Editorials

Measuring the performance of public health agencies

Government, like doctors and hospitals, should meet quality standards 

Performance measurement is a first step towards quality improvement in health care. When systems are in place to measure performance we can reward good performance, develop and evaluate ways of improving performance, and certify (or decertify) providers who perform (or don't perform) according to established standards. In the United States an extensive machinery has emerged to measure and ensure performance, but so far it has not been applied systematically to public health agencies. That situation is about to change, and, as it does, it opens up the interesting possibility of holding elected politicians even more accountable for decisions that affect health.

Efforts to measure the performance of healthcare providers in the US have expanded rapidly over recent years. Much of this activity has been driven by the main purchasers of health carelarge employers and government.¹ The Joint Commission on Accreditation of Healthcare Organizations accredits 18 000 facilities in the US, including hospitals, home care agencies, long term care facilities, and clinical laboratories, allowing them to participate in the federal Medicare programme for the elderly.² The performance of health maintenance organisations is assessed through "report cards"especially the health plan employer data and information set³and through accreditation by the National Committee for Quality Assurance.⁴ Doctors must pass examinations to be licensed to practise medicine, and board certification in their specialties is often required to join medical group practices, to care for members of health maintenance organisations, and to admit patients to hospitals. The American Medical Association has developed the American Medical Accreditation Program to evaluate the credentials, office environment, and clinical competence of individual physicians.⁵ Last year these three organisations (the American Medical Accreditation Program, the National Committee for Quality Assurance, and the Joint Commission on Accreditation of Healthcare Organizations) formed a 15 member Performance Measurement Coordinating Council "to ensure more efficient collection of health care performance measurements across all levels of the US health care system."⁶ If the US Centers for Disease Control and Prevention has its way, public health agencies will soon also be encompassed by a comprehensive and systematic set of performance measures.

On 19 March, at the PREVENTION 99 conference in Arlington, Virginia, the Centers for Disease Control and Prevention outlined plans for developing performance standards for state and local public health systems. The agency's national public health performance standards programme involves: (a) developing, in partnership with key national public health associations, a core set of local and state standards that would define the appropriate infrastructure for public health; (b) developing standards for specific public health programmes; (c) establishing data systems to monitor compliance with standards; and (d) pilot testing the performance standards system. The core set of standards is based on a consensus document outlining the 10 essential public health services (see box). Each essential service has three to five indicators, which are assessed by specific objective questions, referred to as measures. The indicators for "Diagnose and investigate health problems and health hazards in the community," for example, address the identification and surveillance of health threats, the existence of a community emergency response plan for public health disasters and emergencies, the investigation of and response to public health emergencies, and laboratory support for investigating health threats and diagnosing disease and injury. Pilot testing of the core standards began last month in Texas and will be conducted in several other states in April and June.

Standards will be developed for selected public health "modules." The first modulethe capacity to respond to bioterrorism threatswill be constructed over the next eight months and then will be piloted. Others will be added as the programme evolves.

Public health departments will receive certification indicating their level of performance, and the best performing departments will be nationally recognised. The system will be evaluated for its success in raising performance scores. The current programme does not address the possible use of certification scores in funding allocation decisions, but individual states are free to base their funding of local public health agencies on performance.

In 1988 the Institute of Medicine published a landmark report on the state of public health in the US, concluding that the public health system had fallen into "disarray."⁷ Public health practitioners may disagree about whether that indictment was overstated, or about how dire the situation may be today. But there is no disagreement that the infrastructure of public health needs to be strengthened considerably to allow it to achieve its ambitious goals.⁸ The initiative by the Centers for Disease Control and Prevention is a commendable step towards measuring and upgrading the performance of public health agencies and assigning to them the same sort of accountability as other players in the health sector.

Participants at PREVENTION 99 pointed out that the performance of public health agencies is affected substantially by funding. They suggested evaluating the performance of the elected officials responsible for allocating funds to public health departments. Are these politicians fully funding programmes to address the important health problems in the community? To what extend are they funding politically popular but unimportant health programmes? Or worse, are they bending to the whims of antihealth forces such as the gun and tobacco lobbies?

Healthcare professionals, healthcare facilities, health services organisations, and medical training programmes must meet a variety of performance standards to be licensed, certified, and accredited. Public health agencies are now moving in that same direction. Perhaps it's time to develop a process to measure the performance of our legislatorsespecially those who play a major role in determining public health policy.

Ronald M Davis, North American editor, BMJ 

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2. Joint Commission on Accreditation of Healthcare Organizations. www.jcaho.org/ (accessed 20 March 1999).
3. Epstein AM. Rolling down the runway: the challenges ahead for quality report cards. JAMA 1998; 279: 1691-1696[Abstract/Free Full Text].
4. Iglehart JK. The National Committee for Quality Assurance. N Engl J Med 1996; 335: 995-999[Free Full Text].
5. American Medical Accreditation Program. www.ama-assn.org/med-sci/amapsite/index.htm (accessed 20 March 1999).
6. Skolnick AA. JCAHO, NCQA, and AMAP establish council to coordinate health care performance measurement. JAMA 1998; 279: 1769-1770[Free Full Text].
7. Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988.
8. Davis RM. "Healthy People 2010": national health objectives for the United States. BMJ 1998; 317: 1513-1517[Free Full Text].