Consensus Statement on Quality in the Public Health System

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1 Consensus Statement on Quality in the Public Health System U.S. Department of Health and Human Services Office of Public Health and Science Office of the Assistant Secretary for Health Public Health Quality Forum August 2008

2 Foreword T his consensus statement frames quality in the public health system. It is intended to serve as principles to enhance and guide goals of ex isting and future programs that promote quality. The consensus statement was developed by the Public Health Quality Forum (PHQF). Organized under my the direction as the Assistant Secretary for Health (ASH), U.S. Department of Health and Human Services (HHS), the PHQF is stim ulating a national movement for coordinated quality improvement efforts across all levels in the public health system. The motivating factor for convening the PHQF was to establish a venue where characteristics of and a system for quality in public health is consistent with the role of the could be framed at a macro-level. This ASH for providing leadership to the Nation on pub lic health and science. I embrace this function and demonstrate that responsibil ity through this initiative. Providing a national framework for quality will f acilitate consistent implementation of quality improvement processes in every day public health practices. The tools pr ovided are designed to support current and future quality improvement e fforts by providing system-l evel leadership in . The characteristics promote strategic decision- defining characteristics of quality in the system making and resource allocations to focus attentio n on the development of concentrated efforts to improve quality and ultimately improve population health outcomes. Quality must be a value-adding function. The pref erred application is to embed these concepts quality throughout the into daily value-adding practices to ensure the emergence of a culture of public health system. Flowing from this should be greater emphasis on research-based evidence to identify quality public health practices. Policy makers must also embrace quality concepts in the initiation of new policies and the modifica tion and evaluation of existing ones. Ideally, a levels will facilitate public health system containing such a coordinated quality movement at all measuring improvements and result in adding value for the Nation. Garth Graham, MD, MPH, Deputy Assistant Secr etary for Minority Health, serves as the Executive Director of the PHQF. The initial m eeting of the PHQF was held in May 2008 and work is intended to be an ongoing process in th e Office of the ASH. Members of the PHQF and the Federal agencies that they represent are provided in Appendix A. System partners that participated in this process through presentations and reviews are also noted in Appendix A. The HHS Public Health Systems Working Group, chaire d by Peggy Honoré, DHA, participated in the process by providing input into the design of this system for public health quality improvement. 2

3 Background In a 1998 report, the President’s Commission on Cons ality in the Health umer Protection and Qu Care Industry recommended that all segments of the health industry should embrace quality 1 improvement and support this commitment with clearly established aims for improvement. The Commission asserted that all se eded to be accountable for ctors of the health industry ne improving quality. They cited the lack of a syst ematic approach as hindering the industry’s ability to sustain quality and stated that quality improveme nt should be demonstrated by providing information on performan ce using standardized quality measures. Along with this was a recommendation to ensure the wide availability of valid, comprehensive, and comparative data 1 effectiveness for improving health. that it could be used to evaluate Expanding on this was the 2001 Institute of Medicine (IOM) publication Crossing the Quality Chasm: A New Health st System for the 21 Century where six aims for improvement in quality-of-care were 2 documented. Advancements in public health quality improveme nt are progressing, but the goals and tools are less defined than in some sectors of the heal th care industry. Aims for improvement in the quality of public health services have not been universally id entified and indicators of public health quality are not commonplace. Tools comparab le to ones used to assess the quality of patient care such as health plan report cards and the Health Effectiveness Data and Information Set (HEDIS) are not available for most parallel f unctions of the public health system. The recent identification of processes to facilitate qual ity improvement in public health such as accreditation, certification, performance measurement, and quality standards for public health preparedness are positive signs that a culture to increase and mainstream quality improvement concepts is strengthening. However, research findings indicate that public health quality 3 they are driven by strong national leadership. improvement practices are most prevalent when Local public health agency quality improvement initiatives are most common in clinical 3 programs and are least likely to Some challenges to occur in prevention programs. practice include identi fication of meaningful implementing quality improvement in public health 3 Another obstacle is the goals, data collection limitations, and lack of training for the workforce. 4 ce from research as recommended by the IOM. lack of knowledge on best practices and eviden These barriers to creating a culture for quality essed, with particular improvement must be addr attention given to establishing structures fo r routine dialogue and communication on quality improvement concepts and initiative s at all levels of the system. Defining Quality in Public Health The Nation’s public health system is the first line of defense to protect the health of the entire population. This covenant with the Nation for safeguarding popul ation health can be best achieved if concepts of quality and quality improvement are understood and embraced in all segments of the public health system. To pr omote uniformity across the system, the following definition of quality is provided: Quality in public health is the degree to which policies, programs, services, and research for the popu lation increase desired health . outcomes and conditions in which the population can be healthy 3

