indiana’s public health priorities

Indiana’s Public Indiana’s Public Health PrioritiesHealth Priorities

Judy Monroe, MD FAAFPJudy Monroe, MD FAAFP

Indiana State Health Indiana State Health CommissionerCommissioner

PriorityPriority

Sustainable Improvement in Sustainable Improvement in HealthHealth

Sustainable Sustainable ImprovementImprovement

Appropriate goalsAppropriate goals Transparent prioritizationTransparent prioritization Identification of real causesIdentification of real causes System based countermeasures that System based countermeasures that

address underlying causesaddress underlying causes Explicit strong actionsExplicit strong actions Measurement of actionsMeasurement of actions Top leadership involvement/visibilityTop leadership involvement/visibility

SystemsSystems

Simple : standard recipe for successSimple : standard recipe for success Complicated: combines multiple Complicated: combines multiple

subsystems and recreates by subsystems and recreates by following the same procedures following the same procedures (rocket to moon)(rocket to moon)

Complex: multiple subsystems but Complex: multiple subsystems but each application is unique (raising a each application is unique (raising a child)child)

Research QuestionsResearch Questions

What is the right thing to do?What is the right thing to do? How do you get people to do the How do you get people to do the

right thing? (implementation is right thing? (implementation is tougher)tougher)

How do we close the gap between How do we close the gap between promise and delivery?promise and delivery?

The Research QuestionThe Research Question

Systems fail because we try to Systems fail because we try to manage the piecesmanage the pieces..

How do we best manage the integration of How do we best manage the integration of the pieces?the pieces?

Tools for Population Tools for Population Level Level

Behavior ChangeBehavior Change Education Education Marketing/MotivatingMarketing/Motivating Risk CommunicationRisk Communication LeadershipLeadership PolicyPolicy LawLaw

PriorityPriority

Improve Nutrition Improve Nutrition & Physical Activity & Physical Activity

(Decrease Obesity)(Decrease Obesity)

Evidence-Based Evidence-Based StrategiesStrategies

Physical activity - increasePhysical activity - increase Fruits/vegetables - increaseFruits/vegetables - increase Breastfeeding – promote and increase Breastfeeding – promote and increase

acceptanceacceptance Consumption sugar- sweetened beverages Consumption sugar- sweetened beverages

– decrease or eliminate– decrease or eliminate Intake of high density foods - decreaseIntake of high density foods - decrease TV and screen time - decreaseTV and screen time - decrease

DNR and INDOT DNR and INDOT

Born to be BreastfedBorn to be Breastfed – – A Call to Action to Promote BreastfeedingA Call to Action to Promote Breastfeeding

Senate Bill 219 breastfeeding policy Senate Bill 219 breastfeeding policy passed (work place accommodation passed (work place accommodation and storage)and storage)

State FairState Fair


How does urban planning/built environment affect obesity How does urban planning/built environment affect obesity and how does it interplay with individual choice? and how does it interplay with individual choice?

What is the public health and dollar cost of What is the public health and dollar cost of overweight/obesity? overweight/obesity?

What evidence is there that school nutrition policies What evidence is there that school nutrition policies impact childhood obesity? impact childhood obesity?

How can we create healthier environments so as to How can we create healthier environments so as to reduce/eliminate health disparities? reduce/eliminate health disparities?

What are the most effective health messages for general What are the most effective health messages for general community, youth, or communities of color? community, youth, or communities of color?

What are the economic barriers to healthy eating and What are the economic barriers to healthy eating and physical activity? physical activity?

How does the availability of bike-friendly streets/walking How does the availability of bike-friendly streets/walking trails impact obesity? trails impact obesity?

How do we best educate our policymakers?How do we best educate our policymakers?


How can a local health departments How can a local health departments most effectively impact nutrition and most effectively impact nutrition and physical activity?physical activity?

How can the public health system How can the public health system most effectively work together to most effectively work together to positively impact nutrition and positively impact nutrition and physical activity?physical activity?

How can public health and providers How can public health and providers work more effectively together?work more effectively together?

