Quality Improvement Position Statement

I. ASTHO Supports Quality Improvement in Public Health

The Association of State and Territorial Health Officials (ASTHO) supports state and territorial health agencies’ efforts to improve agency performance, with the ultimate goal of improved health outcomes in the United States.

II. Within This Context, ASTHO Recommends:

• The endorsement of the process of establishing a national set of voluntary accreditation standards for state and territorial health agencies underway with the Public Health Accreditation Board.
• Sustainability for quality improvement activity in states through support from federal agencies, legislators and policy makers, including flexible funding opportunities with quality improvement and accreditation preparation activities as allowable expenses in programmatic grants.
• The development of research‐based evidence to ensure inclusion of quality improvement and performance measurement concepts in state and territorial health policy and practice.
• Adequate and sustainable financial and technical assistance resources to support states in their quality improvement and accreditation activities.
• Transforming public health practices so that the tools of quality improvement are an integral aspect of all the work we do in public health. This includes the need to build a discipline of public health quality improvement specialists to lead within every health agency.
• The adoption of quality improvement principles in the state and territorial health agencies as part of a systemic transformation of the entire public health enterprise – federal, state and local.

III. Background: Improving Quality in State Health Agency Performance

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.¹

Advancements in public health quality improvement continue to progress, yet definitions and objectives remain less established than in other sectors of the health industry. The public health system lacks the tools used by other sectors in health industry to assess the quality of patient care such as health plan report cards and the Health Effectiveness Data and Information Set (HEDIS)². Despite the absence of these types of tools, state public health agencies are central to the health and well‐being of our nation. Working closely with community partners in and out of public health, state health agencies function to ensure the public’s health and safety.

Given the economic and public health challenges facing states, health agencies are forced to increase efficiency and provide more services with smaller budgets. In 2009, ASTHO found that nearly one third of state health agencies were operating under a budget smaller than the previous year and that 70% of these agencies expected the next year’s budget to be smaller than the existing year.³

The national trend towards accountability and quality in state health agencies reinforces the increasing importance of quality improvement initiatives in public health. 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 health agency performance, and ultimately improved health outcomes.

Accreditation is an additional means for advancing the overall quality and accountability of state public health practice. By setting benchmarks though performance standards and measures, accreditation programs in other industries have evolved to advance quality in services and improve organizational performance.⁴ The 2003 release of The Future of the Public’s Health by the Institute of Medicine (IOM), called for the exploration of the benefits of accrediting governmental public health departments.⁵   To this end, and 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’s mission is to advance the continuous quality improvement of state, local, tribal, and territorial public health departments. The National Public Health Performance Standards Program, first published in 2003 and revised in 2007, provides performance standards for public health systems, which may be used towards improving public health practice at the state, local and governance levels. These system standards may be used to complement agency accreditation preparation activity.

Quality improvement, including preparing for national accreditation, is an ongoing process that will require state health agencies to institutionalize a culture of accountability and awareness of agency performance. According to the ASTHO Profile of State Public Health, more than 82 percent of state health agencies had a quality improvement process in place, but only about ten percent had it fully implemented agency‐wide.⁶ To sustain existing efforts and build momentum for new activity, state health agencies will need to maximize existing budgets and develop new fiscal strategies to support broad agency initiatives such as quality improvement.

With the creation of incentives by federal agencies and the technical assistance provided by organizations such as ASTHO, state health agencies can make progress in improving performance, ultimately leading to improved health outcomes. Further, national efforts towards quality improvement and accreditation will increase the public’s awareness of public health and promote the value of state health agencies.

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 13, 2009

Board of Directors Review and Approval: December 7, 2009

Policy Expires: December 7, 2012

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:

• ASTHO General Policy Statement
• Performance Policy Statement

Notes

1. Deming, W.E., Out of the crisis. 2nd ed. 2000, Boston: MIT Press.
2. 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
3. Impact of Budget Cuts on State Public Health. 2009, Association of State and Territorial Health Officials: Washington, DC.  Available online at: http://www.astho.org/Research/Data‐and‐Analysis/ASTHO‐Budget‐Cuts‐Survey‐Results/
4. Mays, G. “Can Accreditation Work in Public Health?: Lessons Learned From Other Service Industries.” White Paper Prepared for the Robert Johnson Wood Foundation, November, 30, 2004.
5. Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. Washington, D.C.: The National Academies Press
6. ASTHO Profile of State Public Health, 2009. Association of State and Territorial Health Officials: Washington, DC.