Bernard J. Turnock

A Conceptual Framework to Measure Performance of the Public Health System

OBJECTIVES This article describes a unifying conceptual framework for the public health system as a way to facilitate the measurement of public health system performance. METHODS A conceptual framework for the public health system was developed on the basis of the work of Donabedian and a conceptual model previously developed by Bernard Turnock and Arden Handler. RESULTS The conceptual framework consists of 5 components that can be considered in relationship to each other: macro context, mission, structural capacity, processes, and outcomes. Although the availability of measures for each of these components varies, the framework can be used to examine the performance of public health systems as well as that of agencies and programs. CONCLUSIONS A conceptual framework that explicates the relationships among the various components of the public health system is an essential step toward providing a science base for the study of public health system performance.

Core function-related local public health practice effectiveness.

This article assesses the extent to which the U.S. population in 1995 was being effectively served by public healths three core functions (assessment, policy development, and assurance). A random sample of local health departments (LHDs) stratified by population size and type of jurisdiction was asked to provide their opinion of, as well as indicate performance on 20 core function-related measures of local public health practice. The article concludes that, in 1995, the nation fell far short of its year 2000 national objective, which called for 90 percent of the population to be served by an LHD effectively carrying out public healths core functions. Considerable capacity building and performance improvement is needed within the public health system.

Local Health Department Effectiveness in Addressing the Core Functions of Public Health: Essential Ingredients

Objectives: Objective 8.14 of the U.S. Healthy People 2000 objectives calls for 90% of the population to be served by a local health department (LHD) which is effectively carrying out the core functions of public health (assessment, policy development, assurance). This study seeks to describe the structural and service characteristics of an effective LHD.Methods: Data from a 1993 national random sample survey of LHD practice were merged with data from the 1992–1993 National Association of County and City Health Officials (NACCHO) profile of local health agencies. Using a definition of effectiveness related to the core functions of public health, the correlates of effectiveness were examined for 264 health departments in the matched sample.Results: Effectiveness of local health agencies was not related to jurisdiction size or type. Inputs (structural factors) associated with effectiveness included having a full-time agency head, a larger budget derived from a greater number of funding sources, and a larger number of staff. With respect to outputs (services), effective health departments were also more likely to provide a greater number of services directly, particularly personal preventive and treatment services.Conclusions: Only a few inputs are correlated with core-function related effectiveness. However, a profile of an effective health department emerges. Effective LHDs appear more likely to have full-time leadership which is able to tap diverse funding sources to provide the mix and match of community and personal prevention and treatment services needed to address community needs and improve the publics health.

Quality assessment of perinatal regionalization by multivariate analysis: Illinois, 1991–1993

Objective To identify (1) those elements in the infrastructure of a regionalized perinatal network that have independent effects on the variation in perinatal mortality among nontertiary units (member level I and II hospitals) and (2) shortcomings, if any, in a traditional perinatal data base that impede quality assessment of contemporary regionalized care. Methods We analyzed perinatal surveillance data for 3 years, from 1991 to 1993, in the state of Illinios, representing more than 190, 000 annual births. Fatal death and neonatal mortality reates for the 97 nontertiary hospitals studied were the dependent variables of interest. Two sets of independent variables were studied, those assessing the maternal sociobehavioral risk of populations served and those assessing the network infrastructure (defined as the facilities of member hospitals and their function within the regionalized network). We used multivariate analysis to partition the variation in hospital rates of perinatal mortality into two components, one attributable to maternal sociobehavioral risk and the other to the network infrastructure. Results Material sociobehavioral risk alone explained 73% of the variation in hospital fetal death rates and 38% of that in hospital neonatal mortality rates. When controlling for maternal sociobehavioral risk, rates of inborn very low birth weight (VLBW) deliveries (P < .001) and neonatal transport (P = .01) had independent effects on the variation in hospital fetal death rate; rates of inborn VLBW deliveries (P < .001) and neonatal transport (P < .001), and proportion of VLBW infants transported out (P = .029) had independent effects on the variation in hospital neonatal mortality rate. Conculsions In this mature statewide network, the rate of inborn VLBW deliveries exerted the strongest independent effect on variation in level I and II hospital rates of both fetal death and neonatal mortality. However, that there was such a large effect from maternal sociobehavioral risk alone has important public health implications. Additions and modifications to traditional perinatal surveillance are suggested better to assess the quality of regionalization in a contemporary health care environment.

