Message from the ASH

This commentary originally appeared in Public Health Reports, November–December 2008.

Advancing Quality Improvement in Public Health

The Institute of Medicine (IOM) defines public health as “what society does collectively to assure the conditions for people to be healthy,”¹ while the Merriam-Webster dictionary defines quality as “a degree of excellence.” Taking into consideration these two definitions, the goal for all public health professionals is to help society and all of its components—government, private sector, the public, academia, and all others—to achieve the highest level of health using the highest quality processes and programs of public health.

The goal of helping society achieve its highest level of health seems simple and straightforward, but it is not. The challenge of creating and implementing public health policy that will benefit all members of society is enormous when the tools to measure public health quality are not present. Many competing needs and the finite amount of resources available to create and sustain public health programs can handicap public health policy-making and program implementation. Furthermore, this lack of objective tools to give value to the different public health programs and policies may deter possible benchmarking of efficient and effective policies and programs that improve the quality of public health in a community or our nation, while allowing programs of lesser quality to continue being supported. It should then be a priority that we consider and strive to achieve results consistent with desired outcomes through the application of quality improvement (QI) concepts in public health.

The QI movement in private industry and the public sector began decades ago. The International Organization for Standardization (ISO) first published international standards in 1947,² and the Malcolm Baldridge National Quality Award was created by public law in 1987.³ Health care has followed this trend, though to a lesser degree. QI initiatives include health plan report cards, Healthcare Effectiveness Data and Information Set (HEDIS) measures, program certification, and credentialing. The quality-of-care movement in health care continues to be fueled given IOM reports such as “Crossing the Quality Chasm: A New Health System for the 21st Century.”⁴ The publication has been important for framing the advancement of quality of care with recommendations such as the six aims to characterize health-care improvements: safe, effective, patient-centered, timely, efficient, and equitable.

Advancements in public health QI are progressing but are less rigorous than in other fields. The structure for the accreditation of public health agencies as a method to promote quality is being implemented. Many national public health programs now include performance measures in grantee awards, and tools are being used to measure system performance. Standards for data collection continue to be examined, and Healthy People 2010 is a blueprint for improving population health outcomes.⁵ Despite these accomplishments, greater attention is needed to mainstream quality concepts across all sectors of the public health system.

The organizational center of public health activities in the nation is governmental public health.1 The Office of Public Health and Science (OPHS) is the primary office within the U.S. Department of Health and Human Services (DHHS) for advising the nation on matters related to public health science, and comprises 12 core public health offices and the Commissioned Corps.⁶ The Assistant Secretary for Health (ASH) serves as the Secretary for Health’s primary adviser on matters involving the nation’s public health and science; provides strategic direction for OPHS with the implementation, management, and development of activities related to public health and science; and communicates these issues to the country. A primary role of the ASH is to lead and direct the U.S. Public Health Service (PHS), which includes the Office of the Surgeon General. The more than 6,000 uniformed officers of the PHS are the nation’s lead public health professionals charged with advancing public health science. They deliver national public health promotion and disease prevention programs in health-care and public health organizations across the country. The mission of the PHS is to protect, promote, and advance the health and safety of the nation. Underscoring this goal are the PHS values that emphasize leadership, service, integrity, and excellence.

OPHS plays a critical role in promoting the transfer, integration, and application of public health knowledge throughout the system. As OPHS fulfills this function, a primary goal is to utilize a systems approach to ensure system-wide effectiveness. Achieving system-wide effectiveness is, however, contingent upon mainstreaming concepts for QI throughout the entire public health system. Quality concepts must become embedded into the practice, management, and governance of public health.

Given the necessity of creating this culture for quality, OPHS has taken a leadership role by initiating a national movement for quality in public health. Under the direction of the ASH, two key groups were formed and charged with establishing tools to guide QI in public health. Members of the Public Health Quality Forum (PHQF) include agency heads and staff in leadership roles from across DHHS, including two officers of the U.S. Commissioned Corps. Invited guests at the initial meeting in May 2008 included partners representing the governmental public health system (Association of State and Territorial Health Officials, National Association of County and City Health Officials, and National Association of Local Boards of Health), the American Public Health Association, and the Robert Wood Johnson Foundation.

Officers of the Commissioned Corps also serve on the Public Health Quality Task Force (PHQTF) and that initial meeting was also held in May 2008. The PHQF is focused on the broader public health system, while the specific goal of the PHQTF is to develop QI tools for the PHS. Dr. Garth Graham, Deputy Assistant Secretary for Minority Health, an officer of the PHS, serves as executive director of both groups. Framing goals of the PHQF and PHQTF are recommendations from the 1998 President’s Commission on Consumer Protection and Quality in the Health Care Industry. The Commission called on all segments of health care to embrace QI and support that commitment with the identification of goals for improvement. Based in part on those recommendations, the specific charge to the PHQF and PHQTF is to develop:

A consensus statement and set of aims for QI in public health;
A framework to guide and standardize QI efforts;
Priority areas for QI in the public health system; and
A core set of quality indicators in each of the priority areas.

QI is a value-adding function. While the value of public health is obvious to dedicated public health professionals, too often it is a struggle to communicate this to policy makers and the public. Out of this inability to succinctly demonstrate the value of public health should emerge a sense of urgency to aggressively move toward implementing quality concepts.

Integrity implies that any serious commitment must be aligned with goals. The pioneering work of the PHQF and PHQTF has progressed with eagerness and synergy. Given this commitment to quality, goals for the development and implementation of continuous QI are being woven across organizational boundaries. The guiding coalition of enthusiastic partners that has formed is serving as a catalyst for implementation of quality concepts in the system. The initial reports to communicate the vision and to frame efforts for QI were completed in August 2008. These QI tools articulate quality characteristics that should be present in public health to achieve improved performance and outcomes at all levels in the system. Advance copies of the quality documents can be requested by e-mailing peggy.honore@hhs.gov or wakina.scott@hhs.gov.

ADM Joxel Garcia, MD, MBA
Assistant Secretary for Health, Office of the Assistant Secretary
for Health, U.S. Department of Health and Human Services

References

Institute of Medicine. The future of public health. Washington: National Academy Press; 1988.
International Organization for Standardization. The ISO story: key markers in ISO’s history [cited 2008 Jun 1]. Available from: URL: http://www.iso.org/iso/about/the_iso_story.htm
Baldridge National Quality Award. The Malcolm Baldridge National Quality Improvement Act of 1987, Public Law 100-107; 2001 [cited 2008 Jun 2]. Available from: URL: http://www.quality.nist.gov/ Improvement_Act.htm
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.
Department of Health and Human Services (US). Office of Public Health and Science [cited 2008 Jul 23]. Available from: URL: http://www.hhs.gov/ophs
Office of Disease Prevention and Health Promotion (US). Healthy People 2010 [cited 2008 Jul 23]. Available from: URL: http://www.healthypeople.gov