4 Articulating a clear vision for quality in public health and supporting the implementation of a commitments that are shared and promoted by national framework for quality improvement are stem. An overarching go al, at all levels and partners and stakeholders in the public health sy sectors of the system, is to have continuous ev aluation of public health practices, programs and desired results while giving si gnificant additional attention to policies that produce and promote of quality improvement in public health should those that need to be improved. An ultimate goal be to optimize population healt h, across all populations. The role of research to provide meaningful knowledge and academia for educatin g the workforce are critical components to advancing quality and fulfilling th is goal. Partners agree that quality improvement should be a robust system where practices of quality meas urement are shared responsibilities and are supported by routine examinations to document positive health outcomes for all Americans. The Office of Public Health and Science (OPHS) is the primary office within the U.S. Department of Health and Human Services for advising the Nation on matters related to public health science. The Assistant Secretary for Heal gic direction over OPHS th (ASH) provides strate with the implementation, manage ment, and development of initia tives related to public health and science and communicates on th ese issues to the country. Th e ASH is dedicated to creating a culture of quality in the system and, as a result, OPHS is taking a leadership role in articulating a comprehensive national commitment to quality in public health. Public health system partners stand synergistically with this commitment and are dedicated to ensuring that a framework for quality improvement is developed and mainst reamed into the governance, management, and cal and non-governmental partners practice of public health. Federa l, State, territorial, tribal, lo commit to providing leadership and steering a course of action where quality improvement initiatives are routine, woven into all com ponents of the system (e.g., financing, programming, research, education) and are implemented through an adequately management, governance, rce. Under the directi on of the ASH, this staffed and properly trained public health workfo upported with the identification of: commitment to quality will be s • A set of aims for improvement of quality in public health • A framework to guide and standardize quality improvement efforts • Priority areas for quality improveme nt in the public health system A core set of quality indicators in each of the priority areas • Completing all components of this quality initiative will be a multi-step process with input from nd over a continuous period with emphasis on across the system. The process will exte collaboration and inclusion of existing quality promoting programs. Ideally, these concepts ices as well as into policymaking, governance, should be woven into daily public health pract management, and relevant functions of system partners. This can be best accomplished through a trained workforce and informed leaders who value quality improvement. Weaving quality practices into daily activities was also recommende d in a previous report as a means of reducing 5 the potential of staff burnout from additional programming requirements. Mainstreaming this into daily practices at all levels (e.g., practitioners, board members, policymakers, researchers, educators) also promotes a culture for quality in the system. The concepts should also be applied advancing programs already familiar to the public in continuity with existing and future quality hy People 2010/2020, Guide to Community Prevention Services, health community (e.g., Healt Guide to Clinical Preventive Services, agency accreditation). 4

5 Characteristics of Quality in Public Health Many professions use characteri stics to describe quality specific to their industries (e.g., education, software engineering, communica tions). Healthcare followed this model by adopting the six aims established by the IOM that characterize quality in the delivery of patient 2 care. int to frame and promote consistency with The use of characteristics provides a focal po implementing quality improvement initiatives. ealth system partners led by the ASH, aims Through a consensus building process with public h ality improvement have been identified as an initial step to that characterize public health qu ring quality for increasing positive population fulfilling a commitment to quality. While ensu s to guide public health prac tices across the entire system health outcomes, characteristic should be: protecting and promoting healthy conditions Population-centered – • and the health for the entire population • Equitable – working to achieve health equity • Proactive – formulating policies and sustainabl e practices in a timely manner, while mobilizing rapidly to address new and emerging threats and vulnerabilities • Health promoting – ensuring policies and strategies that advance safe practices by providers and the population and increase the pr obability of positive health behaviors and outcomes • Risk-reducing – diminishing adverse environmental and social events by implementing lity of preventable injuries and illness or policies and strategies to reduce the probabi other negative outcomes • licies to support enhancements to – intensifying practices and enacting po Vigilant surveillance activities (e.g., technology, standardizati on, systems thinking/modeling) Transparent – ensuring openness in the delivery of se • with particular rvices and practices emphasis on valid, reliable, accessible, timel y, and meaningful data that is readily available to stakeholde rs, including the public • Effective – justifying investments by utilizing evid ence, science, and best practices to achieve optimal results in areas of greatest need • Efficient – understanding costs a nd benefits of public hea lth interventions and to facilitate the optimal utilization of resources to achieve desired outcomes Public health system partners recognize that th e intersection between public health and the health act, some public health ag encies are still direct care delivery system needs to be strengthened. In f providers of health care servic , three of the aims for quality es. In recognition of this fact improvement in public health are identical to those identified by the IOM as aims for improvement in quality of health care (equitabl e, effective and efficient). Additionally, the description of another IOM aim, safe, is embedded in the public health ai m of health promoting. The aims are intended to clearly articulate a co nsistent set of characteristics that should be present in public health in or der to achieve improved performan ce at all levels. In addition to practice organizations, the characteristics must be present in the activities of the various governmental and private sector contributors to the Nation’s public health system. Since public health services ar e multidimensional when testing for quality, all of the aims may tion when testing for quality. For other public health functions, apply to a single service or func Routinely examining public health activities for only a subset of the aims may be applicable. 5

