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CELEBRATING TWENTY YEARS IN “The Future of Public Health” OPPORTUNITIES FOR TOMORROW’S LEADERSHIP . Ned Baker Annual Lecture, NALBOH Bowling Green, Ohio April 3, 2008. CELEBRATING TWENTY YEARS IN ‘THE FUTURE OF PUBLIC HEALTH’. Hugh H. Tilson MD, DrPH Public Health Leadership Program

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Celebrating twenty years in the future of public health opportunities for tomorrow s leadership l.jpg

CELEBRATING TWENTY YEARS IN “The Future of Public Health” OPPORTUNITIES FOR TOMORROW’S LEADERSHIP

Ned Baker Annual Lecture, NALBOH

Bowling Green, Ohio

April 3, 2008


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CELEBRATING TWENTY YEARS IN ‘THE FUTURE OF PUBLIC HEALTH’

Hugh H. Tilson MD, DrPH

Public Health Leadership Program

UNC School of Public Health and

Member of the Panel, IOM, 1988


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But FIRST … a word about the Health of the Public in the 21st Century“The Future of the Public’s Health” 2003

A Report from the Institute of Medicine Follow-up Study of the 1988 “Future of Public Health” and its implications for NALBOH’s Public Health Leadership


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T 21st CenturyHEFUTUREOF

THE PUBLIC’S HEALTH

in the 21st Century

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

Committee on Assuring the Health of the Public in the 21st Century


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What’s “ASSURING”?? 21st CenturyWhaddya’ mean “keeping pace”? In THIS mess?



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The National Academies time … could not be CANCELLED!!

The National Academy of Sciences (1863)

The National Research Council (1916)

The National Academy of Engineering (1964)

The Institute of Medicine (1970)


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Why a new study about time … could not be CANCELLED!! the future of public health?

NOT BECAUSE THE ‘OLD’ REPORT WAS WRONG


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Why a new study about time … could not be CANCELLED!! the future of public health?

NOT BECAUSE THE ‘OLD’ REPORT WAS WRONG …IN FACT, IT IS ‘EVERGREEN’!!




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Why a new study about 1988the future of public health?

NOT BECAUSE THE ‘OLD’ REPORT WAS WRONG … IT IS ‘EVERGREEN’!! And DEFINITELY worth a careful look


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The LANDMARK report on the “Future of the Public Health” IOM 1988: BACKGROUND

--The Swine Flu fiasco of 1976

--The Model Standards for Community Preventive Health Services weak response

--The inability of the local infrastructure to respond to the Model Standards

--The crumbling of Federal support

--The politicization of the Federal Public Health leadership


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The 1988 Panel IOM 1988: BACKGROUND

21 of the Brightest and the Best (plus me)

All the right domains represented

All the public health professions

Elected officials

Superb high level professional staffing

Adequate resources … Kellogg, CDC, HRSA funding


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The 1988 Report: the approach IOM 1988: BACKGROUND

“check your assumptions at the door”

Used classic social science methods … broad fact finding, literature reviews, expert testimony, and field site visits

Asked: what is your definition of public health

Used: “tracers”: what was the problem, what did you do about it, who made it happen?


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1988: The Big News IOM 1988: BACKGROUND

“… this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into DISARRAY!”


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1988: the critical re-conception of public health IOM 1988: BACKGROUND

“The committee defines the mission of public health as fulfilling society’s interest in assuring conditions in which people can be healthy”

“The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance”


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1988: the Core Functions IOM 1988: BACKGROUND

Assessment: … regularly and systematically collect, assemble, analyze, and make available information on the health of the community …

Policy Development: … Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process


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1988: The core functions IOM 1988: BACKGROUND

Assurance: … assure their constituents that services necessary to achieve agreed upon goals are provided … encouraging actions by other entities …. Requiring such action through regulation, or by providing services directly

… a set of high-priority personal and communitywide health services that governments will guarantee to every member …


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IOM 1988: Recommendations IOM 1988: BACKGROUND

