"This tip sheet is provided to accredited health departments to use as they prepare their annual reports." "Health equity is noted as an emerging public health issue because best and promising practices are moving the science and practice of public health beyond the traditional considerations of minority health and health disparities to more comprehensive concepts associated with ensuring deliberate consideration of the multiple determinants of health."

1. This tip sheet is provided to accredited health departments to use
as they prepare their annual reports. It describes the terms listed as
emerging public health issues and the terms listed as measures of
efficiency and effectiveness in the template for the PHAB Annual
Report Section II, in order to provide health departments with a
common understanding of those terms.
Annual Report
Annual reports are those reports that are required to be submitted
to PHAB by accredited health departments. Annual reports must
include a statement that the health department continues to be in
conformity with all the standards and measures of the version under
which accreditation was received; include leadership changes and
other changes that may affect the health department’s ability to be in
conformity with the standards and measures; describe how the health
department has addressed areas of improvement noted in the site visit
report; describe how the health department will continue to address
areas of improvement identified in the site visit report and/or by the
health department in their accreditation action plan; and describe
work on emerging public health issues and innovations. (Public Health
Accreditation Board, Alexandria, VA, January 2014).
Emerging Public Health Issues
Serveral issues have been identified, as PHAB works with the field,
as emerging public health issues that will be increasingly emphasized
in the future. PHAB understands that these areas are evolving and as
such, new concepts, strategies, and initiatives will change over time.
PHAB encourages accredited health departments, however, to consider
how their work either addresses these emerging issues or is informing
the development of best and promising practices in these areas. While
no decisions have been made about another revised version of the
standards and measures to further address these areas, PHAB expects
these to continue to be significant topics in the future.
Public Health Workforce
The public health workforce in Tribal, state, local, and territorial health
departments is a key asset to the health department’s performance.
Therefore, workforce development will continue to be an emerging
issue for accredited public health departments. Looking forward to
2020 with a vision for high-performing, accredited health departments,
PHAB’s Workforce Think Tank described an accredited health
department workforce as one that:
• Demonstrates characteristics of a learning organization such as systems
thinking/critical thinking, effective communication, management of change
(situational awareness, problem solving, and forecasting), informatics savvy,
working with diverse populations, and recruiting and managing a diverse
workforce.
www.phaboard.org
Annual Report Section II Guidance: Explanations
of Terms
February 2014
Emerging Public Health Issues:
• Public Health Workforce
• Informatics
• Communication Science
• Health Equity
• Emergency Preparedness
• Public Health/Health Care Integration
• Public Health Chart of Accounts
Measures of Efficiency:
• Time saved
• Reduced number of steps
• Revenue generated due to billable
services
• Costs saved
• Costs avoided
Measures of Effectiveness:
• Increased customer/staff satisfaction
• Increased reach to a target population
• Dissemination of information, products, or
evidence-based practices
• Quality enhancement of services or
programs
• Quality enhancement of data systems
• Organizational design improvements
• Increased preventive behaviors
• Decreased incidence/prevalence of
disease
For more information, contact:
Public Health Accreditation Board
1600 Duke Street, Suite 200
Alexandria, VA 22314
Phone: 703-778-4549
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2. • Demonstrates alignment between the mission, vision,
values, and strategic priorities of the organization and the
management of the workforce. This includes leadership as
a collective enterprise; ability to effectively execute strategy;
ability to manage/lead change and foster innovation; ability
to address public health issues in a multiple determinants
of health model and through a health equity lens; and
ability to lead work across multiple programs, services, and
activities.
• Demonstrates alignment between the mission, vision,
values, and strategic priorities of the organization and
those in the community and the alignment of their
respective workforces. This concept includes leadership
as a collective cross-agency enterprise and staffing as
a complementary effort, adjusting staffing ratios and
competencies to reflect the efforts of all organizations
in the system. Leadership in the public health workforce
arena for the future is focused on advancing/advocating
competencies and workforce accountabilities across a
system that improves population health.
An additional consideration for health departments is creating an organizational culture and work environment that is
supportive of the staff and their maximum productivity.
Informatics
Public health informatics is an emerging issue for Tribal, state, local, and territorial health departments because of the
increase in the amount of available data and because the implications for the use of data to drive decision-making
have received stronger emphasis in the past several years. As new and more sophisticated technology emerges, health
departments will need to be actively engaged in ensuring that their work is supported by and contributes to sound
informatics principles, practices, and techniques. PHAB’s Informatics Think Tank participants identified an informatics-
savvy public health department in the future as one that:
• Creates an informatics strategic vision.
