Policy and Position Statements


Performance Policy Statement

State and territorial health agencies manage and develop public health programs and policies that protect and improve the health of residents in their jurisdictions. They are the statutory agents for public health program oversight and accountability. Central to this work is their responsibility as custodians of the public's trust. Each state and territorial public health agency must continuously monitor and improve their performance in order to track successes, identify deficiencies, and implement improvement processes. As focus increases on the efficiency, effectiveness, and accountability of state and territorial government, state and territorial public health agencies should develop and demonstrate sound financial, infrastructure, and program deployment decisions, and implement effective and cost-saving advancements that improve population health outcomes. To support performance capacity in tribal and local health agencies, state and territorial health agencies also bear an increased responsibility to provide technical assistance and training in performance management, data analysis, evaluation practices, and workforce capacity to these entities.1


Performance management is described by the Public Health Foundation as the practice of actively using performance data for improvement purposes: "This practice involves the strategic use of performance measures and standards to establish performance targets and goals."2 Performance management can be used to prioritize and allocate resources, inform managers about necessary adjustments or changes in policies or programs, frame reports on success in meeting performance goals, and "lay the foundation for improved protection, promotion, and preservation of a community's health."3 Data within a performance management system should also be utilized to improve effectiveness and identify efficiencies.

The following elements are critical to integrate in a public health performance management system:

  • Performance standards: Establishment of organizational or system performance standards, targets, and goals and relevant indicators to improve public health practice.
  • Performance measures: Application and use of performance indicators and measures.
  • Reporting progress: Documentation and reporting of progress in meeting standards and targets, and sharing of such information through feedback.
  • Quality improvement: Establishment of a program or process to manage change and achieve quality improvement in public health policies, programs, or infrastructure based on performance standards, measurements, and reports.4

A. Quality Improvement

Quality improvement generally refers to concepts and methods implemented to improve a product or service. It may also be based on the notion of a systems approach, the need and will to change, use of data to guide and track changes, and the application of knowledge from testing to make measureable improvements.5

Leveraging resources through quality improvement tools and techniques, such as improvement cycles like plan‐do‐study‐act, data‐driven performance management, balanced scorecard approaches, and performance standards, may contribute to improved state and territorial health agency performance and ultimately improved health outcomes. State and territorial health agencies should maintain a multidisciplinary team or council focused on prioritizing, selecting, and implementing quality improvement initiatives. Quality improvement, including preparing for national accreditation, is an ongoing process that requires that state and territorial health agencies institutionalize a culture of accountability and awareness of agency performance.


The public health system includes all public, private, and voluntary entities that contribute to the public health activities within a given area. These systems are a network of entities with different roles, relationships, and interactions. All the entities within a public health system contribute to the health and well-being of the community. Quality improvement ensures quality in public health systems through performance standards, education programs, and policies that promote quality improvement in a range of public health systems.6

A. Systems Assessment

The process of assessing the public health system requires a collaborative effort between the state or territorial health agency and partners and organizations that contribute to and deliver public health services. A systems assessment measures the capacity and infrastructure of the system, identifies partners and community members, engages those partners in health assessment and health improvement planning, and promotes the overall improvement of the public health system. Several national models and frameworks have been developed to facilitate a structured systems assessment process, including the National Public Health Performance Standards (NPHPS), Mobilizing for Action through Planning and Partnership (MAPP) process, which includes the NPHPS assessment, and Community Health Needs Assessment (CHNA) process. ASTHO supports state and territorial health agencies regularly leading or participating in a public health systems assessment in order to accurately evaluate their assets, resources, and public health challenges, which can also lead to:

  • A culture of continuous quality improvement and identification of quality improvement opportunities.
  • Public health data and community input to inform the state or territorial health assessment and health improvement plan.
  • Documentation of specific activities that support requirements needed for accreditation.

B. National Accreditation

ASTHO endorses the Public Health Accreditation Board's (PHAB) current standards and measures as the sole voluntary national accreditation program for public health agencies, and recognizes accreditation as a tool to advance the pursuit of excellence, continuous quality improvement, and accountability for the public's health. The development of PHAB standards and measures is intended to build quality improvement in health departments, reflect emerging public health issues and opportunities, and promote effective internal and external collaborative partnerships. ASTHO supports state and territorial health agencies seeking voluntary national accreditation with the intended goals to:

  1. Improve health outcomes.
  2. Drive continuous quality improvement.
  3. Clarify public expectations of state, territorial, and local health departments.
  4. Establish quality and consistency of performance management and service delivery.
  5. Increase the visibility, credibility, accountability, and public awareness of governmental public health.
  6. Lead to a stronger constituency for public health funding and infrastructure.