States: “… are and must be the central force in public health”

Localities: “no citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system.” “the AGPALL” concept


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1988: Fulfilling the Government Role: Implementing Recommendations

Statutes: … reform; delineate responsibilities and authorities and a core set of functions

Organizational Structure: … an identifiable state department of public health … state health council .,.. Establish standards for local public health functions


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1988: Organizational Structure Recommendations

Localities: “… the larger the population served by a single multipurpose government, as well as the stronger the history of local control, the more realistic … promote local accountability


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1988: Organizational Structure Recommendations

Localities: “… the larger the population served by a single multipurpose government, as well as the stronger the history of local control …… clear focal point: “where the scale of local government activity permits, localities should establish public health councils to report to elected officials on local health needs and on the performance of the local health agency.”

(NOTE TO NALBOH … what happened THREE years after this recommendation?)


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1988: Special linkages Recommendations

Environmental health

Mental Health

Social Services

Care of the indigent: “… until adequate federal action is forthcoming, public health agencies must continue to serve …to the best of their ability, the priority personal health care needs of the uninsured, underinsured, and Medicaid clients.”


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1988: Strategies for Capacity Building Recommendations

Technical: uniform data set; Institutional home for new knowledge; research

Political: relationships with elected officials; competence in community relations; working partnerships and support among local, state, and national medical and professional societies …


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1988: Strategies for Capacity Building Recommendations

Managerial: … training … on managerial and leadership skills; demonstrated management competence … should be a requirement; salaries and benefits

Programmatic: … more emphasis on “factors that influence health-related behavior …”

Fiscal: … Fed to State and State to local, with incentives and sanctions


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1988: Education for Public Health Recommendations

Schools … firm practice links; resources to governments; students “an opportunity to learn the entire scope of public health practice”; research … applied and implementation; full advantage of other faculties; full support to other faculties

Education programs … should be informed by comprehensive and current data on public health personnel…”


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Why a new study about Recommendations the future of public health ?

2000: IOM commissioned a systematic review of progress as part of its commitment to follow-through.

Progress was dramatic on every front. However, challenges and frustrations abounded as well.

IO


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Why a new study about Recommendations the future of public health ?

IOM commissioned a systematic review: PROGRESS is IMPRESSIVE

Conceptualization: The public health working group and the ten essential services

Organization: NACCHO, NALBOH, Council on Linkages

Workforce: PHLI, Management Academy

IO


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Why a new study about Recommendations the future of public health in 2000-2003?

Still, due to the rapidly changing (“flat”) world, public health systems were under greater stress than ever before

Additionally, these changes bring increasingly diverse demands, expectations, opportunities, and resources for public health

Oh, yes … and then there’s the MONEY $$$$$$$$$$$$$$$$$$$



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Why a new study about Recommendations the future of public health in 2003?

And then came September 11th …

And the Anthrax attacks that followed … that changed ‘everything’

… and for the IOM Committee, the urgency for a report to galvanize to concerted action was CLEAR


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Why talk about a twenty year old and a five year old study about the future of public health HERE/NOW?

…because the Nation and States need help from our leadership …a.k.a. YOU !


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But first... about

a word from

our sponsors!


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Centers for Disease Control and Prevention (CDC) about

Substance Abuse and Mental Health Services Administration (SAMHSA)

Health Resources and Services Administration (HRSA)

National Institutes of Health (NIH)

Office of the Secretary, Assistant Secretary for Planning and Evaluation (OS/ASPE)

Office of Disease Prevention and Health Promotion (ODPHP)

The 2003 study sponsors


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Assuring the Health of the Public about in the 21st Century

Who?


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Jo Ivey Boufford about

Christine Cassel

Kaye Bender

Lisa Berkman

JudyAnn Bigby

Thomas Burke

Mark Finucane

George Flores

Lawrence Gostin

Pablo Hernandez

Judith Lave

John Lumpkin

Patricia Peyser

George Strait

Thomas Valente

Patricia Wahl

Gail Warden

Hugh Tilson (Liaison)

George Isham (Liaison)

The 2003 Committee


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Assuring the Health of the Public about in the 21st Century

Who?