–– Demonstrates evidence that information systems
planning is included in the agency strategic plan.
–– Information systems planning elements should support
the agency’s overall scope of service and include some
stretch.
• Leverages data standards.
• Ensures interoperability among information systems.
• Evaluates and improves information systems and
applications.
• Ensures effective management of information systems and
of IT operations.
–– Demonstrates evidence of plans to address emergent
issues in informatics (such as meaningful use, ICD-10,
etc.) based on scope of services.
–– Demonstrates evidence of a process for developing
business requirements prior to implementation of
systems change or new systems implementation.
–– Demonstrates evidence of an agency data inventory.
• Ensures confidentiality, security, and integrity of data.
–– Demonstrates evidence of information systems
vulnerability audits, policies, and internal controls
related to the privacy of information and the security of
information systems consistent with scope of services.
• Integrates clinical health, environmental health, and
population health data.
–– Demonstrates evidence of plans to link individual data
and population data based on scope of services.
• Provides training in informatics to staff on an ongoing basis
as changes emerge.
• Communicates with policy makers, staff, and the public.
• Ensures knowledge, information, and data needs are met.
Annual Report Section II Guidance: Explanations
of Terms
www.phaboard.org
February 2014
Communication Science
Communication science was identified as an emerging public health issue because communication technology and
vehicles have changed significantly over the past few years. There are now multiple modes of communication that
are not only used by the public, but the expectation of communities served by health departments is that those varied
means of communication will also be used and valued by their health departments. Additionally, the population is
more diverse than ever before, creating both challenges and opportunities for health departments to interact with their
communities. Recommendations for health departments to consider for the future to strengthen their communication
strategies include:
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3. www.phaboard.org
• Development and implementation of a strategic approach to
communication that is comprehensive and science-based
(including internal and external multi-modal distribution to
reach different audiences).
• Planning and deliberate implementation of strategies that
uniquely brand the health department. This category also
includes regular, systematic evaluation of the branding
techniques chosen, with planned changes that can be
expedited as appropriate.
• Planning and implementation of broad-based strategies for
dissemination of public health information (website, large
media outlets, and social media).
• Planning and implementation of crisis communication,
including consideration of communication technology
disruption. This category includes consideration of a
24/7 communications infrastructure that is not just for
emergencies.
• Implementation of a planned approach to health education,
including both population-wide education as well as
targeted health education focused on specific population
groups.
• Communications and health education strategies and
initiatives planned, implemented, and evaluated in
partnership with the communities served by the health
department.
• Ongoing vigilance in providing culturally and linguistically
appropriate information to the diverse communities served
by health departments.
Annual Report Section II Guidance: Explanations
of Terms February 2014
Health Equity
Health equity is noted as an emerging public health issue because best and promising practices are moving the
science and practice of public health beyond the traditional considerations of minority health and health disparities
to more comprehensive concepts associated with ensuring deliberate consideration of the multiple determinants of
health. Participants in the PHAB Health Equity Think Tank recommended that accredited health departments in the
future consider a very broad-based approach to their work, using a health equity lens to plan and assess their work.
Accredited health departments in the future should:
• Understand the root causes of health inequities and
historical injustices in their jurisdictions.
• Be proficient at working with community partnerships (e.g.,
ensure transparency).
• Work to understand the community power structure and
how decision making creates inequities (e.g., how hiring
and promotion policies foster inequities).
• Understand how funds are distributed to communities and
develop processes for affecting same.
• Use a social epidemiology basis for determining health
department priorities.
• Maintain an emphasis on human rights in public policies
and health department practices.
• Develop a special emphasis on opportunities for children
and youth to be healthy.
• Maximize and work with grassroots power in developing
and implementing public health priorities.
• Monitor and track institutions that create inequities in their
decision making; engage them in different alternatives that
include community input.
• Seek ways to democratize data, in its collection (“street
science”), its dissemination, and its use.
• Include health equity as part of the community health
assessment, community health improvement plan, and
strategic plan, at a minimum. Plans should address health
equity on three levels: programmatic, community, and
policy.
• Identify health equity indicators: ensure that they are
community driven, involve grassroots and the community,
and use local data. Update plans regularly, on an as needed
basis, or as issues arise.
• Include analysis of accumulated burden in specific
neighborhoods. That is, “place matters.”
• Support the idea of a health equity impact assessment for
policies and programs.
• Educate policy makers concerning how current statutory
authority supports the health department’s ability to
influence health equity.
• Consider requirements related to health equity in
regulations that the health department enforces.
• Educate elected and appointed officials, as well as their
staff about health equity.
