Policy and Position Statements

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Performance Management Position Statement

I. ASTHO Supports Performance Management in Public Health

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."1 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 to "lay the foundation for improved protection, promotion, and preservation of a community's health."2

ASTHO recommends that state and territorial health agencies integrate a performance management system into their agency practices, programs, and interventions.

II. Within This Context, ASTHO Recommends:

  • That state and territorial health agencies use a performance management system to monitor the alignment and achievement of organizational objectives and goals.
  • That state and territorial health agencies integrate performance management in the planning of public health programs and services and use performance management as a strategic planning tool that builds a framework to deliver quality services.
  • That state and territorial health agency leaders demonstrate visible commitment to building and sustaining an agency-wide culture of quality.
  • That state and territorial health agencies identify and select performance measures, standards, indicators, or guidelines to assess state health agency performance, based on agency priorities.
  • That state and territorial health agencies adopt and implement a succinct and continuous cycle of collecting, analyzing, reporting, and acting on performance data.
  • That state and territorial health agencies use performance data to drive the implementation of quality improvement processes.
  • That federal agencies and national foundations provide sustained funding for national performance management and quality improvement initiatives.
  • That federal agencies, legislators, and policymakers support sustained public health improvement activities in states, including the provision of flexible funding opportunities with performance management activities as allowable expenses in programmatic grants.
  • That academia, public health agencies, federal agencies, and nongovernmental partners develop research-based evidence to ensure inclusion of performance management concepts in state health policy and practice.
  • That academia, federal agencies, and nongovernmental partners provide adequate and sustainable technical assistance and resources to support states in their performance management activities.
  • That all state and territorial health agencies increase their capacity to build and sustain a public health workforce equipped to integrate performance management and quality improvement into all aspects of public health practice.
  • That academia and partners providing public health training integrate performance and quality improvement curricula into public health education, training, and management competencies.
  • That all states pursue the adoption of performance management principles in the state health agency as part of a systemic transformation of the entire public health enterprise-federal, state, and local.

III. Background

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."3  Even more explicitly, "System-wide performance management is the active use of data to measure and improve performance across all areas of an agency's activities, including: human resources development; data and information systems; customer focus and satisfaction; financial systems; management practices; public health capacity; and health status."4 Data within a performance management system should also be utilized to improve effectiveness and identify efficiencies.

The national trend toward accountability and quality in state and territorial health agencies reinforces the increasing importance of performance management and quality improvement initiatives in public health. Given the economic and public health challenges facing states and territories, health agencies are continually increasing efficiency and providing more services with smaller budgets. In 2012, ASTHO found that 87 percent of state health agencies (48 states) had experienced budget cuts since 2008 and that the number of states experiencing budget cuts had increased steadily since the recession began.5

In recent years, federal agencies and national partners have provided funding for organizations, such as ASTHO, to provide performance and quality improvement technical assistance to state and territorial health agencies. Similarly, generous funding from the same federal agencies and national partners was allocated to state and territorial health agencies to participate in collaboratives and initiatives that promoted the implementation of quality improvement and performance management practices. Due to this support, state and territorial health agencies have made progress in measuring and improving performance, which will ultimately lead to improved health outcomes and financial benefits to the agency. Further, national efforts toward quality improvement and accreditation will increase the public's awareness of public health and promote the value of state and territorial health agencies.

Over the past few decades, public health practitioners, leaders in academia, and public health agencies have emphasized the importance of integrating performance management into the public health system. In 1988, the Institute of Medicine published the report "The Future of Public Health," which outlined three core public health functions: assessment, policy development, and service assurance. The Core Public Health Functions Steering Committee, including representatives from U.S. Public Health Service agencies and other major public health organizations, took these core functions and developed the framework for the 10 Essential Public Health Services in 1994.6  The essential services provide a working definition of public health and a guiding framework for the responsibilities of local public health systems.

Based on the philosophy that "public health agencies and their partners can be strengthened by linking to other sectors (not just the private healthcare sector, but education, criminal justice, faith communities, business, and others) because the underlying causes of poor health and quality of life are tied closely to social issues that are too complex to be approached by disease models of intervention,"7  the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation developed the Turning Point initiative, which included a Performance Management Collaborative. The collaborative proposed a performance management system that included:

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"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 of 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."8

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In 2013, the Turning Point initiative released a performance management tool that introduced the concepts of visible leadership, transparency, strategic alignment, culture of quality, and customer focus. These elements are critical to integrate in all aspects of performance management.

