforce

Sources of STHA workforce development (rank order)STHA in-house training

Universities

Federal Government

National associations

Other state agencies

Health professional agencies

PH institutes

STHA has a designated training coordinator (62%)

STHA provides workforce technical assistance 74% Local health departments 43% Community-based organizations

70% EMR 30% Laboratories

47% Hospitals

STHA oversees professional licensing 26% Nurses; 24% Physicians and Physician Assistants; and 22% Dentists

Sources of Revenue

Federal (direct) 45%

State Sources 24%

Medicaid/Medicare 15%

Other 9%

Federal (Indirect) 3%

Fees/Fines 4%

*State Health Agency expenditures: Non-clinical prevention (67%), clinical (31%)

Top priorities for STHA for current fiscal year

Health system reform Assuring preparedness for a health emergency Assuring a local public health presence throughout the

state Developing effective health policy Developing innovations in any area Focusing on early detection or population protection

measures Monitoring the state’s population health Implementing quality improvement programs Attaining workforce stability

Marketing State Public Health

The Association of State and Territorial Health Officials

Project Goal

Develop tested, proven messages about state public health that, when communicated to the public, will result in a better understanding of the role, activities, and value of state public health.

Why Market Public Health?

Improve public health visibility

Mitigate the public health workforce shortage

Enhance the public’s health advocacy power

Create public support for public health activities

Improve policymaker support for public health

Barriers to communicating “public health”

Misconceptions about “Branding”

Public health fails to celebrate

We don’t know our audience and they don’t know us

Don’t know how to talk about public health….to the public

Cost of marketing

Public health is many things – hard to synthesize

Objectives and Approach

Objective: Treat the public health branding project like a major consumer branding issue

Quantify: Understand current national perceptions of State Public Health Determine Public Health’s relationship to healthcare in people’s minds Learn about the importance of the various Public Health functions to the nation’s

citizens

Generate: Develop powerful conceptual positioning platform options for Public Health Create some compelling taglines for use with state Public Health logos

Evaluate: Measure the appeal, believability, and power of the various platform options and

taglines

Refine: Deepen our understanding of the winning communication platforms

Recommend Recommend the optimal communication platform - Positioning and Tagline

World Class Marketing Partners

Quantitative Research Lead: Copernicus Cause marketing: Cone Inc. Creative Horsepower: Red Black Design Qualitative Research Lead: Quest Consulting Project Lead: Green Planet Partners

Recent projects of this branding team

Starbucks, 3M, P&G, Banana Republic, Toyota, Johnson & Johnson, Target, Proctor & Gamble, Pepsi, ….. and State Public Health

Brand Strength

Although the public feels the various functions of stateand local public health services are important, there islittle awareness that these are, in fact, the functions performed by these organizations.

Methodology

Quantitative: 1,059 interviews were conducted between April 16 and April 23, 2008.

Interviews were conducted on-line, using an established survey panel, and averaged 15 minutes in duration.

The sample was demographically representative of the US population age 18-64, with respect to: Age and Sex Geography (Northeast, South, Midwest and West) Household income Race and ethnicity (African-American and Hispanics)

Qualitative: 8 qualitative sessions were conducted in 4 US cities comprised of over 80 U.S. adults (L.A., Nashville, Minneapolis and Jackson MS.)

Creative: Creative teams from around the country were asked to submit positioning platforms and tagline options to be tested

Knowledge of functions of Public Health Services

There is generally little awareness of the functions that State or Local Public Health Services perform.

The most commonly recognized functions are: Conducting sanitation and safety inspections of restaurants Giving vaccines

Less than half of the public realizes that State or Local Public Health Services perform the following functions: Developing public policies that make it easier for people to engage in

healthy behaviors Promoting healthy behaviors Providing the latest information on health hazards Monitoring health care providers Assuring there are no environmental health threats in the wake of natural

disasters

There is generally little awareness of the functions that State or Local Public Health Services perform.

