Oregon Performance Assessments

Document Sample
Oregon Performance Assessments Powered By Docstoc
					Oregon Department of Human
          Services
     State Public Health

              Sponsored By
Robert Wood Johnson‟s Turning Point Project




   Oregon Public Health
   System Assessment

              Final Report
              March 2004



         Milne & Associates, LLC
                           Table of Contents

Executive Summary                                                             3

Background & Methodology                                                      4

NPHPSP Assessment of 9 Local Public Health Systems
Conclusions, Recommendations & Next Steps                                     6

Legal Review: State Statues and Administrative Rules                          14
Oregon Revised Statues
Issues for Administrative Rules Action

Appendices                                                                    16
I.    Charter                                                                 17
II.   Oversight Committee Roster                                              21
III. Roster of Participating Counties                                         23
IV. Minutes from the Oversight Committee Meetings                             25
V.    Scope of Work                                                           39
VI. Summary of Conference Call with Counties 2/27/04                          41
VII. Supplemental Questions & Report                                          45
VIII. Evaluation Results                                                      50

IX.     Final Statute & Administrative Code Revisions & Recommendations

X.      Composite Reports
XI.     Comparison of Oregon and Colorado
XII.    Priorities of Essential Services & Indicators
XIII.   Parking Lot Issues & Themes




                                                                          2
                        Executive Summary

The Oregon State Public Health Office (OSPHO) received funding from
Turning Point for the Public Health System Assessment Project, and
contracted with Milne & Associates, LLC, (M&A) to perform the work. An
Oversight Committee was convened, adopted a charter to define its role and
operations, and met five times to review project work and recommendations.

Nine county health departments were selected to participate in the
performance assessment portion of the project. The assessment was
performed using CDC‟s National Public Health Performance Standards tool
with several questions added to reflect portions of the Oregon Public Health
Minimum Standards and the Department of Human Services Performance
Measures not covered by the national tool. The assessments were facilitated
on site in each of the 9 counties by M&A, and were completed in January,
2004. In each case, a number of community partners participated in the
assessment, and expressed interest in partnering to make improvements in
their local public health systems. Analysis of the results of the assessments
was performed by M&A and is included in the text of this report. At the
conclusion of each assessment, M&A entered the results on-line into CDC‟s
scoring database for NPHPSP. Individual county results were available shortly
after the data entry, and were shared with the respective health department
administrators who, in turn, shared the results with their staff and partners.
Overall, strengths were demonstrated in diagnosing and responding to public
health diseases and threats, and in enforcement of laws and regulations. All
areas of the assessment included findings where improvements are needed.

M&A subcontracted with Larry Gostin, LLD, and James Hodge, LLD, of the
Georgetown-Johns Hopkins Joint Center for Law and the Public‟s Health to
conduct the review and analysis. They reviewed of all Oregon statutes and
administrative code, comparing them with the Turning Point Model Act to
identify gaps in Oregon law. Additionally, Keith Kutler, JD, and Rhea Kessler,
JD, both on staff at Oregon‟s Department of Justice, reviewed the Gostin-
Hodge work and offered additional comments. The Oversight Committee
reviewed recommendations for action, and narrowed the issues for legislative
action to three. Several other issues were identified and may be addressed
through the promulgation of rules. The principal finding of this portion of the
project is that Oregon is, by and large, well served by its existing statutes and
administrative code.




                                                                               3
Background & Methodology
The Oregon State Public Health Office (OSPHO) received funding from
Turning Point for the Public Health System Assessment Project, and
contracted with Milne & Associates, LLC, (M&A) to perform and guide the
work. See Appendix V for Scope of Work.

The objectives of the project were to:
    1. Convene an Oversight Committee and staff regular meetings of the
        committee, whose purpose was to provide general project guidance
    2. To solicit the participation of a minimum of 6 local health
        departments (LHDs) that were representative of the state‟s system of
        LHDs
    3. To analyze current Oregon law and rules compared with the Turning
        Point Model Public Health Act.
    4. To develop an assessment tool and work plan for assessing the
        participating LHDs capacities and performance
    5. To facilitate completion of an assessment of the participating LHDs
    6. To analyze the completed assessments
    7. To provide a report to OSPHO which
          a. Identifies gaps in the current, statutorily required Minimum
              Standards for Oregon‟s LHDs
          b. Makes specific recommendations for changes in the Minimum
              Standards
          c. Identifies gaps in local services as identified by the assessment
          d. Describes strengths and weaknesses in Oregon law and rules
              compared to the Model Act
          e. Makes recommendations for changes in Oregon law and rules

Oversight Committee: The committee was convened in October, adopted a
charter to define its role and operations, and conducted meetings in
December 2003, February 2004 and March 2004. A copy of the Charter can
be found in Appendix I. The committee is co-chaired by Dr. Grant Higginson,
State Health Officer, and Dr. Alan Melnick, Health Officer for Clackamas
County and representative of the Oregon Conference of Local Health Officials.
A listing of committee members with affiliations is found in Appendix II.
Copies of minutes from all the Oversight Committee Meetings is found in
Appendix IV.

Solicitation of LHDs: M&A sent a letter to all of Oregon‟s 36 LHDs, describing
the project and inviting them to indicate their interest in participating in the
assessment portion of the project. Responses expressing interest were
received from 9 county health departments. At the recommendation of the
Oversight Committee, a rural health department was recruited. Final


                                                                               4
selection was made for nine of the 10 volunteer LHDs. A listing of the
participant health departments is found in Appendix III.

Law Analysis: M&A subcontracted with Larry Gostin, LLD, and James Hodge,
LLD, of the Georgetown-Johns Hopkins Center for Law and the Public‟s Health
to conduct the review and analysis. Reviews have been completed of all
Oregon statutes and administrative code, and have constructed matrices
comparing the Model Act with what is covered (and not covered) by Oregon‟s
laws and regulations. The Oversight Committee considered the commentary
on the statutes on February 20. Additionally, Keith Kutler, JD, on staff at
Oregon‟s Department of Justice and a participant in Turning Point activities in
the past, has reviewed the Gostin-Hodge work and offered additional
comments. The two co-chairs of the project, along with James Hodge and
Keith Kutler, gave a brief presentation to a hearing before the Oregon
legislatures Joint Committee on Human Services on January 20 at the State
Capitol in Salem. The purpose of the presentation was to inform the
legislators of the work underway and of the potential for legislative remedy
for gaps found through the review. A gap analysis was completed which
narrowed and prioritized the findings to those of most significance. Finally
these priorities were brought to the March 19 meeting of the Oversight
Committee for discussion and approval. The final report received from
Gostin-Hodge (with comments from Keith Kutler) is included in Appendix IX.

Assessment Tool: M&A began with the assumption that CDC‟s National Public
Health Performance Standards Program (NPHPSP) tool would be the most
desirable tool to use for the assessment of the LHDs. They conducted a
comparison of the NPHPSP content with the recently revised Oregon
Minimum Public Health Standards, and identified a few standards from the
latter that aren‟t covered adequately by NPHPSP. Additionally, the Oversight
Committee requested that appropriate measures from the Oregon
Performance Measures be added. With those additions, the Oversight
Committee agreed on use of NPHPSP to complete the assessment.

Assessment of LHDs: Assessments for each of the 9 LHDs is completed, and
all data is entered in CDC‟s database. The dates the assessments were
performed are included in Appendix III. Prior to the assessments, a half day
training for representatives from the LHDs was provided by CDC along with
M&A. M&A provided materials to the LHD‟s administrator, and encouraged
that he or she invite community partners to participate in the day-long
assessment. Several conference calls were conducted with representatives of
the LHDs to explain the process and review the materials. Each assessment
was facilitated by two representatives from M&A, and each of the sessions
was evaluated by the participants. The average attendance at the sessions
was approximately 18, which compares most favorably with the national


                                                                             5
experience with local assessments. See Appendix VI for Summary of
Conference Call with Counties 2/27/04. See Appendix VII for Supplemental
Questions & Report.

Analysis of Assessments: At the conclusion of each assessment, M&A entered
the results on-line into CDC‟s scoring database for NPHPSP. Individual county
results were available shortly after the data entry, and were shared with the
respective health department administrators who, in turn, shared the results
with staff and partners. Composite reports were also shared with the
Oversight Committee as well as all participating counties. See Appendix X for
the full Composite Report, Appendix XI for Comparison of Oregon and
Colorado, Appendix XII Priorities of Essential Services, Appendix VIII for
Evaluation of Results, Appendix XIII for Parking Lot Issues.




                                                                            6
Conclusions, Recommendations & Next Steps:
Local Assessments
Process: In general, the assessments went well in all nine communities. In
each case, a number of local partners participated in the session. Combined
with LHD staff, the number of participants ranged from a low of 15 and a
high of 28 people. In all cases, most of the participants were from outside
the health department. In nearly every case, the leadership of the health
department present at the session participated actively and demonstrated
strong knowledge of public health. (LHD leadership participated only
sparingly and seemed unsure in only one of the sites.)

In most of the communities, participation in the session was well balanced,
with active involvement of local partners. In most, shared leadership on a
variety of public health issues was in clear evidence.