PriorityPriority

Decrease Tobacco Decrease Tobacco Use and AddictionUse and Addiction

Evidence Based Evidence Based StrategiesStrategies

Increase the price (tax)Increase the price (tax) Mass media campaigns*Mass media campaigns* Telephone quit lines*Telephone quit lines* Smoking bansSmoking bans Provider reminder systems*Provider reminder systems* Reducing patient out of pocket costs Reducing patient out of pocket costs

(NRT)(NRT)

* * in combination with other strategiesin combination with other strategies

House Enrolled Act House Enrolled Act (HEA) 1678 (HEA) 1678

Effective July 2007Effective July 2007 Increased cigarette taxIncreased cigarette tax All of the revenue went to healthAll of the revenue went to health

Tobacco Free School Map 2001 2008

100% Tobacco Free Colleges and Universities100% Tobacco Free Colleges and Universities

20082008 34 completely 34 completely

tobacco free college tobacco free college and university and university campusescampuses

As of January 1, As of January 1, 2008, 2008, allall Indiana Indiana UniversityUniversity campuses system-campuses system-wide have enacted wide have enacted individually tailored individually tailored smokefree policies.smokefree policies.

Baseline 2001Baseline 2001

1 tobacco free 1 tobacco free college campus- college campus- Anderson CollegeAnderson College

100% Smoke Free Hospital Grounds100% Smoke Free Hospital Grounds

20012001 No 100% smoke No 100% smoke

free hospital free hospital groundsgrounds

20082008

124 hospitals 100%124 hospitals 100%

32 of 36 critical 32 of 36 critical access hospitalsaccess hospitals

% Hoosiers Protected by Effective Local Smokefree

Workplace Laws2003

1.1%

2008

29.8%


How do we light the fires that How do we light the fires that motivate people?motivate people?

How can research help move the How can research help move the tobacco issue further onto the public tobacco issue further onto the public policy agenda, particularly in the policy agenda, particularly in the developing world?developing world?

How do we improve cessation rates?How do we improve cessation rates? How can public health and providers How can public health and providers

more effectively work together?more effectively work together?

PriorityPriority

Improve Immunization Improve Immunization RatesRates


How do we increase use of CHIRP?How do we increase use of CHIRP?

Is CHIRP the best registry system?Is CHIRP the best registry system?

How can we eliminate double entry of How can we eliminate double entry of data?data?

What impact will anti-vaccine sentiment What impact will anti-vaccine sentiment have onhave on

immunization rates?immunization rates?

How do we use CHIRP (or other registry How do we use CHIRP (or other registry system) across the life continuum?system) across the life continuum?

PriorityPriority

Integrate Quality Improvement into Integrate Quality Improvement into

Public Health PracticePublic Health Practice(and get ready for accreditation)(and get ready for accreditation)

Indiana Public Health SystemIndiana Public Health SystemQuality Improvement ProgramQuality Improvement Program

Julie Novak, DNSc, RN, MA, CPNPDirector, Purdue School of Nursing ClinicsProfessor of NursingPrincipal Investigator

David McKinnis, PhDDirectorTechnical Assistance ProgramCo-Principal Investigator

Judith A. Monroe, M.D.Indiana State Health Commissioner

Local Public Health System Assessments

Distribution by Region

Northern Region n=5 Central Region n=9 Southern Region n=6

PurposePurpose To engage Indiana’s local public health To engage Indiana’s local public health

system partners in a continuous quality system partners in a continuous quality improvement process integrating:improvement process integrating: participation in the NPHPSP, Local, Version 2.0 assessmentsparticipation in the NPHPSP, Local, Version 2.0 assessments empowerment at the local level through a process of team building, empowerment at the local level through a process of team building,

leadership and problem solvingleadership and problem solving development of a unique, evidence-based, public health program development of a unique, evidence-based, public health program

designed to enhance delivery and quality of public health designed to enhance delivery and quality of public health demonstration of performance improvement related to the 10 Essential demonstration of performance improvement related to the 10 Essential

Services of public health and Healthy People 2010 objectives Services of public health and Healthy People 2010 objectives

Phase I – AssessmentPhase I – AssessmentCDC’s National Public Health CDC’s National Public Health

Performance Standards ProgramPerformance Standards Program

Early user of Version 2.0 Local Instruments.Early user of Version 2.0 Local Instruments.

