Culture Shift: Strengthening the Role of Environmental Health in Public Health Performance Improvement Efforts

Many environmental health (EH) programs already feel short on time, staff, and resources. Are performance improvement efforts worth the effort? Evidence from Florida suggests that they are. This column discusses two case studies in which EH improvement tools were effectively integrated with broader performance improvement initiatives, resulting in a clearer understanding of how EH issues intersect with larger public health (PH) concerns and the importance of EH involvement in addressing them.

A significant performance improvement opportunity is the Public Health Accreditation Board’s (PHAB’s) voluntary accreditation process. Health departments seeking accreditation must submit a recent community health assessment, community health improvement plan (CHIP), and agency strategic plan before applying (Public Health Accreditation Board [PHAB], 2011a, 2011b). As an integrated Florida Department of Health (FDOH), Florida county health departments are involved in these efforts through EH performance improvement tools:

• The Environmental Public Health Performance Standards (EnvPHPS) Self-Assessment

  These standards, developed by the Centers for Disease Control and Prevention (CDC), help organizations assess their capacity to fulfill the essential environmental public health services, mirror the National Public Health Performance Standards, and align with PHAB’s domains (CDC, 2010).

• The Protocol for Assessing Community Excellence in EH (PACE EH)

  This 13-step methodology, developed by CDC and the National Association of County and City Health Officials (NACCHO), fosters community involvement in EH decision making and contributes to several PHAB standards (NACCHO & CDC, 2000).

Case Study 1: Walton County, Florida

In 2012, Walton County Health Department’s Division of EH (WCHDEH) used the EnvPHPS self-assessment to determine the county’s environmental capacity and needs. A stakeholder group, which became known as the EH Council, performed the assessment; members included representatives from police departments, schools, community organizations, and local government. The council found the lowest EnvPHPS scores in the two areas of monitoring and linking people to needed resources. In tandem, the WCHIP (Walton County Health Improvement Plan) used Mobilizing for Action through Planning and Partnerships for its process, while the council used PACE EH to continue assessments.

Garden in a bucket program created to promote vegetable intake in Walton County

Early in the CHIP process, WCHDEH realized that EH should be actively involved in WCHDEH’s community health improvement planning initiatives. Stakeholders working on the CHIP learned that many root causes for chronic diseases link directly to environmental factors; in response, they composed specific strategies to address both the community’s EH concerns and the environmental causes of chronic disease. For example, to increase fruit and vegetable intake, a CHIP objective was formed to create a “garden in a bucket” initiative to encourage families to plant small container vegetable gardens and to prepare and enjoy nutritious meals together (see photo above). Now implemented in all county schools, this program was recently designated a NACCHO promising practice (National Association of County and City Health Officials [NACCHO], 2013).

Case Study 2: Indian River County, Florida

The Indian River County Health Department’s Division of EH (IRCHDEH) staff members used PACE EH to review the EnvPHPS-identified service gaps and to develop and prioritize actions. Because IRCHDEH staff members began integrating the EnvPHPS self-assessment data into the CHIP as the CHIP was being developed, the CHIP advisory group realized that EH factors influence issues they were already working on such as obesity, limited access to care, and transportation. This synergistic timing resulted in the CHIP advisory group elevating built environment to the third most important issue in their CHIP.

IRCHDEH case results included an increase in health department staff input in the county’s planning processes and a focus on nonmandatory EH functions: 1) performing built environment interventions in communities with high chronic disease rates, 2) reversing the decline of the Indian River Lagoon, and 3) reducing rates of hospitalization resulting from dog bites. IRCHDEH combined EH work with local stakeholders’ work to create a strong role for EH in accomplishing CHIP priority actions, thus integrating EH into larger health planning and performance improvement activities.

Shifting the Culture

Utilizing PACE EH methodology to mobilize the community was key to integrating necessary processes, from defining issues to implementing action plans. The EnvPHPS self-assessment revealed service gaps, which the health department utilized to define deficiencies within a community and EH scope. Data and action plans from these processes were then incorporated into the larger CHIP. Because accreditation requires applicants to have a CHIP, the FDOH felt strongly that EnvPHPS and PACE EH particularly bolstered PHAB Domain 4 (“Engage with the community to identify and address health problems”) and should be part of community health improvement planning. See Figure 1 for a more thorough crosswalk of how the EnvPHPS and PACE EH align with PHAB domains.

FIGURE 1.

Aligning Public Health Accreditation Board Domains With EnvPHPS and PACE EH

Quick Links on Environmental Health and Performance Improvement.

Environmental Public Health Performance Standards (EnvPHPS) –assessment tool, articles on environmental health performance improvement, and online toolkit on preparing for and conducting the assessment: www.cdc.gov/nceh/ehs/EnvPHPS.

National Public Health Performance Standards (NPHPS)–tools and materials for local, state, and governing entity assessments: www.cdc.gov/nphpsp.

Protocol for Assessing Community Excellence in Environmental Health (PACE EH)–online toolkit, PAcE EH guidance document in English and Spanish, and other resources (you will be prompted to sign up for a free NAccHo login to download documents): www.naccho.org/topics/environmental/PAcE-EH.

Public Health Accreditation Board (PHAB)–review standards and measures and other resources supporting voluntary public health accreditation: www.phaboard.org.

Florida’s experience indicates that high-level leadership support for quality improvement can provide additional impetus for EH involvement. At FDOH, the deputy for Statewide Services emphasizes that “organizational culture trumps strategy every time.” EH issues are often the root of broader public health issues that the health department hopes to address. The evidence from Florida’s experience supports the theory that EH involvement in larger public health quality and community health improvement efforts can help ensure these environmental causes are understood and addressed (Figure 2).

FIGURE 2.

Strengthening Environmental Health (EH) Role in Health Through Performance Improvement