Public Health Performance Management System

Image courtesy of the Public Health Foundation. This framework was prepared by the Public Health Foundation with input from a broad range of public health practitioners and experts. Visit www.phf.org/pmtoolkit for more information.

In 2003, CDC created the National Public Health Performance Standards Program (NPHPSP) to advance the quality and performance of public health systems through the use of public health system standards and performance improvement processes. In 2007 the NPHPSP standards and tools were revised and updated by a collaborative of federal agencies and national partners engaged in public health performance measurement initiatives. "The standards identify the optimal level of performance for state and local public health systems (all organizations that contribute to public health in a given area) and governing bodies. The NPHPSP provides a framework to assess capacity and performance of a public health system and seeks to ensure that strong effective public health systems are in place to deliver essential public health services."9

Accreditation is an additional avenue for advancing the overall quality and accountability of state public health practice. Accreditation focuses on the agency itself, rather than the system-wide perspective. By setting benchmarks though performance standards and measures, accreditation programs in other industries have evolved to advance quality in services and improve organizational performance.10  The 2003 Institute of Medicine report "The Future of the Public's Health" called for exploring the benefits of accrediting governmental public health departments.11  ASTHO members, leadership, and staff played a critical role in contributing to the Exploring Accreditation Project, which examined feasibility and desirability of implementing a national public health accreditation program. After a two-year exploratory phase, the Public Health Accreditation Board was incorporated in 2007 and began work on the development of the first set of national agency level accreditation standards in public health. The Public Health Accreditation Board is "dedicated to improving and protecting the health of the public by advancing the quality and performance of Tribal, state, local, and territorial public health departments."12

The uptake and advancement of performance management related activities in state public health has progressed rapidly and will continue to increase. In December 2011, two months after PHAB began accepting applications for accreditation, 47 state, local, and tribal health departments were actively applying and awaiting review. By November 2013, the number of agencies in queue for accreditation review rose to 167, and 22 had been awarded fully accredited status.13 Federal agencies and national partners continue to provide state and territorial health agencies funding through various improvement initiatives that facilitates the use of performance management practices and the integration of performance management into policies and programs. ASTHO affirms that this trend will lead toward a more efficient, effective, and accountable public health system.


Approval History:

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Board of Directors. Position Statements are not voted on by the full ASTHO membership.

Performance Policy Committee Review and Approval: October 2013

Board of Directors Review and Approval: December 2013

Policy Expires: December 2016

For further information about this Position Statement, please contact ASTHO Performance Policy staff. For ASTHO policies and additional publications related to the Position Statement, please visit www.astho.org.

Related ASTHO Publications:

  • Accreditation Position Statement
  • Performance Policy Statement
  • Workforce Development Position Statement

Notes:

  1. Public Health Foundation. "About Performance Management." Available at http://www.phf.org/resourcestools/Documents/About_Performance_Management.pdf. Accessed 3-19-2013.
  2. 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 10-7-2013.
  3. Public Health Foundation. "About Performance Management." Available at http://www.phf.org/resourcestools/Documents/About_Performance_Management.pdf. Accessed 3-19-2013.
  4. Turning Point. "From Silos to Systems-Using Performance Management to Improve the Public's Health." Available at http://www.turningpointprogram.org/toolkit/pdf/Silos_to_Sytems.pdf. Accessed 11/21/2013.
  5. ASTHO. "Budget Cuts Continue to Affect the Health of Americans: Update March 2012." 2012. Available at http://www.astho.org/display/assetdisplay.aspx?id=6907. Accessed 11-5-2013.
  6. CDC. "The Public Health System and the 10 Essential Public Health Services." Available at http://www.cdc.gov/nphpsp/essentialServices.html. Accessed 3-19-2013.
  7. Ibid.
  8. Turning Point. "Performance Management Collaborative." Available at http://www.turningpointprogram.org/Pages/perfmgt.html. Accessed 3-19-2013.
  9. CDC. "National Public Health Performance Standards Program Frequently Asked Questions." Available at http://www.cdc.gov/nphpsp/documents/faq.pdf. Accessed 3-19-2013.
  10. Mays G. "Can Accreditation Work in Public Health?: Lessons Learned From Other Service Industries." White paper prepared for the Robert Johnson Wood Foundation. 2004.
  11. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: The National Academies Press. 2003.
  12. Public Health Accreditation Board. Available at http://www.phaboard.org/. Accessed 3-19-2013.
  13. Public Health Accreditation Board. Available at http://www.phaboard.org/distribution-of-health-departments-in-e-phab-as-of-september-10-2013/. Accessed 11-21-2013.