Collaboration with partners is critical to developing Collaboration with partners is critical to developing clear, measurable standards for local public health clear, measurable standards for local public health systems. systems.

Final report provides a means of evaluating Final report provides a means of evaluating system-wide performancesystem-wide performance

Results provide a foundation for public health Results provide a foundation for public health system quality improvement processes. system quality improvement processes.

Phase II - TrainingPhase II - TrainingFour Day Training Course: Team Four Day Training Course: Team

Building, Leadership and Problem Building, Leadership and Problem SolvingSolving

Participants learn team building and leadership Participants learn team building and leadership skills.skills.

Teams learn how to apply problem solving Teams learn how to apply problem solving methodologies and tools to identify primary causal methodologies and tools to identify primary causal factors limiting program success in public health.factors limiting program success in public health.

Teams create a foundation for implementation Teams create a foundation for implementation plans to mitigate/remove primary causal factors plans to mitigate/remove primary causal factors and improve program performance related to the and improve program performance related to the 10 Essential Services and Healthy People 2010 10 Essential Services and Healthy People 2010 objectives. objectives.

Phase IIIPhase IIIPerformance Improvement Performance Improvement

ProgramsPrograms

Identify written performance objectives Identify written performance objectives based on RCAbased on RCA

Identify key public health partners to Identify key public health partners to collaboratecollaborate

Create strategies to meet objectivesCreate strategies to meet objectives

Design and implement planDesign and implement plan

Findings of the first 20 local public Findings of the first 20 local public system assessments revealed the system assessments revealed the following areas for performance following areas for performance

improvement in the pilot counties: improvement in the pilot counties:

Essential Service 1: Monitor Health Status to Identify Community Health ProblemsEssential Service 1: Monitor Health Status to Identify Community Health Problems

Model Standard 1.1 Population-Based Community Health ProfileModel Standard 1.1 Population-Based Community Health Profile 33.7%33.7%

Model Standard 1.2 Current Technology to Manage/Communicate Health Data Model Standard 1.2 Current Technology to Manage/Communicate Health Data 39.6%39.6%

Essential Service 4: Mobilize Community ParEssential Service 4: Mobilize Community Partnerships to Identify and Solve Health Problemstnerships to Identify and Solve Health Problems

Model Standard 4.2 Community Partnerships Model Standard 4.2 Community Partnerships 43.2%43.2%

Essential Service 5: Develop Policies and Plans that Support IndividualEssential Service 5: Develop Policies and Plans that Support Individual

and Community Health Efforts and Community Health Efforts

Model Standard 5.3 Community Health Improvement Process/Strategic Planning Model Standard 5.3 Community Health Improvement Process/Strategic Planning 34.5% 34.5%

Essential Service 8: Assure a Competent Public and Personal WorkforcEssential Service 8: Assure a Competent Public and Personal Workforce e

Model Standard 8.1 Workforce Assessment, Planning, and Development Model Standard 8.1 Workforce Assessment, Planning, and Development 31.7% 31.7%

Essential Service 9: Evaluate effectiveness, accessibility, and quality of personal and Essential Service 9: Evaluate effectiveness, accessibility, and quality of personal and

population-based health services. population-based health services.

Model Standard 9.3 Evaluation of Local Public Health SystemsModel Standard 9.3 Evaluation of Local Public Health Systems37.3%37.3%

Research QuestionResearch Question Following the completion PHSQI Year 1, survey of the Following the completion PHSQI Year 1, survey of the

pilot counties indicates an overwhelming response that - pilot counties indicates an overwhelming response that - focus on evaluation of the local public health system has focus on evaluation of the local public health system has strengthened both communication and collaboration strengthened both communication and collaboration among partners. among partners. However, by far, the majority of counties indicate that it However, by far, the majority of counties indicate that it has not improved 'capacity' of their local public health has not improved 'capacity' of their local public health system. system.

How can effective approaches be developed to utilize How can effective approaches be developed to utilize existing and now more recognized local partnerships to existing and now more recognized local partnerships to improve and enhance the 'capacity' of the public health improve and enhance the 'capacity' of the public health services delivered within the system - such that there is services delivered within the system - such that there is an improved infrastructure and measurable outcome in an improved infrastructure and measurable outcome in the population served?the population served?