Nearly all of the administrators have indicated that they plan to follow up with
their community partners, sharing the results and planning how to address a
number of public health system issues that arose during the assessment (the
“parking lot issues”)

Strengths: Those essential services that are most consistently and
adequately financed, monitored and measured consistently received the
highest scores across all participating counties. Those included the following:
a.        Diagnose and Investigate Health Problems (Essential Service #2).
Many of the indicators in this category cover emergency preparedness
activities, which are supported through federal Bioterrorism funding. (Score:
93.6)
b.        Enforce Laws and Regulations (Essential Service #6). Statute and
ordinance enforcement is typically supported through a variety of fees at the
local level. (Score: 89.8)

Areas in Need of Improvement: Services that are not consistently funded,
monitored, measured and/or those which require community collaboration
were found to be inconsistently implemented and vary in quality and
comprehensiveness. Included among these were the following:
a.       Mobilizing Community Partnerships (Essential Service #4) received
the lowest rating of the essential services (Mean score: 52.9). Inasmuch as
the emerging paradigm for public health relies heavily on involvement of the
community, this finding is of concern. An indicator under this essential
service, “Partnerships”, rated 2nd lowest of all indicators, with a score of 35.0.
b.       Monitor Health Status (Essential Service #1) was among the lowest
of the essential services overall with a score of 59.5. Many of the indicators
associated with this essential service rely on development of a community


                                                                                 7
health profile, which virtually none have completed (score: 53.4). Even more
significantly, the indicator “technology” as part of this essential service
received one of the very lowest indicator scores at 39.4.
c.       Develop Policies and Plans (Essential Service #5) was generally weak
across all LHDs, with an overall score of 62.1. One of the indicators under
this category, “Health Improvement,” calls for development of a community
health improvement plan. This indicator received the lowest rating overall
with a score of 30.1.
d.       Evaluate Effectiveness, Accessibility and Quality (Essential Service
#9) had the 2nd lowest rating among the 10 essential services at 59.3. Of
some concern was the low score received for “Evaluation of the Public Health
System” indicator, 49.2. Such work is of importance in assessing and
improving collaborative relationships.

Effect of Size of Public Health Systems: Comparisons of results have been
made between three cohorts of “public health systems:”
1. Those serving fewer than 100,000 residents (3 counties)
2. Those serving between 100,000 and 350,000 residents (3 counties)
3. Those serving more than 300,000 residents (3 counties)

Overall, the scores on the essential services among three cohorts is similar.
However, there are some noteworthy differences, particularly among
individual indicators, briefly summarized below.
a. Larger systems
    Relative strengths: greater access to academia, surveillance capacity
    Challenges: community partnerships, health promotion
b. Medium-sized systems
    Relative strengths: health education/promotion, evaluation of personal
       health services
    Challenges: policy development/planning, research
c.       Smallest populated systems:
    Relative strengths: constituency development, training, policy
       development
    Challenges: technology, research capacity

State Minimum Standards and Performance Measures: As noted above,
supplemental questions were added to the national tool to assure full
coverage of the Minimum Standards and the Department‟s Performance
Measures. While a few were fully met by individual counties, none of the
counties fully achieved all of the standards or measures. One standard
(confidentiality) is fully met by all 9 of the LHDs, while two performance
measures (track teen pregnancies; track immunization rates of infants) were
fully met by all. Four LHDs scored 3.5 (on a 4.0 scale) or higher overall for




                                                                                8
the minimum standards, while 5 LHDs scored 3.5 or higher overall on the
performance measures.

The two minimum standards with the lowest scores were (1) investigation of
deaths (2.8) and soliciting feedback on enforcement (2.6). Scores on 5 of
the performance measures were below 3.0, and the two lowest were (1)
Health education to prevent adolescent suicide (2.2) and tracking the percent
of adult over 65 years of age who are fully immunized (2.0).

Performance Measurement Results: Based on conversations M&A have held
with local health officials, most are planning to follow the assessment process
with work in their communities. The process in all will start with sharing the
assessment results with the partners who participated in the process.

Three levels of focus for future work seem to have evolved from the review
of the assessment results:

1. Internal Department Improvement: Needs identified in this category
include strengthening health department capacity and the performance of
health department staff; leadership and vision within the health departments,
changing mindsets about what should constitute the principal focus areas for
local public health (more emphasis on populations-based services); and
restructuring for success. Since there are similar needs across the state, this
category is particularly well-suited for the development of regional or state-
wide “improvement collaboratives” where locals could work together to
improve practice.

2. The Community Level: Issues in this category include strengthening
collaboration with community partners; “formalizing” the community public
health system; developing extended leadership among community partners
for public health issues; increasing coordination of activities to, for example,
formalize a community resource guide/directory; creation of an integrated
community profile; and development of a community public health
improvement plan.

3. The State-Local Interface: To maximize the potential for success, it is of
critical importance that the assets, capacities, roles and strengths of the state
and local health departments are aligned and complement each other, and
that leadership perspectives are aligned as well. Once the state completes
the NPHPSP Assessment (May), the LHDs are interested in reviewing the
results of both the state and local assessments, and in working with the state
to assure that in places where locals are weak, that the state has capacity, as
well as the reverse. The results of this process may show that, to achieve




                                                                                   9
maximal effectiveness state-wide, there may need to be some shifting of
responsibilities and roles.

The NPHPSP assessment was demonstrated to be an excellent tool for
identifying the overall performance the public health system that communities
have in place. The results of assessments are best used as markers for
improvement and are not intended to represent an academic or objective
research-based indicator. Participants universally reported success in bringing
community players together and increasing their collective understanding of
public health practice. They also reported it provided information on areas for
improvement that are critical to assuring the core functions of public health
are adequately addressed.

Recommendations:

1. Support follow-up in each of the counties where the assessments were
completed. Most are planning such follow-up, which is important in order to
take full advantage of the assessments and the community involvement in
the assessment process. State or other assistance will be needed with the
following:
     Interpreting the results/scores from their assessment and in developing
       strategies for improvement. This support could come in the form of
       workshops, emails/listserves, group meetings, conference calls, sharing
       of resources, challenges and lessons learned.
     Providing data from other locations around the country, preferably by
       size and demographic groupings, to provide some basis for comparison
       with national performance (CDC has indicated they are working on this
       and hope to have results by the end of Spring 2004)
     Convening a process for local health departments (and perhaps the
       state) to work together to improve public health practice, based on the
       findings from the local and state assessments. This might be
       accomplished through a special task force of CLHO or a state-
       sponsored committee that focuses on state-wide improvements in the
       public health system
     Complete a review and analysis of the listing, by category, of parking
       lot issues from all counties compiled during their assessments

2. Expand the reach of the assessment, completing the performance
assessment process in the remaining 27 counties. Achieving some measure
of consistency within the public health system in Oregon will be dependent
upon strengthening all components of the system. Activities which should be
considered include the following:




                                                                            10
    Convening once or twice a year with CLHO to update other counties on
     the progress, challenges and lessons learned. This would provide
     opportunities to seek the involvement of other LHDs.
    Identify funds to support completion of the assessment by the
     remaining counties (M&A are looking for resources to accomplish this;
     according to the CDC Guidance, BT money can be used to complete
     the NPHPSP and/or MAPP. Colorado is using BT funds for dual use 1)
     improving preparedness and 2) improving public health practice.

3. Develop strategies to strengthen leadership and vision among local health
officials and their partners. While many good and capable people work in the
public health system at present, there is a demonstrable need to assist the
growth and future orientation of some current leaders and to develop the
leadership “pipeline” for the future.

4. Recommend working with CLHO to consider changing Oregon‟s Public
Health Minimum Standards to match the National Public Health Performance
Standards. The national standards are based on the Ten Essential Services of
Public Health, which are in themselves national standards, both in terms of
nomenclature and content. Oregon‟s Minimum Standards use a different
nomenclature (“Essential Functions”), and the standards themselves are
different from the national standards, and in some places are significantly
different. Absent a clear logic for employing separate standards and
nomenclature, it is recommended that they be changed to match the national
model.


Next Steps:

The contract between the Oregon State Public Health Office and Milne &
Associates ends in March. However, Milne & Associates will be doing the
following:
1. Provide a final report to the state.
2. Make a presentation to CLHO members and interested others about the
project, lessons learned and possible next steps.
3. Continue the search for additional resources (to supplement county and
state BT funding) in order to
     Provide technical assistance to the 9 counties for data interpretation
       and for their “next steps”
     Complete the assessment in eventually all Oregon counties
     Create a resource in Oregon or the NW region for improving public
       health practice




                                                                               11
In conclusion, M&A are of the strong opinion that the assessment process
was a very valuable and useful exercise for each of the communities that
experienced it. The scores, while helpful as benchmarks for future work and
references, are really of secondary importance. In the first place, the tool
comprises a set of "optimal" standards which are intended to be difficult if not
impossible to fully achieve. But most importantly, the process in each of the
counties brought people together, resulted in increased understanding among
community partners about the role and importance of public health, and
invariably led to a number of "a-ha's" that will lead to further collaboration
and progress. The future effectiveness of public health is absolutely
dependent upon community collaboration and ownership, particularly in the
current environment of economic challenges. The quality and dedication of
the local health department staff and community partners was a bright spot
throughout this project. Their collective optimism that improvement can be
achieved bodes well for the health of Oregonians.