What?

When?

Where?

How?



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Methodology TODAY …

Literature review on all relevant topics

Hearings and expert testimony at Committee meetings

Input from the Committee’s Liaison Panel and from the general public

Qualitative and quantitative data from

  • Federal, state, and local public health systems

  • State and local community organizations

  • National and professional organizations

    Site visits

    Futures visioning and scenario building



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Futures visioning and TODAY …scenario building

The committee examined the drivers, or the forces that are likely to shape the future, and used “visioning” to generate scenarios, or potential realities for which public health must be prepared.


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Futures visioning and TODAY …scenario building

The committee ascertained the drivers, or the forces that are likely to shape the future, and used visioning to generate scenarios, or potential realities for which public health must be prepared. .. AND a great way for YOU to LEAD, too”


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Some important “drivers” of population health TODAY …

Changes in the environment

Disparities in health status and access to care

Infectious disease threats

Globalization

A social and political environment that prioritizes health

Advances in biotechnology and information technology


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Some important “drivers” of population health TODAY …

Changes in the environment

Disparities in health status and access to care

Infectious disease threats

Including MAN-MADE ONES!!

Globalization

A social and political environment that prioritizes health

Advances in biotechnology and information technology


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Public health TODAY …is preparing for whatever comes next.


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Some important “drivers” of population health TODAY …

Changes in the environment

Disparities in health status and access to care

Infectious disease threats

Including MAN-MADE ONES!!

Globalization

A social and political environment that prioritizes health

Advances in biotechnology and information technology

glumbert/media/shift


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T TODAY …HEFUTUREOF

THE PUBLIC’S HEALTH

in the 21st Century

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

WWW.NAP.EDU


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The Context for the Report TODAY …

  • 1988 report is ‘evergreen’ and there is GREAT National Health Achievement in the 20th Century BUT …

  • US falling short in international comparisons

  • Poor return on investment in health

  • Concern about the government public health infrastructure’s ability to meet future health challenges, both local and global


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Background in the Report TODAY …

  • Health = Public Good

  • Government has fundamental, statutory duty to assure the health of the public


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Background in the Report TODAY …

  • Health = Public Good

  • “Without Health there can be no happiness” (attributed to Thomas Jefferson IOM p xi)

  • Government has fundamental, statutory duty to assure the health of the public


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Background in the Report TODAY …

  • Health = Public Good

  • Government has fundamental, statutory duty to assure the health of the public, BUT …

  • Government cannot do it alone

  • Need for inter-sectoral engagement in partnership with government (the 1988 report mission statement is indeed EVERGREEN!)

  • Health = social goal of many sectors and communities

  • The root causes of ill health must be addressed by many outside the public health system


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The Committee’s Conclusion TODAY …

  • An inter-sectoral public health system is needed

  • In 1988 report, public health refers to the “organized efforts of society, both government AND OTHERS, to assure conditions in which people can be healthy”

  • THIS report elaborates on the efforts of the other potential public health system actors.


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The Committee’s Vision TODAY …

  • The committee adopts as its vision the vision of Healthy People 2010: Healthy People in Healthy Communities

  • NOTE: The committee explicitly elected NOT to ‘re-discover the wheel’ … a good principle to keep the pace!


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MAJOR opportunities for NALBOH from the 1988 and 2003 IOM Reports

  • The SYSTEM components and their roles

  • The TEN Essential Services

  • Core Competencies

  • Public Health SYSTEM Performance Standards

  • Certification

  • Accreditation



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The Official Public Health Agency Infrastructure report

The Community

The Private Sector/Industry

The Medical Care System

The Media

Academia

The Committee’s Conception: The Public Health SYSTEM!!