Emergency Preparedness
Emergency preparedness and response will continue to be an emerging public health issue as long as there are
natural and man-made disasters. PHAB, along with accredited health departments, expects to keep this topic high on
the list for monitoring best and promising practices as the realities and needs of communities change. The concept of
community resilience will continue to be developed and explored. Community resilience is a measure of the sustained
ability of a community to utilize available resources to respond to, withstand, and recover from adverse situations.
(http://www.rand.org/topics/community-resilience.html).
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4. Public Health/Health Care Integration
The core principles of public health/health care integration include a common goal of improving population health,
as well as involving the community in defining and addressing its needs. Strong leadership that works to bridge
disciplines, programs, and jurisdictions; sustainability; and the collaborative use of data and analysis are the other
principles. When there is mutual awareness, primary care and public health are informed about each other and each
other’s activities. (Institute of Medicine, Primary Care and Public Health: Exploring Integration to Improve Population Health.
March 2012).
Public Health Chart of Accounts (COA)
A chart of accounts is a created list of the accounts used by a business entity to define each class of items for which
money or the equivalent is spent or received. (http://en.wikipedia.org/wiki/Chart_of_accounts).
In April 2012, the Institute of Medicine recommended creation of a COA to provide a common framework and system
for tracking the flow of funds across the U.S. governmental public health system, similar to the systems that have been
developed for other health and social service sectors. (Institute of Medicine, For the Public’s Health: Investing in a Healthier
Future, April 2012).
Annual Report Section II Guidance: Explanations
of Terms
www.phaboard.org
February 2014
Measures of Efficiency*
Time saved Time from initiation to completion of a process or a service. Specific activities or events that
start and end the process / service delivery must be identified to calculate time. Examples of
time measures include but are not limited to:
• Time to award contracts,
• Time to process a bill,
• Time to provide permits / vital records (e.g., time saved through movement to electronic systems),
and
• Time to complete and report public health laboratory tests.
Reduced number of steps Number of discrete steps or tasks necessary to complete a given process or service delivery.
An example is a decrease in the number of steps required to approve communications to the
public during a public health emergency.
Revenue generated due to
billable services
Revenue generated by changing the implementation of a billable process or service. This
can be achieved by increasing the number of instances that a billable process/service is
delivered.
An example is an increase in revenue through increase in the average number of permits
issued on a monthly basis.
Costs saved Reducing existing costs of completing a process or delivering a service. The intent is to
lower existing costs while maintaining the quality of a certain process or delivering a service,
allowing the cost savings to be redirected to address other agency priorities. Examples
include but are not limited to:
• Reduction in the cost of process implementation – These represent efficiency gains that can be
tracked over a shorter timeframe. Examples of measures include:
–– Reduced costs through eliminating waste of lab materials,
–– Reduced labor costs by automating data entry, and
–– Reduced costs for record storage.
• Reduction in the cost of service delivery – These represent broader efficiency gains that may require
longer follow-up and more detailed data collection. Examples of measures include but are not
limited to:
–– Reduced costs of conducting diabetes outreach program and
–– Reduced costs of conducting restaurant inspections.
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5. www.phaboard.org
Annual Report Section II Guidance: Explanations
of Terms February 2014
Costs avoided Reducing future costs due to innovations in, or changes to, process implementation or
service delivery. This measure may be used when the health department’s QI activities are
intended to result in efficiency gains by preventing future costs that are certain to occur
should those activities not be implemented.
This outcome is applicable when a health department forecasts potential future costs that are
minimized or avoided because of QI activities. It does NOT apply to reducing costs already
incurred, as that is reflected by the costs saved outcome. Examples include but are not
limited to:
• Investments in preventive services that are certain to reduce the number of and thereby cost of
preventable hospitalizations/ER admissions, and
• Investments in staff development/ training that are designed to offset future hiring and salary costs.
Measures of Effectiveness*
Increased customer/staff
satisfaction
Percentage of individuals that represent a defined target population satisfied with a process
or service. The target population may be external customers (e.g., those seeking health
department permits, recipients of health education programs, public health community
partners, health system partners) or internal staff (e.g., staff engaged in a process or delivery
of a service), depending upon the specific process or service.
Increased reach to a target
population
Percentage of individuals in an identified target population that are offered or receive a given
service. Reach can be defined in different ways:
• Number of individuals in a target population offered services
• Number of individuals in a target population receiving at least one instance of an identified service
• Number of individuals in a target population receiving a complete service package (e.g., number of
school classes who receive a complete curriculum on nutrition)
• Number of individuals in a target population who gain access to a public health service or activity
(e.g., new walking/running/biking paths)
Dissemination of information,
products, or evidence-based
practices
Dissemination of public health-related information, health department products, and/or
evidence-based practices to the public and/or public health system partner organizations.
