文章基本信息

标题：Local Health Department Factors Associated With Performance in the Successful Implementation of Community-Based Strategies: A Mixed-Methods Approach
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作者：Elizabeth Gyllstrom ; Kimberly Gearin ; Renee Frauendienst 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2015
卷号：105
期号：Suppl 2
页码：S311-S317
DOI：10.2105/AJPH.2014.302419
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined which local health department (LHD)–level factors contributed to successful implementation of policy, systems, and environmental change strategies in Minnesota. Methods. We used a retrospective mixed-methods design to evaluate the relationship between the Statewide Health Improvement Plan (SHIP) grant initiative and key predictor variables (2009–2011). We obtained quantitative capacity data for 91 cities and counties in Minnesota; in addition, we conducted 15 key informant interviews to examine factors that facilitated and acted as barriers to LHD performance. Results. Grantee performance was distributed as follows: exceeds expectations (29.7%), meets expectations (55.0%), and is approaching expectations (15.3%). Organizational quality improvement (QI) maturity was strongly positively associated with grantee performance on SHIP. Organizations with high QI maturity, effective leadership, efficient decision-making, and successful regional or cross-jurisdictional partnerships were more likely to be rated as exceeding expectations. Conclusions. This study successfully translated practice-based research findings into tangible outcomes, including new system-level performance measures for local public health and recommendations for shaping the statewide initiative examined in this study. The approach taken in this study to systematically monitor communications, dissemination, and translation may be a model for others. Public health services and systems research (PHSSR) focuses on system-level factors and their association with public health delivery systems and population health. 1 Studies have examined the role of different organizational, financial, and structural characteristics of local health departments (LHDs) and how those factors may affect the delivery of public health services in the community. 2–5 Yet these studies have had mixed results, and much remains to be learned about how to measure LHD capacity and how such capacity matters in improving population health. Two more recent studies demonstrated a connection between local public health expenditures and population health outcomes, suggesting that it is possible to identify these relationships. 6,7 In this article, we report on work related to performance management and quality improvement (QI), which is a priority area of the national research agenda for PHSSR. 1 This work represents a major and crucial step forward in research to link QI, evidence-based practice, and statewide implementation of local, population-based health initiatives. It also contributes to research priorities related to accreditation, particularly the impact of QI on LHD performance. 8 QI is defined as a disciplined approach to increase organizational performance using specific methods and techniques. 9 Standards and QI are not new concepts in public health, and the variation seen across health departments has been well documented, providing the basis for the accreditation movement. 9 The voluntary public health department accreditation program 10 and new national standards have motivated improvement initiatives in Minnesota LHDs. However, although all improvement requires change, not all change results in improvement. The literature has suggested that to realize the full potential of improvement initiatives, QI should be implemented in a supportive organizational climate. 11 Riley et al. 11,12 have emphasized that the quality of QI matters and conceptualized a continuum of QI for public health departments, with an entry-level orientation to QI that focuses discretely on individual programs at one end of the continuum and a comprehensive, organization-wide commitment to continual improvement at the other. This continuum represents a type of organizational maturity model originally developed to improve software engineering and now widely used for a number of topics (including project management, product development, and QI) across many industries, including health care and, increasingly, public health. 13–15 In applying organizational maturity to QI and public health, Joly et al. defined organizational QI maturity as “a theoretical concept that reflects an agency’s culture, capacity and alignment of on-going and systematic improvement efforts.” 16 ^(p1) Moreover, Joly et al. developed a QI Maturity Tool that classifies health departments along a 5-stage continuum ranging from those that are beginning (the absence of QI practice, culture, capacity, and alignment), to those that are developing awareness and gaining experience, and ultimately to those that are excelling (an ideal state with a pervasive culture of improvement throughout the organization). 16 This continuum approach is also reflected in the Roadmap to a Culture of Quality Improvement developed by the National Association of County and City Health Officials. 17 Characteristics of health departments at the most mature end of this continuum include departments with a fully integrated performance management system in place, routine reports of progress to all customers and stakeholders, and QI competencies and action plans incorporated into job descriptions and performance appraisals. In contrast, departments that fall at mid-range on the continuum do engage in periodic QI projects, although the leadership and infrastructure (e.g., an organization-wide QI council) to fully support and align QI across the department is not yet in place. The Minnesota Statewide Health Improvement Program (SHIP)—an integral component of Minnesota’s 2008 health reform legislation—seeks to improve population health and reduce demands on the health care system by decreasing the percentage of Minnesotans who are obese or overweight as well as by decreasing the percentage who use or are exposed to tobacco. The SHIP initiative is driven by an array of evidence-based policy, systems, and environmental strategies within a matrix of settings that have demonstrated success in promoting healthy nutrition, increasing opportunities for physical activity, and reducing tobacco use. 18 SHIP strategies were developed on the basis of evidence presented in the literature, with a strong emphasis on strategies recommended in the Community Guide to Preventive Services. 19 Implementation of these evidence-based policy, system, and environmental strategies is expected to reduce the leading risk factors for chronic disease and ultimately lead to measurable improvements in population health. In the 2009 to 2011 budget years, SHIP distributed $47 million in grant awards to LHDs covering all 87 counties and 9 of 11 tribal governments. We examine the first biennium of SHIP (SHIP 1.0). Minnesota statute provides local jurisdictions with considerable discretion in their governance and organizational structures for delivering local public health services. All jurisdictions provide public health through the oversight of a community health board (CHB); however, there are a variety of different governance and organizational structures, including (1) the CHB functions within a broader human services board, (2) local public health is organized as a stand-alone department versus as part of a larger department, and (3) some CHBs consist of 2 or more counties, and others represent a single county or city. In addition to this variation in structure, Minnesota LHDs vary widely in terms of their size and expenditures. 20 For example, the median population size served is approximately 33 000 (range = 4122–1 157 400), and the median per capita expenditure for public health was $52 in 2009, with a range from $13 to $214. 21 Very little PHSSR has examined statewide rollout of evidence-based strategies by LHDs and their partners. In developing a conceptual model for PHSSR, Meyer et al. 22 emphasized the importance of examining performance relative to capacity. Better measurement and understanding of the linkages between capacity and performance will help strengthen public health systems and ultimately improve population health metrics. 23 We used existing local public health performance data during the initial 2 years of SHIP to examine factors at the LHD level that may have contributed to success in implementing community-based interventions. Of particular interest was the role of organizational QI maturity and how it contributed to the performance of LHDs. However, as noted by Meyer et al., 22 defining capacity is difficult, and other factors may also have influenced SHIP performance.