                                                                             12
NPHPSP Local Assessments by
County
For information and or specific results on the NPHPSP local assessments,
please contact the counties directly.

County                                     Date of Assessment
Jackson County                             December 1, 2003
Hood River County                          December 8, 2003
Washington County                          December 9, 2003
Multnomah County                           December 15, 2003
Deschutes County                           January 6, 2004
Grant County                               January 8, 2004
Linn County                                January 13, 2004
Clackamas County                           January 26, 2004
Benton County                              January 28, 2004




                                                                           13
    Legal Review: State Statues and Administrative Rules

                             Oregon Revised Statutes
                                 PUBLIC HEALTH
    Final Recommendations for Legislative Action from 3/19/04 Meeting

                  Action                                           Notes
1, Add a requirement to adopt appropriate     The legislature will need to understand how
national standards for public health          this differs from the Oregon Benchmarks.
performance management (Model Act 3-          Include language specifying that
103)                                          implementation would be “subject to the
                                              availability of funds.”

2. Add definitions of “Conditions of Public   It was agreed to move this recommendation
Health Importance and add parameters for      forward, but not suggesting changes for local
the exercise of public health powers (Model   authorization, only for state authorization to
Act 5-101)                                    address all preventable diseases, adding
                                              similar authorizing language presently in
                                              place for local health departments:
                                              “…including without limitation preventable
                                              diseases…”

3. Add authorization for administrative       Current statutory language does not
searches and inspections related to vector    authorize health departments to gain access
control, sewage contamination (Model Act      to private property where there are
5-112)                                        suspected public health hazards. Keith
                                              recommended the language tie to
                                              communicable diseases.


Issues NOT to be Considered for Further Legislative Action

                   Issue                                          Notes
1. Add a mission statement for public         Has been challenged in the past. Suggested
health (Model Act 2-101                       that a conversation occur with Sen. Morisette
                                              on this issue before completely eliminating it
                                              from further consideration.

2. Multnomah County Issue re Quarantine       Issue resolved
and Isolation (Model Act 5-108)

3. Health information release restrictions    Issue not suited for legislative action.
on State Laboratory


                                                                                         14
Issues with Potential for Future Legislative Action

  1. Consider statutory authority to cover priority areas which currently rely on
     the “full power” clause, including:
        a. Information Practices (also referred to as “surveillance”) (TP 5-102)
        b. Reporting (TP 5-103)
        c. Counseling & Referral (Partner Notification) (TP 5-105)
        d. Vaccinations (other than schools) (TP 5-109)

  2. Consider recommendations from Task Force studying improvements to
     public health practice efficacy (some of which may have economic
     implications)
        a. Public Health Infrastructure (TP 3-101)
        b. Leadership (TP 3-102)
        c. Training (TP 3-102)
        d. Credentialing (TP 3-102)
        e. Accreditation (TP 3-104)
        f. Incentives (TP 3-105)




Issues for Administrative Rules Action

  1. Consider full alignment of the Oregon Public Health Minimum Standards
     with the Ten Essential Services of Public Health. (TP 2-102)

  2. Create a task force to consider strategies for improving the efficacy of
     public health in Oregon (TP 3-102, 3-104, 3-105)

  3. Consider, after consultation with the respective licensing boards, rules
     requiring reporting by veterinarians and pharmacists (TP 5-103)

  4. Research security of medical records for persons who have legal capacity to
     consent for medical care (TP 7-105)




                                                                                15
Appendices




             16
                                Appendix I
                   Oregon Department of Human Services
                            State Public Health
              Oregon Public Health System Assessment
                             CHARTER
                                  Approved 12/03

Background
Nationally, the practice of public health has changed substantially over the past
decade. The framework of practice has evolved from “ill-defined” to that defined
by the “core functions” (as elaborated by the Institute of Medicine) and the
“essential services of public health” (as developed by the National Public Health
Functions Steering Committee, chaired by the U.S. Surgeon General). The
framework is now well established and has been broadly implemented at the local,
state, and federal levels. The core functions and essential services describe in non-
programmatic, population level ways activities which comprise a fully functioning
public health system, encompassing work on communicable disease, maternal and
child health, chronic diseases, environmental health, accident prevention, public
health emergency preparedness, and the full gamut of programs and services.
Performance standards for public health practice that are consistent with the
framework have been developed, competencies have been defined, and workforce
development focused within the framework is a national focal point.

While much of this work was well underway before September 11, 2001, national
concern about the risks of bioterrorism and other public health emergencies such
as West Nile Virus and SARS have led to increased attention and interest in
assuring that an adequate public health system is in place across the country. The
implications of national security have added both funding and increased
responsibilities to the nation‟s state and local health departments.

All of these and many other changes that are underway nationally have
implications for the organization, financing, and workforce aspects, as well as the
legal underpinnings of public health. In this environment, it is of critical
importance that the Oregon public health system be well-positioned to address
tomorrow‟s requirements and challenges.


Mission
To plan and implement a statewide assessment initiative which measures capacity
and performance of the state‟s local health departments in addressing state and
national standards, identifies gaps in statutorily required standards, and assures
that the statues and regulations governing public health in Oregon are adequate
and appropriate to address current and emerging issues.



                                                                                  17
Vision
The capacity and performance of local health departments serving Oregon‟s
citizens meet or exceed state and federal standards; the system of statutes and
regulations which governs public health practice in Oregon is consistent in scope
and content with a national model act, further assuring that Oregon‟s citizens
enjoy full protection from disease, injury, and disability. All residents and guests in
Oregon are served by a highly efficacious public health system.


Objectives of the Project:
o To determine the general capacity and level of performance of local health
  departments in Oregon through the assessment of a subset of local health
  departments using the National Public Health Performance Standards Program
  or a tool more specific to public health in Oregon
o To create a means of identifying and sharing strengths, best practices, and
  emerging practices in public health within Oregon
o To determine gaps in the current system, using the statutorily required
  Minimum Standards for Oregon local health departments as well as the
  National Public Health Performance Standards Program (NPHPSP)
o To identify deficiencies and changes needed in Oregon Law and Rules by
  comparing the state‟s public health laws to a nationally developed “Model
  Public Health Act”

Oversight Committee:

 Objectives:

   An oversight committee will be convened by the Department. The specific
   objectives of the committee include:
      1. To review and provide comment and advice on the proposed project
          methodology
      2. To review and offer comments on the selection of participating local
          health departments, on findings from the assessment of local health
          departments, and on draft recommendations regarding changes in
          Oregon law which are needed to assure high performance of the public
          health system
      3. To provide advice regarding expansion of the assessment to include all
          local health departments
      4. To provide evaluation commentary at the conclusion of the project.

 Membership:

   The oversight committee membership shall include the following:


                                                                                     18
     1. External members (5), including representatives of OMA, the hospital
        association, academia, and the legislature
     2. Local Public Health (3), as appointed by the Conference of Local Health
        Officials and one of whom will co-chair.
     3. State (3), including the state health officer (co-chair), and other
        representatives appointed by the Department of Human Services.

Values:

 Participants in the project, including the Oversight Committee, staff,
 contractors, and participating local health department representatives, are
 encouraged to subscribe to and act congruently with the following values:
    o We treat each other with respect
    o We actively commit to developing and using evidence based public
         health practices, acknowledging the importance of utilizing good data in
         measuring performance and assessing our legal underpinnings
    o We understand that the diversity of our public health agencies requires
         multiple strategies to achieve high quality public health services and
         activities (i.e. “one size does not fit all”)
    o We understand that, to be effective, our communities must be active
         partners in the work we do and in our efforts to improve the quality of
         public health activities and services
    o We support an environment of continuous learning (including quality
         improvement approaches) which shares lessons learned and is not
         punitive in nature
    o We recognize the necessity to work together to share our collective
         wisdom and experience, to share our weaknesses and failures, and to
         share data descriptive of both as essential learning aids
    o We work for the overall good of the people we serve

Responsibilities of the Oversight Committee

 The committee will function in an advisory capacity for the Oregon Public
 Health System Assessment Project, providing review and recommendations
 with regard to the project methodology, analyses of findings, and the final
 recommendations for action. The committee will consider activities and
 recommendations regarding both the assessment of local health department
 performance and the review and findings regarding the legal mandates defining
 Oregon‟s public health system and practices. The Oversight Committee will
 meet four times between late September, 2003, and March, 2004.




                                                                               19
Meeting Schedule (Revised 10/17/03)

Each meeting will be held in Portland (with the possible exception of the March,
2004 meeting) and will be between 2 and 4 hours in duration.