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What is the Public Health System? report

Health

care delivery system

  • More than just the public health agency

  • “Public health system”

    • All public, private, and voluntary entities that contribute to the delivery of public health services within a jurisdiction.

Community

Assuring the Conditions for Population

Health

Governmental

Public Health Infrastructure

Employers

and Business

Academia

The Media

(IOM, 2003)


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The Public Health System … report

  • … GREAT progress since 1988

  • …”Despite this progress, the Committee found that in many important ways, the public health system that was in disarray in 1988 remains in disarray today.”


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The Public Health System … report

  • And so how can NALBOH’s members help public health agencies to gain the status, recognition, and respect to lead the system while we must “run the business…”?



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Monitor health status SERVICE”??

Diagnose and investigate health problems

Inform and educate

Mobilize communities to address health problems

Develop policies and plans

Enforce laws and regulations

Link people to needed health services

Assure a competent health services workforce

Evaluate health services

Conduct research for new innovations

The Essential Public Health Services building on 1988


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THE TEN Essential Services SERVICE”??

  • Monitor health status …

  • Diagnose and investigate health problems ..

  • Inform, educate and empower people …

  • Mobilize community partnerships …

  • Develop policies and plans that ….

  • “My Day Is Made Pushing …”


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THE TEN Essential Services (cont) SERVICE”??

  • Enforce laws and regulations …

  • Link people to needed personal health svcs..

  • Assure a Competent public health AND personal health care workforce

  • Evaluate effectiveness, accessibility and quality of personal and population based Services

  • Research for new insights and innovative solutions to health problems

  • …”Everything Likely to Win Some Resources!!”



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THE EIGHT Core Competencies COMPETENCY”??(Council on Linkages building on 1988)

  • Analytic/Assessment Skills

  • Policy Development/program planning

  • Communication

  • Cultural Competency

  • Community Dimensions of Practice

  • Basic Public Health Sciences

  • Financial Planning and Management

  • Leadership and Systems Thinking


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THE EIGHT Core Competencies COMPETENCY”??and CERTIFICATION

  • What are the credentials needed to work in the public health system?

  • How can these be tied to competencies?

  • How should we go about documenting competency to practice?

  • If “certification”, how should we certify, and whom, and for what?


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THE EIGHT Core Competencies COMPETENCY”??and CERTIFICATION

  • What are the credentials needed to work in the public health system?

  • How can these be tied to competencies?

  • How should we go about documenting competency to practice?

  • If “certification”, how should we certify, and whom, and for what?

  • What challenges lie ahead for the “American Board of Public Health”?


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THE EIGHT Core Competencies COMPETENCY”??and CERTIFICATION

  • AND MOST IMPORTANT: HOW CAN WE DO ALL OF THIS WHILE ADDRESSING THE CRITICAL WORKFORCE SHORTAGE FOR PUBLIC HEALTH IN THE DECADE AHEAD??



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The National PH Performance Standards Program(NPHPSP) building directly on the Model Standards in the 1988 report

  • THREE “instruments”

  • OMB approved with ‘control numbers’

  • STATE

  • LOCAL

  • GOVERNANCE


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Four Concepts Applied in building directly on the Model Standards in the 1988 reportNPHPSP

  • Based on the ten Essential Public Health Services

  • Focus on the overall public health system

  • Describe an optimal level of performance

  • Support a process of quality improvement


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The local public health system assessment instrument building directly on the Model Standards in the 1988 report

  • OMB Control Number 0920-0555

  • 24 hours per response

  • “…ALL entities that contribute to the delivery …”


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The local public health system assessment instrument building directly on the Model Standards in the 1988 report

  • “How much of this Model Standard is achieved by the local PHS collectively?”

  • What percent of the answer reported in Q 1 is the direct contribution of the local PH agency?