Research QuestionsResearch Questions With the knowledge that the local public health With the knowledge that the local public health

department workforce is aging, that recruitment is department workforce is aging, that recruitment is difficult due to salaries, and there exists in many areas difficult due to salaries, and there exists in many areas minimal competency for the type of essential services minimal competency for the type of essential services required to be performed (accreditation requirements), required to be performed (accreditation requirements), what is the potential/future status of maintaining the what is the potential/future status of maintaining the local public health department workforce? local public health department workforce?

What strategies should be considered now to prevent a What strategies should be considered now to prevent a brain-drain/ experience drain when retirements occur brain-drain/ experience drain when retirements occur and new practitioners are not available to support the and new practitioners are not available to support the LHD services? LHD services?

How close are we in IN to experiencing a reduction in How close are we in IN to experiencing a reduction in LHD workforce? Would salary increases make a LHD workforce? Would salary increases make a difference or is it the type of work that does not interest difference or is it the type of work that does not interest nurses and environmentalists? nurses and environmentalists?

PriorityPriority

Improve Public Health Improve Public Health PreparednessPreparedness

Research QuestionsResearch Questions How do we improve the usefulness of How do we improve the usefulness of

training? training? What is the optimal design and What is the optimal design and

implementation of training?implementation of training? What is the optimal design and structure for What is the optimal design and structure for

integrating preparedness into public health?integrating preparedness into public health? How do we improve communication?How do we improve communication? What are the factors for successful What are the factors for successful

response/recovery in a community?response/recovery in a community? How should we measure preparedness?How should we measure preparedness? How do we effectively stockpile resources?How do we effectively stockpile resources?

PriorityPriority

Improve Patient SafetyImprove Patient Safety

Indiana Medical Indiana Medical Error Error

Reporting Reporting SystemSystem

Goal of the Medical Error Goal of the Medical Error

Reporting SystemReporting System Obtain dataObtain data

Assess data to identify patient safety Assess data to identify patient safety issues and issue annual reportissues and issue annual report

Utilize information to develop and Utilize information to develop and implement patient safety initiativesimplement patient safety initiatives

Evaluate outcomes Evaluate outcomes

Number of reported Number of reported events events

2006: 85 – total reported events2006: 85 – total reported events

2007: 105 – total reported events2007: 105 – total reported events

Top four reported events Top four reported events for 2006 and 2007for 2006 and 2007

Stage 3 or 4 pressure ulcers acquired after Stage 3 or 4 pressure ulcers acquired after admission – 26 in 2006 / 27 in 2007admission – 26 in 2006 / 27 in 2007

Retention of a foreign object in patient after Retention of a foreign object in patient after surgery – 23 in 2006 / 24 in 2007surgery – 23 in 2006 / 24 in 2007

Surgery performed on the wrong body part – 11 Surgery performed on the wrong body part – 11 in 2006 / 23 in 2007in 2006 / 23 in 2007

Death or serious disability associated with a Death or serious disability associated with a medication error – 6 in 2006 / 8 in 2007medication error – 6 in 2006 / 8 in 2007

Outcomes of Medical Outcomes of Medical Error Reporting Error Reporting

Increased awareness of medical Increased awareness of medical errorserrors

Allocation of resources to patient Allocation of resources to patient safetysafety

Increase in number and activity of Increase in number and activity of patient safety coalitionspatient safety coalitions

Quality Indicator SystemQuality Indicator System

ISDH will contract with an entity to ISDH will contract with an entity to collect, analyze, interpret, and collect, analyze, interpret, and disseminate findings on a statewide disseminate findings on a statewide basis regarding patient safetybasis regarding patient safety

Entity will develop policies, best Entity will develop policies, best practices, and procedures that practices, and procedures that enhance patient safetyenhance patient safety


How do we make catching and How do we make catching and reporting mistakes the norm and reporting mistakes the norm and reward this behavior?reward this behavior?

How do we speed up our journey of How do we speed up our journey of culture change?culture change?

How do we make it easy to do the How do we make it easy to do the right thing?right thing?

indiana’s public health priorities

Documents

public health system

tobacco free colleges

effective health messages

local health departments

healthtobacco free school

prioritydecrease tobacco

multiple subsystems

right thing