Date, Time and Location     Focus

October 17,2003             Review of project methodology and work plan,
                            draft Charter, and applicant local health
                            departments
December 17, 2003            Preliminary report of law review progress
 Afternoon                     (materials in advance, subcontractor
 State Office Bldg,            presents)
Portland                     update on LHD assessments
                             Presentation on project in other states

February 20, 2004            Review of LHD assessments and data
 Morning                     Consideration of draft legal recommendations
 State Office Bldg,           for legislative and/or administrative action
Portland
March 19, 2004              Review final recommendations; determine next
 Morning                    steps:
 (Possibly Salem, near or       Legislature
    in State Capitol)           State
 Advance Press Release          LHD/CLHO
 Bring Governor in              Dissemination of information/report
                                Funding for 2nd Phase of Project
                                Future role of Advisory Committee
                            Evaluation of the project




                                                                                   20
                            Appendix II
               PROJECT OVERSIGHT COMMITTEE MEMBERS


Oregon Medical Assn. Representative
Robert Gluckman, MD
Providence Health Systems
Portland OR 97225

OAHHS Representative
Kent Ballantyne
Oregon Association of Hospitals & Health Systems
Lake Oswego OR 97034

Conference of Local Health Officals Representatives (4)
Anne Peltier, RN, MPH
Linn County Department of Health Services
Albany OR 97321

Alan Melnick, MD, MPH, Co-Chair
Clackamas County Health Services
Portland OR 97201

Georganne Greene
Curry County Health Department
Gold Beach OR 97444

Karen Gillette
Lane County Health & Human Services
Eugene OR 97401

Dept. of Human Services Representatives
Grant Higginson, Co-chair
Office of the State Public Health Officer
Department of Human Services
Portland OR 97232

Mel Kohn, MD
Office of Disease Prevention & Epidemiology
Department of Human Services
Portland OR 97232




                                                          21
Donalda Dodson, RN
Office of Family Health
Department of Human Services
Portland OR 97232

Liana Winett, DrPH, CHES
Oregon MPH Program
Portland, OR 97207-0751

Public Health Advisory Board Representative
Gloria English
Salem OR 97310

Legislative Representation (3)
Senator Bill Morrisette
Springfield OR 97477

Representative Alan Bates
Ashland OR 97520

Representative Jeff Kruse
Roseburg OR 97070




                                              22
                                APPENDIX III

              PARTICIPATING LOCAL HEALTH DEPARTMENTS
                      With Dates of Assessments

Benton County Health Department            January 28
Tom Eversole
Administrator

Charlie Fautin
Project Liaison

Clackamas County Health Services           January 26
Marina Stansell
Director

Alan Melnick, Health Officer

Deschutes County Health Department         January 6
Daniel Peddycord
Administrator

Grant County Health Office/FPC             January 8
Karen Triplett
Administrator

David Cary
Project Liaison

Hood River County Health Dept              December 8
Ellen Larsen
Director

Jackson Co Health/Human Srvs               December 1
Henry W. Collins, Jr.
Health Director

Viki Barbour
Nursing Director

Gary Stevens
Environmental Health Director




                                                        23
Linn County Health Department         January 13
Frank Moore
Administrator

Anne Peltier
Nursing Director


Multnomah County Health Department    December 15
Lillian Shirley
Director

Consuelo Saragoza, MPA
Project Liaison

Bonnie Kostelecky
Project Liaison

Washington County Department of Health and Human Services
Susan Irwin
Director                               December 9

Roberta Hellman
Nursing Director




                                                            24
                                Appendix IV
                 Oregon Public Health System Assessment
                      Oversight Committee Meeting
                            October 17, 2003

                                Meeting Notes

Participants:
 Committee Members:
 Alan Melnick, MD, CLHO, Co-Chair     Grant Higginson, MD, MPH, DHS, Co-Chair
 Kent Ballantyne, OAHH                 Anne Peltier, CLHO
 Georganne Green, CLHO                 Karen Gillette, CLHO
 Mel Kohn, MD, DHS                     Donalda Dodson, DHS
 Peggy Pederson, OMPHP                 Gloria English, PHAB
 Sen. Bill Morrisette                  Rep. Jeff Kruse

  Others:
  Marti Franc, Clackamas County HD
  Dan Peddycord, Deschutes County HD
  Roberta Hellman, Washington County HD
  Tom Engle, DHS
  Sue Cameron, Milne & Associates
  Casey Milne, Milne & Associates
  Tom Milne, Milne & Associates

Opening:
 Co-chair Grant Higginson opened the meeting with a brief overview of the
 project, its purposes and rationale. Members and other participants then
 introduced themselves.

Committee Charge:
 Co-chair Higginson led a discussion of the draft charter for the oversight
 committee. The following changes in the draft were agreed to and will be
 incorporated into the document and sent out electronically:
    1. The background section should be expanded to broaden the context
        beyond communicable diseases, to include environmental health and
        other aspects of public health.
    2. Revise the project objectives, inserting a new 2nd bullet: To create a
        means of identifying and sharing strengths, best practices, and emerging
        practices.”
    3. Revise objective #1, changing “or a locally developed tool” to “or a more
        state-specific tool.”




                                                                               25
  Committee Meeting Dates, times, locations:
   It was agreed that the draft meeting schedule and agendas for future meetings
   would be revised as follows:

Date, time, and Location       Focus
December 17, 2003               Preliminary report of law review progress
 Afternoon                       (materials in advance, subcontractor presents)
 State Office Bldg, Portland    update on LHD assessments (LHD participation
                                 encouraged)
                                Presentation on project in other states

February 20, 2004               Review of LHD assessments and data
 Morning                        Consideration of draft legal recommendations for
 State Office Bldg, Portland     legislative and/or administrative action

March 19, 2004               Review final recommendations; determine next
 Morning                     steps:
 (Possibly Salem, near or in     Legislature
    State Capitol)               State
 Advance Press Release           LHD/CLHO
 Bring Governor in               Dissemination of information/report
                                 Funding for 2nd Phase of Project
                                 Future role of Advisory Committee
                             Evaluation of the project


  Overview of National Public Health Performance Standards:
   Joyce Essien, MD, MBA, represented the Centers for Disease Control (CDC),
   Public Health Practice Program Office, and reviewed the development and
   content of the national performance program. She noted that health department
   (both state and local) capacity, competence, and performance are the essential
   components of efficacy. She made the following recommendations/comments:
      o Each local health department (LHD) should identify its principal
          stakeholders in advance, and invite them to participate in the assessment
      o Each stakeholder should contribute to the assessment relative to their
          assets and contributions to the “public health system”
      o Once the assessment sheets are completed, they will be scored by CDC;
          each LHD will receive a report including graphical display of the
          assessment results (“scores”) often within 48 hours of submission
      o Maximum benefit will be achieved if all LHDs, the state health department,
          and local boards of health complete their respective performance
          assessment tools



                                                                                    26
     o It is recommended that local assessments be facilitated by external third
       parties to help assure full and candid responses to the assessment
       questions
     o After the LHD receives the results from CDC, it is recommended that a
       local planning group be convened to take the information into an action
       mode, working to improve local performance. It is recommended that the
       management element of this be considered in advance
     o Members of the Oversight committee, participating LHDs and the State
       health department should find a review of the Turning Point document
       “From Silos to Systems” very useful in follow-up work to the assessment
     o Public Health Foundation (www.phf.org) tools relative to the essential
       services of public health, performance measures, etc., are also very useful

Discussion of Tool:
  Sen. Morisette: Concerned about the tool; would prefer a series of small
    steps with more immediate outcomes and accountability measures
  Rep. Kruse: Interested in knowing more about the “sticks and carrots” that
    drive MAPP and Healthy People 2010.
  Dr. Higginson: For now, our focus is on assessment. We can consider
    implementation at the last meeting of the committee
  Dr. Essien: Capturing content of the dialogue around each of the
    performance measures during the assessment is probably more important
    than the “score”

Performance Assessment of Oregon LHDs:
 Dr. Higginson discussed the assessment process, listed the 8 counties that will be
 assessed by Milne & Associates and noted that two additional, Klamath and Linn,
 will be assessed by the state. He discussed the Oregon Public Health Minimum
 Standards, and the Milne group discussed the differences between the minimum
 standards and the national tool. Dr. Higginson discussed each of 4 options that
 staff recommended for committee review to select a tool to be used to conduct
 the assessment for this project.

Decision re Tool to be Used:
 After discussion of four options for the tool to be used in the assessment, it was
 agreed to select option #3, “Use the NPHPSP tool and add „drill-down‟
 questions.” It was suggested that staff will review the Oregon Minimum Public
 Health Standards, and add questions to those national standards that don‟t
 reflect Oregon‟s “evidence of success.” Sen. Morisette suggested that staff also
 consider whether Oregon‟s Minimum Standards, adopted by the state legislature,
 “measure the right things.”




                                                                                 27
 Discussion followed regarding whether adequate LHD representation is included
 in the 10 counties agreeing to the assessment. It was suggested that a coastal
 county and a rural county without a hospital be added.

Legal Review:
 The Milnes described the process to be used in having the ORS and OAR
 pertaining to public health reviewed. A subcontract for the majority of this work
 has been made with Larry Gostin, JD, chair of the Georgetown University Center
 for Public Health Law. Two associates, James Hodge, JD and Webb Hubbell, JD,
 will assist with the review. They will begin by comparing the ORS to a “Model
 Public Health Act” developed through a national Turning Point collaborative over
 the past 3 years. It was noted that Keith Kutler of the Oregon Department of
 Justice, has agreed to review the preliminary recommendations to assure there
 are no unanticipated conflicts with other ORS.