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The local public health system assessment instrument building directly on the Model Standards in the 1988 report

  • For the LPHS … asks about GOVERNANCE

  • For the GOVERNANCE instrument, critical issues to NALBOH include …


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Mobilizing for Action building directly on the Model Standards in the 1988 report throughPlanning and Partnerships (MAPP)

  • Developed by NACCHO and CDC

  • Based on the 1988 recommendations, development began in 1996, released in 2001

  • Community strategic planning tool

  • Web-based tool – www.naccho.org


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NPHPSP and MAPP building directly on the Model Standards in the 1988 report

  • NPHPSP Local Instrument used within MAPP to assess public health system capacity

  • MAPP provides the process for addressing weaknesses and building on strengths


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NACCHO Operational Definition of a Functional Local Health Department

  • Co-funded by CDC and RWJF

  • Goal: Shared understanding of what people can reasonably expect from LHDs

  • Builds on the “AGPALL” 1988

  • Framed around the ten Essential Services but presented in more common language

  • Accommodates variety in LHD structure and governance


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DepartmentPublic health is a complex concept, but the operational definition can help dispel the mystery. Eventually public health can be recognized and valued even when—particularly when—things are going well.”

Susan Gerard

Director, Arizona Department of Health Services



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IOM a meaningful identifiable BRAND Reports 1988/2003 – National Catalyst for Accreditation

  • Establish a “national commission to explore accreditation”

  • Further states…

    • “This (accreditation) commission should focus on the development of a system that will further the efforts of NPHPSP.”


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Building on the 1988 recommendations: Exploring Accreditation

  • Co-funded by CDC and RWJF

  • Jointly led by NACCHO, ASTHO, NALBOH and APHA

  • Informed by the Multi-State Learning Collaborative

  • Model addressed governance, standards, financing and incentives, and evaluation

  • Model for voluntary accreditation developed and approved

Accreditation for state and local health departments is both desirable and feasible!


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THE TEN Essential Services (cont) Accreditation

  • Enforce laws and regulations …

  • Link people to needed personal health svcs..

  • Assure a Competent public health AND personal health care workforce

  • Evaluate effectiveness, accessibility and quality of personal and population based Services

  • Research for new insights and innovative solutions to health problems

  • Oh, yes … and number ELEVEN: Governance and management of heath department resources


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Public health system assessment instruments and A CCREDITATION

  • Can achievement of a “passing grade” on a performance assessment be used for accreditation?

  • How should WHO accredit WHOM and HOW? (not to mention WHY?)


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Public health system assessment instruments and ACCREDITATION

  • Can achievement of a “passing grade” on a performance assessment be used for accreditation?

  • How should WHO accredit WHOM and HOW? (not to mention WHY?)

  • SEE: “Exploring Accreditation” and CDC’s NPHPSP website


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Public health system assessment instruments and ACCREDITATION

  • AND MOST IMPORTANT, HOW CAN WE KEEP ON TOP OF THE SPECIFIC HEALTH CHALLENGES WHILE WE TEND TO THE INFRASTRUCTURE??


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LEADERSHIP Questions for NALBOH: ACCREDITATIONHow can Essential Services, Competencies, and Performance Standards inform accreditation and certification? Especially NOW!!


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Essential Services=Essential, Competencies=Unique and necessary, and Performance Standards and a new formulation can inform advocacy for public health!Especially NOW!!


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Sometimes the best way to lead progress is to take a moment to look back

SO … let’s celebrate twenty years of “the future”



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T 1988HEFUTUREOF

THE PUBLIC’S HEALTH

in the 21st Century

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

… and FIVE years into Assuring the Health of the Public in the 21st Century


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The best way to predict the future is to CREATE it. (P 1988Drucker)

SO .. LET’S TALK… NALBOH’s leadership counts!!!


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THANKS! 1988



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The Public Health System: What We Don’t Know but YOU can help us to find out!!

  • RESEARCH … the tenth “essential service” … ie not someone else’s job

  • Public Health Systems Research … much in need of help but enormous progress (Council on Linkages!)

  • FAILURE to collect the evidence base precludes evidence-based policy

  • (witness the IOM report)


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The Public Health System: What We Don’t Know but YOU can help us to find out!!