6 these characteristics advances uniformity in public health practice because it represents a consistent approach to framing quality improvement efforts. Impacts The impact of this national public health qual ity movement will be multifaceted. It will promote a special focus on fostering health equity and quality along all dimensions of the system with on set of quality characteristics will facilitate eliminating health disparities. Applying a comm cross-jurisdictional comparisons and tracking of progress. This should be a stimulus and incentive for knowledge sharing on best practices. Quality is described in some sectors as value to users of goods and services. An early driver of the quality improvement movement in private in dustry was to increase value through reducing costs while providing be tter goods and services . The availability of timely and reliable data (e.g., health status, financial, outc omes, etc) will diminish barrie rs to determining the value of public health services. Other impacts accruing from the application of this framework should be a system-wide culture oncept in public health along with a solid where quality improvement is a sustained c commitment to and recognition of the value of workforce educa tion to ensure implementation and organizational change. Of par ticular significance already is the synergy that has been created by addressing quality with the engagement and consensus of partners throughout the public health system. The work of the PHQF to define and frame quality improvement characteristics across public health will continue through the work of vari ous partners throughout the system. The PHQF r emphasizing and improving quality in public framework presented provides a broad vision fo health. As the efforts move forward it is rec ognized that we will need flexible and tailored strategies to meet the need rward to engaging all communities of local communities. We look fo across the county in an inclusive cooperative vi sion for improving the h ealth of all communities in the United States. 6

7 References 1. President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality First: Better health care for all Americans. (March 12, 1998). Accessed on May 24, 2008. Available at: http://www.hcqualitycommission.gov/ . 2. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the st Quality Chasm: A new health system for the 21 century. Washington DC: National Academy Press, 2001. 3. Leep CJ. Quality Improvement at Local Health Departments: Strategies for the adoption of quality improvement for public health impact. National Association of County and City Health Officials. January 18, 2008. st Institute of Medicine. The Future of the Public’s Health in the 21 4. Century. Washington DC: National Academy Press, 2002. 5. Leonard BA. The Leonard Group. Adapting Quality Improvement to Public Health. Highlights and Conclusions. Conference sponsored by the Robert Wood Johnson Foundation. Cincinnati, Oh io. February 7, 2007. 7

8 Members of the Public Health Quality Forum and Participants in the Quality Process Appendix A: Representative Public Health Quality Forum Members Agency/Office U. S. Department of Health and Human Services Office of Public Health and Science Joxel Garcia Office of Public Health and Science/Office of Minority Health Garth Graham Office of Public Health and Science Lee Shakelford Office of Public Health and Science Lee Wilson Office of Public Health and Science Clara Cobb Office of Public Health and Science Patrick O’Carroll Agency for Healthcare Research and Quality Carolyn Clancy Centers for Disease Control and Prevention Julie Gerberding Centers for Disease Control and Prevention Stephanie Bailey Centers for Medicare and Medicaid Services Barry Straub Health Resources Services Administration Betty Duke Health Resources Services Administration Denise Geolot Substance Abuse and Mental Health Services Administration Terry Cline Representative Stakeholder Participants Organization American Public Health Association Georges Benjamin d Territorial Health Officials Association of State an Paul Jarris National Association of County and City Health Officials Patrick Libbey National Association of Local Boards of Health Marie Fallon Robert Wood Johnson Foundation James Marks Robert Wood Johnson Foundation Debra J. Perez U. S. Department of Health and Human Services Pu blic Health Systems Working Group Representative Agency/Office Office of Public Health and Science Peggy Honoré Office of Public Health and Science Willis Morris Office of Public Health and Science Wendy Braund Office of Public Health and Science Lisa Tonrey Agency for Healthcare Research and Quality Tricia Trinité Agency for Healthcare Research and Quality Sally Phillips Centers for Disease Control and Prevention Evan Mayfield Centers for Disease Control and Prevention Timothy Van Wave Centers for Disease Control and Prevention Cathleen Walsh Centers for Disease Control and Prevention Vilma Carande-Kulis Centers for Disease Control and Prevention Barbara Ellis Centers for Disease Control and Prevention Mildred Williams-Johnson Health Resources and Services Administration Kaytura Felix-Aaron National Center for Health Statistics Linda Bilheimer National Institutes for Health Cynthia Vinson Substance Abuse and Mental Health Services Administration Beverly Watts-Davis Reviewers Representative Organization Trust for America’s Health Jeffrey Levi Institute of Medicine Rose Marie Martinez National Governors Association Joyal Mulheron East Carolina University Lloyd Novick Yale University School of Public Health Paul Cleary Harvard University Judith Steinberg University of Minnesota School of Public Health William Riley University of Minnesota School of Public Health Doug Wholey School of Public Health Louisiana State University Leonard Jack apel Hill School of Public Health University of North Carolina-Ch Cheryll Lesneski Johns Hopkins University Bloomberg School of Public Health Leiyu Shi Tulane University School of P ublic Health and Tropical Medicine Maureen Lichtveld Los Angeles County Department of Health Dawn Jacobson Johnson County Kansas Health Department Leon Vinci Maine Center for Public Health Kala Ladenheim

9 Staff Representative Agency/Office U. S. Department of Health and Human Services d Science/Office of Minority Health Office of Public Health an Wakina Scott 9

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