 It was suggested that, in order for the legal recommendations to have enough
 time for pre-session processing, that they be presented in December if at all
 possible. It was agreed that if that is not possible, that the committee should
 consider a January meeting, possibly rescheduling the February meeting to late
 January, to consider the recommendations. It was also suggested that Keith
 Kutler and Bill Taylor (House Judiciary staff) be invited to both the December and
 February meetings.

Commentary:
  Donalda Dodson suggested that the next meeting materials include a sample
   of how such an assessment of LHDs has gone in one or two other states
   regarding the environment, what happened, outcomes.
  Both co-chairs, Drs. Melnick and Higginson, thanked the committee members
   for their participation and noted that representatives of the 10 local health
   departments would be meeting this afternoon to begin the process.




                                                                                28
                 Oregon Public Health System Assessment
                      Oversight Committee Meeting
                          December 17, 2003
                              Meeting Notes

Participants:
 Committee Members:
 Alan Melnick, MD, MPH, CLHO, Co-Chair
 Grant Higginson, MD, MPH, DHS, Co-Chair
 Bob Gluckman, MD, OMA              Anne Peltier, CLHO
 Georganne Green, CLHO                       Karen Gillette, CLHO
  Liana Winett, DrPH, OMPH Program Peggy Pederson, OMPHP
  Gloria English, PHAB              Lisa Millet (for Mel Kohn, DHS)

  Others:
  Roberta Hellman, Washington County HD
  Tom Engle, DHS
  Keith Kutler, JD, DOJ
  Consuelo Saragoza, Multnomah County HD
  Sandra Zeleuka, DHS
  Casey Milne, Milne & Associates
  Tom Milne, Milne & Associates

 By Telephone:
 Sue Cameron, Milne & Associates
 Ellen Larsen, Hood River Health Department
 Marina Stansell, Clackamas County Health Department
 James Hodge, JD, Johns Hopkins Center for Law & the Public's Health

Opening:
 Co-chair Alan Melnick opened the meeting at 1:15 pm and called for
 introductions of those present and on the telephone.

 A motion to accept the minutes from the October 17, 2003 meeting was made,
 seconded, and passed unanimously.

 A motion to adopt the Project Charter as revised (and distributed in advance of
 the meeting) was made, seconded and passed unanimously.

Project Component #1: Assessment of Local Health Departments:
 The Assessment Tool: Co-Chair Grant Higginson described the assessment tool
 which is being used. It comprises CDC‟s National Public Health Performance
 Standards Program assessment tool, as written, with 8 questions added to cover
 the Oregon Minimum Standards which are not addressed by the national tool,


                                                                                   29
 and 17 questions added to cover relevant areas of the Oregon State Performance
 Measures which are not addressed by the national tool. The latter were added
 at the suggestion of Oversight Committee member Senator Bill Morrisette at the
 October meeting.

 Progress: Co-Chair Alan Melnick reported that assessments have been
 completed in four counties: Jackson County, Hood River County, Washington
 County, and Multnomah County. He noted that a conference call had been held
 on December 16, and included participation of representatives of the health
 departments which have completed the assessments as well as of the health
 departments which are scheduled for assessments. Issues discussed included
 the need for glossaries of words and phrases used, how to determine who to
 invite from the community, what information may be deemed “proprietary” by
 hospitals and other community partners, and the recommendation to include
 commissioners in the assessments.

 Representatives from Hood River, Washington, and Multnomah Counties
 provided feedback to the Oversight Committee regarding the experience. All
 found the assessment very useful in a variety of ways. Relationships with
 community partners were strengthened, needs for better data were identified,
 new initiatives were suggested, an increased understanding of public health was
 gained by community participants, and in one county, plans have been made to
 create a public health advisory board as a result of the assessment.

Project Component #2: The Assessment of Oregon Statutes and
Regulations:
 James Hodge, JD, called in to provide an update of progress of the statute
 review, which has been nearly completed. He explained that the Robert Wood
 Johnson-funded Turning Point Project included development of a Model Public
 Health Act, which is now in final form, and which he and Larry Gostin, JD, led in
 the development. The Act serves as a template for the review and
 recommendations for changes needed in state statutes and regulations. He
 emphasized that the legal underpinnings of public health practice are critical for
 achieving the work of public health. James followed his introductory remarks
 with several observations from the ORS review, which included:
     Inadequate inclusion of the Essential Services of Public Health
     Poor coverage of public health infrastructure in the statutes
     Prevention and Control of Conditions is framed better by the Model act,
        while the ORS don‟t include some of the specific functions. Most notably,
        Surveillance is very poorly covered by the ORS. There are no provisions
        to create a surveillance system, or for partner notification. No
        authorization exists for vaccinations of other than school-aged children.
     Public Health nuisances are not covered by the ORS




                                                                                 30
       While Oregon is one of 32 states that have adopted statutes about public
        health emergencies, there is no provision for an emergency plan
       There are no provisions in ORS to acquire public health information

 James acknowledged that some provisions may be included under Oregon
 Administrative law, but suggested that the statutes have more authority. He
 noted that a review of the OARs will occur next.

 Keith Kutler, from the Oregon Dept. of Justice, noted that he has communicated
 with James and Larry Gostin. He indicated that a goal is to determine what
 legislative changes are needed. James and Larry will identify possible gaps,
 while Keith and Rhea Kessler will determine if an argument can be made—and
 how strong the argument is—that the gap needs to be addressed by legislation.
 Then, the Oversight Committee would be called on to weigh both the gaps and
 the arguments for addressing them and decide what recommendations to make.

 Keith noted that regarding the OAR, there may be more of a legislative
 imprimatur than is found for administrative law in other states because proposed
 rules must go to the legislature for determination of whether or not they are
 authorized. He suggested that the OAR be reviewed where there are gaps in the
 ORS to determine of the gaps are covered by the OAR.

 Grant Higginson indicated that he would distribute the matrix reviewing the ORS,
 as provided by James, to the program people in state public health for review.

 Grant noted that the Joint Interim Health and Human Services Committee of the
 legislature is meeting on January 20, and has requested a presentation regarding
 the statute assessment. Total time available is 30 minutes. He suggested that
 an informal meeting of the Oversight Committee be held in conjunction with the
 committee meeting for those members who are able to attend, noting that no
 policy decisions would be made. Brief presentations would be made by Alan,
 Grant, Keith, and James. Program people from the state would be invited to
 participate for the longer committee meeting (it was suggested that the program
 people provide regulatory comments of relevance to Keith in advance of the
 meeting). It was also suggested that representative from local health
 departments and/or CLHO, including representative of the health departments
 which have completed the assessments, be invited as well.

Next Steps:
     1. The Council agreed to support completion of the state version of the
        national assessment tool, perhaps by the end of March, suggesting that
        the same facilitators be used.
     2. The Council recommended that the assessments be conducted on the
        remaining county health departments after the first set are completed.


                                                                                 31
        The Council recommended that the resources needed to accomplish that
        be sought from whatever sources are available, and that for consistency,
        the same facilitators be used if possible.
     3. Any continuing role of the Oversight Committee, once the project is
        completed, would need to be discussed.

Next Meeting:
 The next meeting of the Oversight Committee is scheduled for February 20 in the
 morning. The agenda will include the legal recommendations, and review of
 data from the assessment of local health departments.
 Co-chair Alan Melnick adjourned the meeting at 4:15 pm.




                                                                              32
                    Oregon Public Health System Assessment
                         Oversight Committee Meeting
                              February 20, 2004

                                   Meeting Minutes

Participants:
 Committee Members:
 Alan Melnick, MD, CLHO, Co-Chair
 Gloria English, PHAB
 Karen Gillette, CLHO
 Liana Winett, DrPH, Oregon MPH Program

  Others:
  Consuelo Saragoza, Multnomah County HD
  Roberta Hellman, Washington County HD
  Keith Kutler, Oregon Dept. of Justice
  Tom Engle, DHS
  Katy King, DHS
  Sue Cameron, Milne & Associates
  Casey Milne, Milne & Associates
  Tom Milne, Milne & Associates

Opening:
Alan Melnick convened the meeting at 1:15 p.m. He noted that co-chair Grant Higginson
had been detained by another meeting. The minutes were approved as written, and the
agenda was reviewed and approved. Alan noted that the next meeting of the Oversight
Committee, March 19, will be the last meeting unless the mission of the organization is
revised.

Legislative Timing:
Katy explained that it would be very helpful to have the legislative concepts soon, by April
1 to be safe. Keith indicated that there remains a need to do intensive review, item by
item, before recommendations can be generated. Katy responded that another option is
to have the legislators on the Oversight Committee introduce the bill. She will also talk
with the Governor‟s office to see if a placeholder can be set.

County Performance Assessments:
Casey Milne provided a general overview of results from the assessment of 9 local health
departments, all of which are now completed. The input of county data from the
assessments has been completed, and reports have been generated for all of the health
departments; charges from an aggregate report were shared. In general, the
performance scores were highest for indicators related to “Diagnose and Investigate
Health Problems” and to “Enforce Laws and Regulations,” and lowest for indicators related
to “Mobilizing Community Partnerships” and “Monitor Health Status.” She noted that
Milne & Associates would do a more analysis and present the final report at the next
meeting.