Roadmap for Public Health Workforce Preparedness

Major initiatives to improve the public health workforce since 1997 have been driven by a hundred-fold increase in federal financial support, technologies providing greater access to public health workers, and an emerging national priority to prepare for and respond to bioterrorism and other urgent threats. This report examines the status of the national public health workforce development agenda, including its major strategies and emphases, and offers a roadmap for assessing, enhancing, and recognizing competent performance through comprehensive public health workforce preparedness management systems.

Capacity-building influences on Illinois local health departments.

Illinois local health departments (LHDs) were surveyed in 1992 and again in 1994 in order to assess changes in, influences on, and results of practice performance during this two-year period. Illinois LHDs serving both small and large populations were found to have greatly increased the extent to which they carry out practice measures related to public healths core functions. The Assessment Protocol for Excellence in Public Health (APEXPH) and its Illinois adaptation were cited as the most positive influences on practice performance. LHDs viewed the most significant consequences of participation in needs assessment and planning processes as increased understanding of internal strengths and weaknesses and of community health problems. These findings and implications suggest that significant improvements in LHD practice performance can result from widespread implementation of APEXPH and its derivatives.

Competency-based credentialing of public health administrators in Illinois.

This article describes an initiative to develop and implement a competency-based credentialing program for public health managers and administrators that is linked with practice performance standards for local public health systems. The Illinois Public Health Administration Certification Board represents an innovative model for credentialing public health workers, placing equal value on competencies secured through education and training and those demonstrated in practice. Competency-based credentialing of public health administrators may have applicability for other segments of the public health workforce.

Can public health performance standards improve the quality of public health practice

Recent developments suggest that a national public health performance standards program could succeed in improving the quality of public health practice. Public health standards also may be useful for enhancing accountability and strengthening the science base of public health practice. For national public health performance standards to have a substantial influence on the quality of public health practice, several important issues must be addressed. These include agreement as to the ultimate purpose and appropriate unit of measurement, delineation of the specific qualities to be measured, and expansion of strategies to promote widespread use of public health practice standards.

Is public health ready for reform? The case for accrediting local health departments.

Reform of the governmental public health system in the United States has been stymied by changes in political, economic, and medical care landscapes since public health was called to action by the Institute of Medicine report in 1988. Despite a new national health objective calling for 90 percent of the population to be served by a local health department effectively addressing public healths three core functions by the year 2000, capacity building initiatives have not been deployed extensively, and there is little likelihood of reaching the year 2000 objective. A national program of accrediting local and state health departments could energize public health capacity building. Accreditation would build on recent initiatives in states like Washington and Illinois, promote wider use of the Assessment Protocol for Excellence in Public Health, and facilitate reform of the public health system around public healths core functions. Key questions addressing the why, how, and who of such an initiative set the stage for consideration of a national accreditation program.

Building bridges between schools of public health and public health practice.

A 1988 Institute of Medicine report, The Future of Public Health, characterized the current public health system as fragmented, particularly with regard to relationships between public health agencies and academic institutions. As one response to the report, the Health Resources and Services Administration established the Center for the Development of Public Health Practice at the University of Illinois to advance linkages between schools of public health and public health agencies. Surveys of schools of public health and of state health agencies were conducted in 1992 to collect baseline data on the practice links between the two. Responses reveal that there is a substantial amount of informal collaboration between them. Formalization of collaborative activities between schools and agencies is beginning to occur and is expected to expand owing to increased focus on public health practice at schools of public health.