  • What is the optimal allocation of responsibilities among partners?

  • What is the appropriate funding formula for the system?

  • What is the minimal staffing for a competent local official health agency?

  • What is the minimum size below which an efficient/effective infrastructure is not possible?


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The Public Health System: help us to find out!!What We Don’t Know

  • What is the largest population to be served and still be ‘local’?

  • What is the optimal mix of disciplines or competencies in the competent agency?

  • How far is too far away for a local agency?

  • What is the appropriate or optimal relationship between the State Health Agency and the local official agency(ies)?


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The Public Health System: help us to find out!!What We Don’t Know but YOU need to help with!

  • What do we know about governance and what do we need to know? How does this differ across the “five … or is it more? … Americas”

  • What is the evidence for best performance from a Local Agency or Board of Health?

  • How many jurisdictions can a local agency manage or a board of health “govern”?

  • How can public health most effectively relate to local general purpose government?


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Ahead of the pace … “Who will Keep the Public Healthy?”

  • The PIPELINE is dangerously empty and the audience is dangerously “graying”

  • SO: we needed to assess the past and current state of training and education for public health professionals and develop recommendations for strengthening public health education


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Companion Study Healthy?”“Who will keep the Public Healthy?”

  • Utilize recommendations and other information from the Assuring the Health report

  • Ten-year look forward


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Companion Study Healthy?”“Who will keep the Public Healthy?

  • Kristine Gebbie Mark Cullen

  • Linda Rosenstock Bob Goodman

  • Susan Allan Alan Guttmacher

  • Kaye Bender Rita Kukafka

  • Dan Blazer Sheila Smythe

  • Scott Burris Roxanne Parrott


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Companion Study Healthy?”“Educating Public Health Professionals for the 21st Century”

  • Process and development of recommendations similar to “Future of the Public’s Health” study

  • Final Report issued on November 4 and ‘launched’ at APHA in the late fall 2002!


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Companion Study Healthy?”“Educating Public Health Professionals for the 21st Century”

  • A MODEL of health that emphasizes the linkages and relationships among multiple factors (or determinants) affecting health is an ECOLOGICAL MODEL”


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“Educating Public Health Professionals for the 21 Healthy?”st Century”KEY Recommendations

  • SIX major responsibilities: Educate the leaders; focal point for Transdisciplinary Research; contribute to policy; collaborate with other schools for public health content; life-long learning; engage actively with various communities to improve the public’s health


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“Who will Keep the Public Healthy?” Keep the basics; ADD Eight new competencies

  • Epidemiology, Statistics, Health Policy, Environmental Health, Social and Behavioral Sciences

  • Informatics, genomics, communication, cultural competence, community based participatory research , global health, policy and law and public health ethics


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“Educating Public Health Professionals for the 21 ADD Eight new competenciesst Century”KEY Recommendations

  • Primary Educational Mission: the preparation of individuals for positions of senior responsibility

  • Emphasize the centrality of the ECOLOGIC Approach

  • NEW competencies in genomics, communications, leadership, policy, law and ethics


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“Who will Keep the Public Healthy?” For EACH of the Eight new content areas

  • Competencies be identified;

  • Each area be included in graduate level public health education;

  • Continuing development and creation of new knowledge be pursued; and

  • Opportunity for specialization be offered.


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NALBOH … a ‘closing keynote’ … a new time of Eight new content areasoppor-TUNE-ity

  • G-minor: Gee, there are certainly some minor problems (ahem!!) getting there

  • B-flat: Be flat-out proud of what our field and this state have already accomplished

  • B-sharp: There are wonderful opportunities ahead, but it will take a trained eye to see them in the current context

  • C-major!!


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The best way to keep pace with progress is to be ahead of it!!

SO .. LET’S TALK… YOUR leadership counts!!!


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After all, Public Health is a work in progress... it!!

I want to hear from YOU

NOW … and always!

[email protected]


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