                                                                                          33
Law Review:
Tom Milne gave a brief overview of “law” related materials in the packet, noting that the
review of statutes discussed at the last meeting with James Hodge (by phone) had gone
through the next level of review, with Keith Kutler and Rhea Kessler from DOJ providing
additional commentary. Additionally, Hodge and Larry Gostin (Center for the Public‟s
Health and the Law, Georgetown University) completed a review of the Oregon
Administrative Rules, comparing them with the statutes against a model Public Health Act.
That work is under review by Kutler and Kessler.

Keith indicated that Rhea has noted that the Department of Agriculture and DEQ statutes
cover some of the gaps identified by the first task completed by Hodge. He said that once
we define “what is a gap”, the next step will be to determine if it can be filled by rule. He
suggested that there is a pretty high likelihood all or most gaps can be filled by Rules, as
the Department has broad administrative authority.

Alan suggested that a matrix be devised, building on the one developed by Hodge, to
include the following information:

Model Statute          ORS               OAR              Gaps         Recommendation

A meeting is being held on March 4th to review the gaps and draft recommendations for
consideration of the Oversight Committee at its next meeting. It was also mentioned that
CLHO has a subcommittee to give feedback to the law portion of this project.

State Assessment:
The recommendation from the last meeting of the Oversight Committee was for the state
to conduct a performance assessment, using the CDC tool for state departments of health.
Milne & Associates have been invited to submit a proposal to conduct the work, due March
12. The assessment likely would occur in May, 2004. It was suggested that oversight of
that review would be a logical role for the Oversight Committee. General interest was
expressed in continuing in an oversight capacity, but is was recognized that (1) very few
members of the committee were present today, and (2) the current project ends March
31. This issue will be discussed at the March 19 meeting.

Next Meeting:
The next (and final) meeting of the Oversight Committee is scheduled for March 19, from
9:00 am to noon. It was agreed to conduct the meeting in Portland at the State Office
Building, 800 N.E. Oregon.

Adjournment:
The meeting was adjourned at 2:25 p.m.




                                                                                          34
                 Oregon Public Health System Assessment
                      Oversight Committee Meeting
                             March 19, 2004

                             Draft Meeting Notes

Participants:
 Committee Members:
 Grant Higginson, MD, DHS, Co-Chair
  Alan Melnick, MD, CLHO, Co-Chair
  Anne Peltier, CLHO, Lane County
  Donalda Dodson, DHS
  Bob Gluckman, OMA
  Gloria English, PHAB (by phone)
  Karen Gillette, CLHO (by phone)
  Liana Winett, DrPH, Oregon MPH Program (by phone)

  Others:
  Keith Kutler, Oregon Dept. of Justice
  Ellen Larsen, CLHO, Hood River County
  Katy King, DHS
  Consuelo Saragoza, Multnomah County HD
  Sue Cameron, Milne & Associates
  Casey Milne, Milne & Associates
  Tom Milne, Milne & Associates

Opening:
Grant Higginson convened the meeting at 9:09 a.m. The minutes were approved
as written, and the agenda was reviewed and approved. Grant noted that the
meeting would be the last for the Oversight Committee unless action taken today
extends the committee.

Legislative Changes Proposed:
As proposed at the February 20 meeting, a subcommittee comprising Grant, Alan,
Keith, Sue, Casey, and Tom met two weeks prior to today‟s meeting to review the
findings and recommendations of contractors James Hodge and Larry Gostin, and
to develop recommendations for the Oversight Committee. Six recommendations
for possible legislative change and 4 suggestions for administrative (rule) change
were forwarded. Grant noted that full back-up information on all issues is
available at the meeting and on request from the Milne‟s. Summaries of discussion
about the legislative recommendations follows with the corresponding Turning
Point Model Act reference in parenthesis.




                                                                                35
1. Add a mission statement for public health (Model Act 2-101): This
   recommendation was made to define clear parameters for public health‟s
   role in the state, and to avoid confusing cross-connections with other state
   offices and departments. During discussion, it was noted that there is
   reluctance in the legislature to set “policy” in statute, and that prior
   attempts to insert a mission statement have been opposed by a variety of
   groups who were uncertain of the purpose of such a statement. It was also
   noted that the “related” clause (i.e. anything related to public health…) is
   troublesome in this context. Brief discussion followed about putting a
   mission statement into rule, but the “risk” there is the same. No consensus
   was reached on moving this forward, but it was agreed to ask Sen.
   Morisette for his perspective. Until that happens, this recommendation is
   off the table.

2. Add a requirement to adopt appropriate national standards for public health
   performance management (Model Act 3-103): It was noted that even
   without a mission statement, a performance management system would
   define what the legislature expects from public health. It was also noted
   that the legislature will need to understand how this differs from the
   Oregon Benchmarks. It was agreed to move this recommendation forward
   with the provision that language be included specifying that implementation
   would be “subject to the availability of funds.”

3. Add definitions of “Conditions of Public Health Importance and add
   parameters for the exercise of public health powers (Model Act 5-101):
   Keith explained that by spelling out the “condition,” the legislature knows
   what authorization they are granting. After discussion of 431.416, it was
   agreed that the gap is with state authorization to address all preventable
   diseases. Language similar to that covering local health departments
   (“…including without limitation preventable diseases…”) is needed for the
   state. It was agreed to move this recommendation forward, but not
   suggesting changes for local authorization, only for state authorization to
   address all preventable diseases.

4. Multnomah County Issue re Quarantine and Isolation (Model Act 5-108):
   Keith researched this issue with the Multnomah County prosecutor. A 2003
   amendment allows local health departments to quarantine property but
   provides no provisions for each person inside the property to seek remedy
   for their release. They agreed that 433.019, Writ of Habeas Corpus, covers
   this and no additional language is needed. The issue will go no further.

5. Add authorization for administrative searches and inspections related to
   vector control, sewage contamination (Model Act 5-112): Current statutory
   language does not authorize health departments to gain access to private


                                                                                 36
      property where there are suspected public health hazards. Keith
      recommended the language tie to communicable diseases. The group
      agreed to move this recommendation forward for legislative consideration.

   6. Health information release restrictions on State Laboratory. The issue
      raised by Laboratory Director Mike Skeels is that HIPAA doesn‟t provide for
      the release of negative laboratory results, only positive results. It was
      suggested that Mike work with Linda Grim, and that ASTHO might be a
      resource. No further action was contemplated at this time.

The issues to be considered for administrative actions were briefly summarized.
They include the following:

   5. Consider full alignment of the Oregon Public Health Minimum Standards
      with the Ten Essential Services of Public Health. (TP 2-102)

   6. Create a task force to consider strategies for improving the efficacy of
      public health in Oregon (TP 3-102, 3-104, 3-105)

   7. Consider, after consultation with the respective licensing boards, rules
      requiring reporting by veterinarians and pharmacists (TP 5-103)

   8. Research security of medical records for persons who have legal capacity to
      consent for medical care (TP 7-105)

Grant indicated that he would carry these back to the offices within state public
health for consideration and to determine what next steps will be taken. Grant
concluded this discussion saying he will be pleased to go back to the legislature
and say that, after a comprehensive review of the statutes and administrative
code, the state of Oregon has solid public health laws.

County Performance Assessments:
The three representatives from contractor Milne & Associates, LLC, presented
findings from the assessments of the 9 local public health systems, discussing the
aggregate scoring, strengths and weaknesses. The data will be summarized in a
final report, to be submitted to the OHSPH by the end of the month. A summary
provided for this meeting has been distributed to members of the Oversight
Committee. It was also noted that responses to the supplemental questions,
added to address Oregon Minimum Standards and the Oregon Performance
Measures not covered by the national assessment tool, showed that, by and large,
most local health departments are fulfilling those requirements.

There is still strong interest in conducting the assessments with he remaining 26
counties (25 health departments), and efforts are proceeding to find the needed


                                                                                    37
resources. Donalda suggested that the Five Year MCH assessment process will be
due this year, and perhaps the resources needed to perform that function could be
applied in part. Bioterrorism funding has, at least through this federal fiscal year,
been encouraged as a source of funding for this activity. Finally, Casey Milne
shared that 5 of the 9 counties included representatives on a follow-up conference
call to discuss next steps. They are having some difficulty in most places with
analysis of the data and/or in determining what to do with next steps. Milne &
Associates will provide limited follow-up within the few remaining contract
resources, and agreed to make a presentation to CLHO and to the Public Health
Administrators group. She noted that it is critically important for some follow up
activity occur reasonably soon within the 9 counties which have completed the
assessments to capitalize on the collaboration with partners, energy and insights
generated.

State Assessment:
The state has received a proposal from Milne & Associates, LLC, to complete an
assessment of the performance of the state public health system. Grant indicated
he is now discussing this activity with partner organizations within the state
system. . The committee reaffirmed its earlier recommendation to DHS that
OSPHO retain the current consultants to complete the work and to assure
consistency from the local process. It was noted that several local health
departments are eager to compare results with those of the state to identify
overlapping strengths and weaknesses.

After discussion and consideration of options, the Oversight Committee members
agreed that it would continue to meet to advise regarding the state system
assessment, and then to consider a continuing role at the completion of the state
assessment. A workgroup meeting will be convened at the DHS-Public Health
offices in advance of the assessment process and would provide telephone access
for interested members of the committee. The committee would meet after
conclusion of the assessment to review results and make recommendations about
next steps.

