State Public Health Infrastructure and Performance: Insights from Recent ASTHO Surveys

1. State Public Health Infrastructure and Performance: Insights from Recent ASTHO Surveys Jim Pearsol, Chief Program Officer Association of State and Territorial Health Officials September 16, 2008

2. 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

3. 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.

4. Funding support ASTHO’s Baseline Survey and Marketing Projects are supported through funding from: Robert Wood Johnson Foundation & Centers for Disease Control and Prevention

5. ASTHO baseline survey: Background Survey 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)

6. 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

7. 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 Survey Subheadings

8. 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 health agencies 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

9. Collaboration (relate to NPHPSP state tool – section on state-local collaboration) More than 83% reported collaboration on the following with local public health agencies: Exchanging information Working together on activities or projects Providing financial resources Over 90% reported working together on projects or activities with: Hospitals Community health centers Other health care providers Regional cancer society Emergency responders Schools Community based organizations Faith communities Universities

13. Population-based Primary Prevention Services

14. 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 activities 73% Veterinarian PH activities; 70% trauma system; and 67% Institutional Review Board

15. 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 services 67% CSHCN 27% Non-WIC nutrition counseling 48% WIC 29% School health (non-clinical) 42% Early intervention 23% EPSDT 30% Family planning/prenatal care

16. Scope and Source of State Health Agency Authority

17. Develop Public Health Policies and Plans Developed Health Improvement Plan (HIP): 56% within 3 years 22% 3 years ago 21% 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%)

18. 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

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

20. 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

21. Marketing State Public Health The Association of State and Territorial Health Officials

22. 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.

23. 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

24. 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

25. 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

26. 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

27. Brand Strength Although the public feels the various functions of state and local public health services are important, there is little awareness that these are, in fact, the functions performed by these organizations.

28. 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

29. 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

30. 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

31. Overall, “Promoting health. Reducing costs” is the most preferred tagline.

32. Positioning Testing 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.

33. 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!”

34. Next Steps • ASTHO/ASPH Public Health Marketing Meeting • Public Health Language Development • Online Toolkit • Corporate partnership to benefit all of public health

35. 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

36. 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

37. Thanks! • For more information, contact: • jpearsol@astho.org • mdickey@astho.org • jjimenez@astho.org • lcaldwell@astho.org • bpetersen@astho.org • aholland@astho.org