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The Dynamics of Public Health Performance Management

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Andrew Ballard
January 29, 2018

In recent years, a growing desire to monitor and improve organizational performance has emerged in health departments around the country. This trend has been slower than in other government service areas due to the many unique complexities public health agencies face in both the delivery and conceptualization of their work.

The primary challenge for public health performance is linking the operational performance of an organization to improved population health. Much of performance measurement and indeed management consists of linking inputs, to outputs, to outcomes in service areas, which present a rather clear connection between the three. For example, if your desired outcome is improved transit vehicle reliability, you can design a series of inputs and outputs that directly address the underlying causes of vehicle unreliability. However, improving population health is a complex and multi-dimensional issue. Determinants of population health range from availability of food, crime rates, education levels and everything in between.

In an ideal system, the activities undertaken by an agency generate measurable change in the underlying processes being monitored within the performance system. This change should happen within a relatively short period of time strengthening the causal inference made between the activities and the outcomes. The classic example used is the allocation of police in an area identified as a high-crime location. In a relatively short manner, the occurrence of crime in a localized region can be reduced simply by an increased police presence. This process is not the same in public health, however. The strength of an intervention is rarely sufficient to cause immediate change in the health of a population, therefor the effects of any process or activity are difficult to measure and difficult to report in a performance framework.

A simple lens though which to view this challenge is the balance of “quality” measures and “quantity” measures of performance. An example of this would be measuring the timeliness and comprehensively of inspection services rather than just measuring the number or frequency of inspections. Some examples of performance system development in the U.S. may inform attempts to develop quality measures. The state of North Carolina used participant satisfaction surveys to measure the quality of services offered through their Women, Infants, and Children (WIC) program and to guide programmatic changes. Even though a high level of “customer satisfaction” is not direct evidence that the programs are working to reduce poverty, it is a good metric for monitoring things like the ease of access for qualified individuals. High satisfaction in government programs may not end poverty over night, but it can help to rebuild trust in the public service.

One response to this difficulty has been to focus less on the macro issues in the day-to-day operations of a performance system and instead consider things like operational efficiency with an assumption that the actions taken by public health professionals contribute to the overall wellbeing of the population. Organizations have begun tracking things like resource expenditure per activity and the time it takes to conduct routine operations. Even though an efficient inspection may not reduce the likelihood of a foodborne illness at that particular restaurant, as public health agencies are able to perform more inspections per unit of input, the assumption that overall risk of foodborne illness may indeed decline.

Another challenge faced by public health agencies is the lack of a uniform performance model within the field. In other fields, such a transportation services, sanitation, and others, the “performancestat” model has emerged as a primary vehicle by which agencies track and discuss organization data. Bob Behn provides an insightful overview of this format in his book “The PerformanceStat Potential.” In this model, organizations establish either agency-wide or department specific targets, collect data on those operations, and hold regular and integrated meetings to systematically discuss their progress. The process of designing measures, identifying goals, collecting data, and using that data for organizational learning has yet to develop standard procedures in public health. There is a need for a strong conceptual framework for what performance means to health organizations and how agencies can link their activities to that notion of performance. Organizations like the Centers for Disease Control and Prevention (CDC), the National Association of County and City Health Officers (NAACHO), and the Public Health Accreditation Board (PHAB), have all attempted to design standards for performance management in public health but progress is slower than the overall performance movement. The good news is public health agencies are full of data savvy inspectors, epidemiologists, health officers, and other professionals so progress may be slow, but it is indeed moving in the right direction.


Author: Andrew Ballard is the Managing Director of the National Center for Public Performance and a lecturer in public management at Rutgers University. an[email protected], @AP_Ballard

The National Center for Public Performance (NCPP) co-located at Suffolk University and Rutgers University is a research organization devoted to improving productivity in the public sector.

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