C. Workforce Development

A skilled state public health workforce is essential for protecting and improving the health and wellness of the public and responding to major health threats. The public health community must improve its ability to assess the needs of the current public health workforce, communicate the value of the public health workforce, and equip future public health leaders with the skills necessary to carry out essential public health responsibilities and respond to the changing landscape of the U.S. public health system. Recent national efforts surrounding performance standards and accreditation have focused on strengthening the governmental public health workforce. As more tools are developed to measure performance and accountability in serving the public, a robust, capable public health workforce will be required to meet increasingly rigorous standards. ASTHO supports the development of innovative solutions to fulfill the needs of the public health workforce and renewed public and private investments through:

  1. Communication about workforce needs to a wide audience.
  2. Advocacy for increased federal resources for states and territories to further develop their workforce activities.
  3. Continued evaluation of public health workforce needs through research and enumeration.
  4. Activities that replenish the workforce by marketing public health careers and highlighting the benefits of working in public health.
  5. Improved competitiveness of careers in public health.
  6. Formation of partnerships within and outside of the public health system.
  7. Fostering of innovation in filling workforce gaps.
  8. Supporting efforts to ensure a diverse public health workforce that can meet the needs of the communities it serves.
  9. Facilitating the integration of public health and healthcare through education and development of current and future members of the public health and healthcare workforces.
  10. Succession planning to strengthen a state and territorial health agency's current and future workforce by developing the skills, knowledge, and talent needed for leadership continuity.


To facilitate positive change in governmental public health services, systems, and infrastructure, state and territorial public health agencies must assess their performance. Data must be continuously utilized throughout feedback cycles and should be collected and analyzed to address agency capacity, processes, and outcomes. These data should include services, personnel, organizational structure, scope of work, financing, planning and quality improvement, health information technology and health information exchange, agency mission, relationship with local and tribal health agencies, partnership and collaboration, emergency preparedness structure, and performance activities, which may inform public health policies and practices at the federal, state, and local levels. ASTHO supports the collection and reporting of such data to:

  1. Improve health outcomes and address health disparities and inequities.
  2. Assist state and territorial public health agencies in providing evidence to support resource allocation, program, and infrastructure decisions to policymakers, funding agencies, public health practitioners, researchers, and consumers.
  3. Build a comprehensive ASTHO database of state and territorial public health agency information related to the central functions of state and territorial public health agencies.
  4. Participate in and promote public health systems and services research to develop public health system improvements and link capacity and process to improved health outcomes.
  5. Support state and territorial health agencies' use of evidence-based practices by disseminating relevant findings in a timely manner.
  6. Support state and territorial health agencies in utilizing existing evidence to innovate and develop more effective and efficient public health policies and practices.
  7. Be utilized in performance dashboards and performance management systems that use comparable operational indicators that assess state and territorial health agency processes.

Approval History:

Performance Policy Committee Review and Approval: December 2014
Board of Directors' Review and Approval: December 2014
Ratified by the ASTHO Assembly of Members: December 2014
Policy Expires: December 2017

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO's actions and external communications.

Related ASTHO Documents:

Position Statements:
Performance Management
Services and Systems Research
Workforce Development


  1. Public Health Accreditation Board. "PHAB Standards and Measures Version 1.5" Available at http://www.phaboard.org/wp-content/uploads/SM-Version-1.5-Board-adopted-FINAL-01-24-2014.docx.pdf. Accessed 6-20-2014.
  2. Public Health Foundation. "About Performance Management." Available at http://www.phf.org/resourcestools/Documents/About_Performance_Management.pdf. Accessed 6-20-2014.
  3. Public Health Accreditation Board. "What Are the Benefits of National Public Health Department Accreditation?" Available at http://www.phaboard.org/accreditation-overview/what-are-the-benefits/. Accessed 6-20-2014.
  4. Turning Point. "Performance Management Collaborative." Available at http://www.phf.org/resourcestools/pages/turning_point_project_publications.aspx Accessed 6-20-2014
  5. Deming WE. Out of the Crisis. 2nd ed. Boston, Massachusetts: MIT Press. 2000.
  6. Center for Disease Control and Prevention. "National Public Health Performance Standards Factsheet." Available at http://www.cdc.gov/nphpsp/documents/nphpsp-factsheet.pdf. Accessed 6-20-2014.