Adjournment:
Grant Higginson briefly summarized the decisions of the meeting. The meeting
was adjourned at 10:40 a.m.




                                                                                   38
                                  APPENDIX V

Scope of Work: The Contractor will:

1. Convene and staff an oversight committee, and meet regularly with the Office
   of the State Public Health Officer (OSPHO).
    Meet with OSPHO to determine committee membership
    Solicit and obtain commitments to participate from potential members
    Develop agendas and regularly convene the committee
    Meet regularly with OSPHO
   Deliverables:        First meeting with OSPHO by Sept 1
                        First committee meeting by Oct 1
                        OSPHO meetings at least every two weeks
                        Committee meetings at least every two months

2. Identify and solicit a minimum of 6 local health departments (LHD's) willing to
   participate in the assessment project. These should be LHD‟s representing the
   population of Oregon and the variety of LHD‟s.
       Prepare letter of solicitation to be reviewed by OSPHO
       Solicit and obtain commitments to participate from LHD's
       Review panel of willing LHD's and make recommendation to OSPHO on
           which LHD's should be selected
      Deliverables:       Letter of solicitation to OSPHO by Sept 7
                          LHD's selected by Oct 1

3. Analyze current Oregon Law and Rules compared to Model Public Health Act.
       Review and perform gap analysis comparing ORS, OAR with Model Act
         (may be sub-contracted to someone familiar with Oregon law)
       Work with the RWJ Turning Point National Collaborative to identify
         national-level assistance with analysis.
      Deliverables:     Initial gap analysis to OSPHO by Feb 1
                        Final report with recommendations by Mar 31

4. Develop an assessment tool and work plan.
    Review the National Public Health Performance Standards recently
      published by CDC.
    Review Oregon minimum public health standards and related documents
    Draft an assessment tool for OSPHO review
    Develop a work plan that includes time lines for the reviews and follow-up
      activities
   Deliverables:Draft tool and work plan to OSPHO by Oct 1




                                                                                  39
5. Organize and facilitate the completion of an assessment of selected LHD‟s
   using the tool based on the NPHPS. Use NPHPS staff as consultants on the
   project.
       Meet on-site with LHD's to introduce project and determine roles and
          responsibilities
       Meet, or be in contact, regularly with LHD's
       Upon request, provide technical assistance to LHD's, including facilitation
          with the completion of the assessment
       Periodically review LHD's progress towards completion of the
          assessment
      Deliverables:       Initial meetings will all LHD's by Nov 1
                          Monthly report on contacts/progress with LHD's
                          Assessments completed by Jan 31

6. Analyze the completed assessments.
       Design an analysis template and sample report
       Input assessment tool data into a database
       Perform an initial analysis and present findings to OSPHO
       Finalize data analysis
      Deliverables:    Template design to OSPHO by Dec 1
                       Data input complete by Feb 15
                       Initial analysis to OSPHO by Feb 30
                       Completed analysis by Mar 15

7. Provide a report that:
    Informs DHS about gaps in the current, statutorily required, Minimum
      Standards for Oregon Local Health departments.
    Makes specific recommendations for changes in the Minimum Standards
      based on the findings from the NPHPS-based assessment.
    Informs DHS about gaps in local services as measured by the assessment
      tool.
    Describes in detail the strengths and weaknesses of Oregon Law and Rules
      compared to the Model PH Act.
    Make recommendations for changes in Oregon Law and Rules
   Deliverables:Final report to OSPHO by Mar 31




                                                                                40
                                 Appendix VI
                          Oregon Assessment Project
                               COUNTIES CALL
                                  2/27/04

Participants:
        Anne Peltier, Linn County
        Roberta Hellman, Washington County
        Bonnie Kostelecky, Multnomah County
        Marty Franc , Clackamas County
        Ellen Larsen, Hood River County
        Tom Milne, Milne & Associates, LLC
        Casey Milne, Milne & Associates, LLC

                               Meeting Summary

The purpose of the call was to provide an opportunity for counties which have
completed the NPHPSP assessment of their public health systems to share insights
and to discuss next steps. Some of the points discussed included the following:

   2. We need assistance in interpreting the data. (None is available at present,
      but efforts are underway to identify resources to support this and the next
      steps)

   3. Not sure what to do with low scores. (It was suggested that the place to
      start with local improvement efforts is with those areas identified as being
      of highest priority where performance was lowest. Milnes will provide a
      form that can be of use in guiding this process.)

   4. It will be important to match the strengths and weaknesses identified
      through this process with those of the state. (The state is working towards
      organizing an assessment using NPHPSP; it is tentatively set for May, 2004)

   5. The participants on the call indicated they have no problem sharing their
      scores with other counties, and that it would be good to work together on
      addressing common issues.

Next, participants shared what is happening in their respective counties:

   1. Linn County has talked with the AHEC, who offered during the assessment
      to assist with future meetings. Another meeting will be needed, and Linn is
      not sure how to phrase what should happen next. Some help is needed.




                                                                                     41
2. Washington County is waiting to look at their data in more detail, and want
   to convene their public health advisory board, both as an outcome of the
   assessment discussions and to keep the discussion going.

3. Multnomah County has reviewed the data and have had one in-house
   meeting to discuss it. Currently are planning next steps and would very
   much like to see the results from the state assessment to help guide next
   steps. Would also like to have access to the data from other counties with
   similar size and demographics. (We have passed this request on to CDC;
   they are in the process of compiling a report that is very similar to this
   request and hope to have it completed/available by the end of March 2004.)

4. Benton County wasn‟t on the call, but it was noted that they are using a day
   during National Public Health Week to reconvene the community group
   (those that participated in the assessment as well as additional partners),
   share the data, and begin planning next steps. They are also gearing up to
   use MAPP to develop a community public health improvement plan.


The discussion centered around three levels of focus that the performance
standards tool brings counties to:

1. The Community Level: Issues include collaborating with community
   partners, “formalizing” the community public health system, increasing
   coordination of activities to, for example, formalize a community resource
   guide/directory, create an integrated community profile, and develop a
   community public health improvement plan.

2. Internal Department Improvement: Included here are strengthening the
   capacity and the performance on health department staff in doing the work
   of public health, changing mindsets about what should constitute the
   principal focus areas for local public health, restructuring for success. Since
   there are similar needs across the state, this category is particularly well-
   suited for the development of regional or state-wide “improvement
   collaboratives” where locals could work together to improve practice.

3. The State-Local Interface: To maximize the potential for success, it is of
   critical importance that the assets, capacities, roles and strengths of the
   state and local health departments are aligned and complement each other.
   Once the state completes the NPHPSP Assessment (May?), the results
   should be shared and compared to assure that in places where locals are
   weak, that the state has strengths, and viz. There may need to be some
   shifting of responsibilities and roles for this to happen.




                                                                                42
   Assistance Needed:

   In order to take full advantage of the assessments and the community
   involvement in the assessments, help is needed with the following:

      1. Completion of the assessment by the remaining counties (M&A are
         looking for resources to accomplish this; according to the CDC Guidance,
         BT money can be used to complete the NPHPSP and/or MAPP. Colorado
         is using BT funds for dual use 1) improving preparedness and 2)
         improving public health practice.
      2. Help in interpreting the scores on an individual county-by-county basis
         and with determining how to share the data with community partners
         (i.e. “what does the data mean?”)
      3. Convening, maybe on a regular basis, the 9 LHDs which have completed
         the assessment to share lessons learned, mistakes made, progress.
         Perhaps a Listserve would be useful…
      4. Data descriptive of the results in other locations around the country,
         preferably by size and demographic groupings
      5. Information on which states have completed and are using the results of
         the assessment
      6. A listing, at least by category, of parking lot issues other counties made
         during their assessments
      7. The convening of a process for local health departments (and perhaps
         the state) to work together to improve public health practice, based on
         the findings from the assessments
      8. A summary of this call

Next Steps: The contract between the Oregon State Public Health Office and
Milne & Associates ends in March. However, Milne & Associates will be doing the
following this month:
    4. Provide a final report to the state, and at least executive summaries to the
       participating counties.
    5. Make a presentation to a CLHO meeting re the project and what is coming
       from it.
    6. Continue to search for resources (beyond counties BT funding) needed to
           a. Provide technical assistance to the 9 counties for data interpretation
               and for their “next steps”
           b. Complete the assessment in all Oregon counties
           c. Create a resource in Oregon or the NW region for public health
               improvement
           d. Address the needs listed above as “assistance needed”
    7. Send out to the 9 LHDs the listing of priorities for each of the 10 Essential
       Services and for the Indicators




                                                                                   43
8. Send a file with a graphic which can be useful in prioritizing issues to be
   addressed locally
9. Send a summary of the call to the 9 LHDs.




                                                                                 44
                                      Appendix VII
                            Local Public Health Assessment
                             SUPPLEMENTAL QUESTIONS

The performance assessment of 9 local health departments in Oregon was based
principally on the tool developed for local assessments as part of the National
Public Health Performance Standards Program developed by the Centers for
Disease Control and Prevention (CDC). At the request of the Oversight Committee
for the project, the national tool was compared with the Oregon Minimum
Standards (2003 Revision). That comparison identified 8 issues which are included
within the Oregon standards but are not covered by the national standards.
According, questions were added to the assessment to reflect those 8 issues.

