For the Public's Health The Role of Measurement in Action and Accountability (2011) / Chapter Skim
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4 Measurement and Accountability
4 Measurement and Accountability
Pages 111-144
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From page 111... ...
mechanisms that pertain to the work of local public health agencies are among the stronger and more concrete levers for holding agencies accountable. This chapter examines performance2 indicators and how they can be implemented both at the level of governmental public health and in the con 1 The National Public Health Performance Standards Program defines governing body as "the individual, board, council, commission, or other body with legal authority over the primary governmental public health agency" (HHS and CDC, 2008)
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is a somewhat more recent focus in the public health community, and this is in part due to the complex array of factors that contribute to population health and the challenging nature of communicating about them. As described in Chapter 1, one challenge is that health outcomes (such as disease and death)
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accountable and to spur continuous quality improvement to increase the effectiveness, efficiency, and equity of actions taken to improve population health. Performance measurement is the main way to monitor accountability in the health system.
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. Those who influence population health can be held accountable through two models: · ontract model: When an oversight party has direct control over C implementers (for example, through statute or funding)
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An important element of the framework is that health-system partners need to align and coordinate their efforts consistently to ensure the greatest impact and achieve population health goals. Challenges for Measurement and Accountability There are many challenges to implementing a measurement framework for accountability.
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As a result, relatively little evidence suggests what scale of implementation must be achieved to produce a sustained effect on population health at the level of an entire community, region, or state. For example, some evidence suggests the vaccination coverage that needs to be achieved to provide optimal protection against vaccine-preventable diseases, but this type of evidence is lacking for many other types of public health programs, policies, and interventions, such as those which target obesity-prevention programming and food-safety inspection.
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Those practices include community health as sessment, epidemiologic investigation, community health planning, policy devel opment, communication, workforce development, evaluation and monitoring, and quality improvement. For the public health interventions, programs, and policies that currently are supported by strong evidence, a measurement system is needed to assess adoption, reach, and implementation fidelity at state and local levels.
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Because of those factors, there is confusion and inconsistency regarding how to implement a framework for accountability in the nation's health system (again, defined as the multiple partners working to improve population health)
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and at the end after coordination and development of a strategy and its execution (for example, to measure outcomes of processes of a health department or business)
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* Gov Public Health Other Gov Community Media Level C: Organizations Academia Medical Care Figure 4-2 broadside Employers/Business Level B: Microsystem (programs, interventions, evidence base on specific areas of population health)
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and as components of the health system. The organizations include the local public health agency, hospitals and other clinical care entities, community organizations, schools, businesses, religious congregations, and many others that perform roles that influence health outcomes.
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. Public health agencies also have a long history of planning and evaluation, facilitated by such tools as the National Association of County and City Health Officials Mobilizing for Action through Planning and Partnerships framework and the IOM-developed Community Health Improvement Process (IOM, 1997; University of Wisconsin Population Health Institute, 2010)
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Collaborative efforts with public health agencies and others can support these stakeholders for example, through the preparation of regular reports on the state of a community's health to inform stakeholders and help them to measure their progress. Part of the role of governmental public health agencies is to understand the effectiveness, cost, and outcomes of public health services delivered by all stakeholders; these characteristics could be included in assessing the performance of other actors.
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.5 A recent example of the use of tax benefits is found in New York City's FRESH program and in the state of Michigan, both of which offer property-tax incentives for some types of retail food establishments, such as grocery stores (Michigan Department of Community Health, 2008a; NYC Department of City Planning, 2010)
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With the enactment of the Affordable Care Act (ACA) , the role of public health agencies in providing safety-net medical care services (part of Essential Public Health Service 7; see Box 4-2)
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. To reduce high infant mortality, Detroit's health department has worked with other parts of local government to improve the services and supports available to pregnant women and has thus transformed the social and economic environmental factors partly responsible for poor outcomes (Michigan Department of Community Health, 2008b)
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However, many communities already have a strong record of collaborative efforts to improve health that commonly are facilitated or convened by a local public health agency. Many of the local-level indicator sets that the committee reviewed (some are provided as examples in Appendix B)
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Public health agencies play several major roles with implications for accountability. They deliver funded public health programs that include traditional activities such as sanitation and food safety and some safety-net clinical care services, and they have the potential to and often do mobilize or convene the overall health system in a community to transform the conditions for health.