The most commonly recognized functions are: Conducting sanitation and safety inspections of restaurants Giving vaccines

Less than half of the public realizes that State or Local Public Health Services perform the following functions: Developing public policies that make it easier for people to engage in

healthy behaviors Promoting healthy behaviors Providing the latest information on health hazards Monitoring health care providers Assuring there are no environmental health threats in the wake of natural

disasters

Importance of functions ofPublic Health

The most important functions include: Monitoring and controlling the spread of diseases, and alerting people to

these diseases and how to avoid them• These two functions are perceived as more important by respondents who

prefer either Concept 2 (Minimizing health costs) or Concept 5 (Prevent, promote and protect)

Conducting sanitation and safety inspections of restaurants Monitoring air and water quality Assuring there are no environmental health threats in the wake of natural

disasters Providing health care services to the disadvantaged

The least important functions are perceived to be: Developing public policies that make it easier for people to engage in healthy

behaviors Promoting healthy behaviors

Overall, “Promoting health. Reducing costs” is the

most preferred tagline.

% Select each Total

1: Our work is the health of the

population

2: We minimize health costs to individuals and

society by promoting health and preventing

diseases

3: We live on the front lines, fighting new health threats

as they emerge

4: We are working to make the

wealthiest country also the healthiest

5: We prevent disease, promote health and protect

communitiesBase: Total Respondents (1059) (239) (282) (107) (163) (268)

Promoting health. Reducing costs. 19% 10% 32% 12% 17% 16% Prevention is the best defense 16 15 16 12 14 20 In pursuit of a stronger, healthier nation 15 20 11 14 20 13 Healthy people, healthy communities 15 16 12 8 8 23 Because we're only as healthy as the world we live in 12 16 10 16 12 10 Creating a healthier, safer world - Millions at a time 7 6 6 12 11 6 Because health threats never rest 7 8 4 13 5 6 America's immune system 4 3 2 9 4 6 Getting the most for the nation's health dollars 4 2 6 2 6 1 The secret weapon in the battle for health 2 5 2 2 4 0

Favorite Concept

The two most favored concepts (2 and 5) share the ideas of promoting health and preventing disease.

Concept 2, the quantitative “winner” (by a small margin), adds the idea of minimizing health costs.

1: Our work is the health of the population

2: We minimize health costs to individuals and

society by promoting health and preventing

diseases3: We live on the front lines, fighting new

health threats as they emerge

4: We are working to make the wealthiest

country also the healthiest

5: We prevent disease, promote health and protect communities 23%

27%

10%

14%

26%

Positioning Testing

Strategic Communications Linksafety, security, reduced health

costs

“Public health and I care fundamentally about a really important thing and they’re actually doing huge work around it - the safety and well-being of my family.” They then said things like:

“You should tell people about this!”“People should know” “I can’t believe we haven’t been told this before”

Unlike most branding projects, while talking to consumers, nobody ever poked holes in our work or our desire to communicate. They understood the benevolent nature of our practice; they just don’t know very much about us. But once they know, they care, and it matters, they’re like:

“wow, this matters”“This is cool” “You guys rock!, You got our back!”

Next Steps

ASTHO/ASPH Public Health Marketing Meeting

Public Health Language Development

Online Toolkit

Corporate partnership to benefit all of public health

MLC-3 Target Measures

5 Capacity and Process target areas were identified: Community Health Profiles Culturally Appropriate Services Health Improvement Planning Assure Competent Workforce Customer Service

5 Health Outcome target areas were identified: Reduce the incidence of vaccine preventable disease Reduce preventable risk factors that predispose to chronic

disease Reduce infant mortality rates Reduce the burden of tobacco related illness Reduce the burden of alcohol related disease and injury

Performance readiness

ASTHO survey information on structure and function Value - increased awareness and recognition by

professional peers NPHPSP Version 2, MLC-3 and PHAB standards

ASTHO branding research Challenge - Consumers unaware

Implications for “selling” assessments? (whether they be NPHPSP or PHAB)

Accreditation “readiness” toolkits When? Now is probably a good time

Thanks!

For more information, contact:

jpearsol@astho.org mdickey@astho.org jjimenez@astho.org lcaldwell@astho.org bpetersen@astho.org aholland@astho.org