The chart below shows the composite score of the 9 local health departments. A
rating of 4.0 indicates full compliance with the standard. The composite score
demonstrates that local health departments are in full or substantial compliance
with 6 of the 8 Oregon Minimum Standards examined. The health departments
are in partial compliance with investigating deaths and with providing feedback to
individuals/organizations in areas for which local health departments have
regulatory responsibility. The actual questions asked are included at the end of
this document.


                 Supplemental Questions -
                                               Record system-
                   Minimum Standards           confidentiality? (OMS 7.2)
                                               Recruiting subpopulations?
           4.0                                 (OMS 8.2)
           3.5                                 Local budget-reflects
                                               priorities? (OMS 5.1)
           3.0
                                               Make-up of staff reflects
           2.5                                 community? (OMS 8.2)
   Score




           2.0                                 Board of health meets? (OMS
           1.5                                 5.1)

           1.0                                 Consistent PH enforcement ?
                                               (OMS 6.2)
           0.5
                                               Investigate deaths? (OMS
           0.0                                 2.1)
                           Question            Feedback on enforcement ?.
                                               (OMS 6.2)



In addition, each department of the State of Oregon has adopted a set of
performance measures against which they are held accountable. This project
identified 23 questions to be added to the assessment of local health departments
to fully reflect the performance measures for which public health has
accountability. The aggregated scores for those 23 questions, asked to each of
the 9 local health departments, are reflected in the three charts which follow.


                                                                                45
Responses to the 8 of the questions were met with nearly full compliance by all 9
local health departments, as can be seen below.


                Supplemental Questions -         Track numbers of teen
             Oregon Performance Measures - 1     pregnancies?
                                                 Track percent 19-35 month old
                                                 - immunized?
          4.0                                    Assure Prenatal care for low -
          3.5                                    income w omen?
          3.0                                    Assure Immunization
          2.5                                    services19-35 months old?
  Score




          2.0                                    Track tobacco use among
          1.5                                    pregnant w omen?
          1.0                                    Health Ed programs address
          0.5                                    HIV prevention?
          0.0                                    Statistics are available for HIV
                                                 infection rates?
                           Questions
                                                 Health Ed programs address
                                                 Teen pregnancy?




The aggregated scores for the next 8 questions demonstrate substantial
compliance by the health departments.


                  Supplemental Questions -         Track percent unintended
              Oregon Performance Measures - 2      pregnancies

             4.0                                   Track percent terminated
                                                   pregnancies?
             3.5
                                                   Track Tobacco Use Among
             3.0                                   Youth?

             2.5                                   Health Ed programs address
     Score




                                                   Unintended pregnancies?
             2.0
                                                   Assure influenza vaccine
             1.5                                   adults > 65 years?
                                                   Track tobacco use among
             1.0
                                                   Adults?
             0.5                                   Track percent prenatal care
             0.0                                   1st 4 months pg?

                            Question               Track rate of adolescent
                                                   suicide?



Finally, the level of compliance dipped somewhat for the last 7 questions asked,
and was significantly lower for the questions dealing with the provision of health
education programs to prevent youth suicide and with tracking the percentage of



                                                                                    46
adults over 65 years of age who have been fully immunized against preventable
diseases.


        Supplemental Questions -
    Oregon Performance Measures - 3
                                            Assed law compliance- Sale
                                            of tobacco to minors?
           4.0                              Sponsor Health Ed programs
           3.5                              - Pg w omen smoking
                                             Track number cigarette
           3.0
                                            packs sold per capita?
           2.5                              Sponsor Health Ed programs
   Score




           2.0                              target Youth smoking
                                            Sponsor Health Ed programs
           1.5                              target adult smoking
           1.0                              Health Ed programs address
                                            prev.adolescent suicide?
           0.5
                                            Track percent of adults >65
           0.0                              immunized?
                     Question




                                                                                47
                        NPHPS Assessment
        Questions Added to Reflect OR Performance Measures

1.1.7   Does the LPHS have access to behavioral risk factors for the community?
        1.1.7.OMS Do you track the following:
         1.1.7.OMS1 Numbers of teen pregnancies?
               1.1.7.OMS2 The percentage of pregnancies that were
                      a. unintended
                      b. terminated?
         1.1.7.OMS3 Tobacco use among
                      a. Adults?
                      b. Youth?
                      c. Pregnant women?
         1.1.7.OMS4 Number of cigarette packs sold per capita?


1.1.10 Does the LPHS have access to maternal and child health data?
       1.1.OMS5 Do you track the percentage of 19-35 month old children who are
                 adequately immunized?
       1.1.OMS6 Do you track the percentage of low-income women who receive
                 prenatal care in the first 4 months of pregnancy?


1.1.11 Does the LPHS have access to death, illness, and/or injury data?
       1.1.11.OMS7 Do you track the rate of adolescent suicide?


1.1.12 Does the LPHS have access to communicable disease data?
       1.1.12.OMS8 Do you track the percentage of adults aged 65 and over who are
                    adequately immunized?


2.1.2   Does the LPHS monitor changes in the occurrence of health problems and
        hazards?
        If so, are local statistics available for:

        2.1.2.1 Communicable diseases?
                2.1.2.1.OMS9 HIV infection rates?


3.1.3   Does the LPHS sponsor health education programs?
        If so, do these programs:
        3.1.3.2 Target particular health risks commonly faced in the community (e.g.,
                  infectious disease, lack of exercise, smoking, obesity, substance abuse,
                  and a failure to wear lap and shoulder restraints in automobiles)?
                 3.1.3.2.OMS10 Do any specifically target smoking by
                       a. Youth?



                                                                                             48
                       b. Adults?
                       c. Pregnant Women?
                 3.1.3.2.OMS11 Do any address
                       a. Teen pregnancy?
                       b. Unintended pregnancies?
                 3.1.3.2.OMS12 Do any address prevention of adolescent suicide?
                 3.1.3.2.OMS13 Do any address HIV prevention?


6.3.4   In the past five years, has the governmental public health entity reviewed the
        activities of institutions and businesses in the community (e.g., schools, food
        establishments, day care facilities) to assess their compliance with laws,
        regulations, and ordinances designed to ensure the public‟s health?
        If so, did reviews:

        6.3.4.OMS14 Include attention to enforcement of laws pertaining to the sale of
                     tobacco to minors?

7.3.2    Does the LPHS provide outreach and linkage services for the community?
         If so, does the LPHS assure:

        7.3.2.OMS15 Prenatal care for low-income women?
        7.3.2.OMS16 Access to immunization services for children 19-35 months old?
        7.3.2.OMS17 Access to influenza vaccinations for adults over 65 years of age?




                                                                                          49
                                    Appendix VIII
                           Evaluation by Counties

As part of the assessment, the local health department administrators (or their
designees) were asked to complete a standardized evaluation form. The data was
input into the CDC database by Milne & Associates, LLC. Several questions were
related to the process and the community participants. Question #6 is particularly
noteworthy and provides some insight into the value of the process as perceived
by the administrators. The question asked the following:

   To what extent did the assessment process influence the following:

       A. For Internal Relations (i.e. within the health department)
             1. Communication
             2. Collaboration
             3. Knowledge of the public health system
             4. Knowledge of system improvement needs
             5. Intent to implement system improvements

       B. For External Relations (i.e. outside the health department but within
          the public health system)
             1. Communication
             2. Collaboration
             3. Knowledge of the public health system
             4. Knowledge of system improvement needs
             5. Intent to implement system improvements

   Responses were rated as follows:
       Positive Effect          4 points
       Minimal Positive Effect 2 points
       No Effect                0 points
       Minimal Negative Effect -2 points
       Negative Effect         -4 points

 Responses to questions regarding internal relations ranged from 6 to 20 points
(20 is the maximum achievable score), with an average score of 13.6 points.
Responses to questions regarding external relations ranged from 10 to 20 points,
with an average of 17.3 points. It is not surprising the internal relations “benefited
less” than external relations, inasmuch as the employees of the local health
department are expected to have knowledge about the public health system, and
departments should have more established communications and collaboration
internally than externally. The table below displays the response by county.




                                                                                    50
                          Evaluation of Assessment Process

             20

             15
   "Score"




                                                                                 Internal
             10
                                                                                 External
             5

             0
                  B       G   H       D   J       L   M       W   C       Ave.
                                          County



The next chart compares responses to the 5 questions by internal and external
relations impact. With a maximum possible score of 36 for each question, the
scores for internal relations questions ranged from a low of 18 (collaboration) to a
high of 30 (knowledge of public health system). The scores for external relations
questions showed much less variability, ranging form a low of 30 to a high of 34.


                          Assessment Evaluation: Questions

             36

             27
   "Score"




                                                                                 Internal
             18
                                                                                 External
             9

             0
                      1           2           3           4           5
                                      Question Number



In summary, it is evident that the process was seen as a success, particularly in
term of how it impacted external relations. It appears that all participants, health
department staff and community partners, received the greatest benefit in gaining
a better understanding of the public health system and its improvement needs.




                                                                                            51

				
DOCUMENT INFO
Description: Oregon Performance Assessments document sample