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, nurture new relationships and alliances, and restructure existing programs and structures to maximize available resources. There are several challenges to the ability of the public health infrastructure to address high-priority population health concerns effectively and efficiently.
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Public health agencies are held accountable in a variety of ways: directly to funders, heads of the executive branch, and boards of health where applicable, and indirectly to the communities they serve (see, for example, Alameda County Public Health Department, 2008; Communities Count, 2008; Department of Population Health Sciences, 2008; Office of Health Assessment and Epidemiology, 2010; Summers et al., 2009)
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For a variety of reasons, traditional modes of governance and action in public health need to be complemented with alternative approaches that depend on the specific problem at hand. That is due partly to the widespread recognition in public health that the government public health infrastructure generally "owns" neither the problems nor the solutions and thus needs to engage and collaborate with multiple stakeholders to find effective new ways to improve population health.
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Recommendation 7 The committee recommends that the Department of Health and Human Services work with relevant federal, state, and local public sector and private-sector partners and stakeholders to 1. Facilitate the development of a performance-measurement system that promotes accountability among governmental and private sector organizations that have responsibilities for protecting and improving population health at local, state, and national levels.
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The current environment of severely constrained resources and preparation for an uncertain or unclear future (in light of an aging population, technologic advances, geopolitical and infectious-disease threats, and changes in the clinical care delivery system) could compel public health leaders to consider innovative and unconventional solutions to position their agencies to demonstrate effectiveness and efficiency; ensuring this will also require incentives that are outside the scope of the present report.
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For clinical care services delivered in public health department clinics, it may be most reasonable to consider measurement strategies that are used in the clinical care delivery sector. Such strategies (Healthcare Effectiveness Data and Information Set [HEDIS]
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Such measurement systems as HEDIS may serve as a partial model, but there are considerable differences, compared with clinical settings (described in more detail earlier in this chapter) , in the ability to link cause and effect in population health and in how accountability is traced both in the government public health infrastructure (which is supported by taxpayers and accountable to them and to elected officials)
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For example, the Centers for Disease Control and Prevention National Public Health Performance Standards program is designed to measure public health practices at the state and local levels and provides the tool Mobilizing for Action through Planning and Partnerships, which evaluates the capacity of local public health systems to conduct the Ten Essential Public Health Services. In the clinical care setting, the NQF uses continuous quality improvement as part of its vision, which is a facet of a measurement framework for accountability recommended by the committee.
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Implementation of the Measurement Framework for Accountability Chapter 1 discusses the causes, and causes of causes, that lead to the untoward health outcomes of infant mortality and cardiovascular disease. As is true for the vast majority of conditions or illnesses, neither of those outcomes is amenable to improvements that are influenced solely by public health agencies.
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. For example, in a community that has unacceptable infant mortality, the local public health agency might serve as the convener of stakeholders, alerting other community organizations to the problem's root causes by presenting evidence of associations between different types of changeable risk
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For example, the local public health or social services agencies would commit to better links to clinical care providers who are working with newly pregnant women to ensure that at-risk women receive case management and other essential services. The public health agency and clinical care providers in the community might develop agreements to ensure that no pregnant woman misses prenatal care services because of insurance status or difficulty in accessing a provider.
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Simple measures of accountability (clear lines from inputs to outputs) based on quantified improvements in health outcomes, although desirable, are not possible, so the three-part, more complex framework of accountability measurement and continuous quality improvement presented in the report is needed.
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. Final Recommenda tions for a Voluntary National Accreditation Program for State and Local Public Health Departments.
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Lansing: Michigan Department of Community Health. NACCHO (National Association of County and City Health Officials)
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:341-359. University of Wisconsin Population Health Institute.
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