This is, in essence, a different type of ‘reach,’ where the focus is on reaching the public and/
or public health system partners with information, materials, products or evidence-based
practices in order to:
• Improve access to public health information or resources and/or
• Improve the performance of the public health system.
This outcome allows health departments to capture improvements resulting from increased
outreach, or enhancements to products or resources that lead to their greater uptake by
health system partners. Examples include but are not limited to:
Information
• Increased number of individuals accessing public health information on the health department
website
• Increased percentage of health departments engaging in QI/performance management/
accreditation readiness activities due to health department technical assistance and support
Products
• Increased percentage of Tribal or local health departments using the state health agency’s web-
based system for disease surveillance or case management
• Increase in the number of community partners using the CHIP for priority setting and program
development
• Increased percentage of testing sites using the T-SPOT TB test
Evidence-based practices
• Increased percentage of public schools using evidence-based school health asthma guidelines
• Increased percentage of health departments using the Guide to Community Preventive Services in
select programs due to health department support
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6. Annual Report Section II Guidance: Explanations
of Terms
www.phaboard.org
February 2014
Quality enhancement of
services or programs
Improving the quality of the delivery of a given service or implementation of a program.
The focus of this aspect of quality enhancement is on improved delivery of the health
department’s services or implementation of their programs. The types of specific
improvements intended to be captured by this outcome are as follows:
• Improved standardization or consistency in meeting existing standards or protocols of service or
program delivery
• Increased fidelity to existing protocols, procedures, or evidence-based practices
Examples include but are not limited to:
• Introduction of standard quality or performance criteria (e.g., checklists or protocols across
programs or staff )
• Increased compliance with established policies or procedures across health department programs
Quality enhancement of data
systems
Improving the quality of specific aspects of a data collection or health information system.
The focus of this aspect of quality enhancement is on improvements to an agency’s data or
health information system(s). The types of specific improvements intended to be captured by
this measure are as follows:
• Improvement in the accuracy of the data collection / health information system
• Improvement in or enhancement to the functionality of a system such as improving data displays or
reporting capacity
• Alignment of a system with external standards or requirements
• Increased completeness of data captured in system
• Increased access to data by health department staff or other entities
Examples include but are not limited to:
• Increased percentage of relevant birth records marked “deceased” in the agency’s digital
management system for infants and persons under 50 years of age
• Increased percentage of agency databases that are compliant with relevant standards
• Increased agency IT capacity for public health information exchange
• Improved functionality of linked data systems by adding the ability to automatically generate linked
data sets for a specific population.
• Increased ability of agency staff to meet external legal requirements and internal procedures related
to data acquisition, security and dissemination in key chronic diseases
Organizational design
improvements
Certain improvements to operations, processes, programs, or services require changes to
how, where, or when they are performed. These changes may occur within an organization
(i.e., the accredited health department), or they may occur by coordinating their delivery
across organizations (e.g., the accredited health department and another public health
agency).The types of organizational design improvements that may result from QI initiatives
include but are not limited to:
• Cross-jurisdictional sharing of public health skills, resources, and programs
• Reorganization of health department programs or services
• Reallocation of staff or other resources to more effectively address organizational priorities
NOTE: The intent of this outcome/measure is to track improvements that were needed due to
recognition that processes, services, or programs were not being implemented as effectively
as possible. In other words, improvements should result from intentional actions to address
an identified issue or area for improvement.
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7. www.phaboard.org
Annual Report Section II Guidance: Explanations
of Terms February 2014
Increased preventive
behaviors
Increase in the rate of preventive / health promoting behaviors and/or reduced risk of
preventable risk factors.
Examples of actual changes in preventive behaviors include but are not limited to:
• Increased percentage of adults who engage in 30 minutes of physical activity 5 or more days a
week
• Decreased percentage of adults who smoked at least 100 cigarettes in their lifetime, and are current
smokers
• Increased percentage of individuals who always use a seat belt while driving or riding in a car
Early Indicators/Intermediate Outcomes: Measurable characteristics or changes that indicate
progress towards the identified preventive/health promoting behavior of interest to the health
department.
• Awareness or Knowledge – increased awareness and/or knowledge about the need for behavioral
change to improve health
• Acceptability and Support – increase acceptability and/or support of behavioral change to improve
health
• Motivation to engage in preventive behaviors/access public health services – increase in motivation
to access services as a proxy for behavioral change
Decreased incidence/
prevalence of disease
Decreased incidence or prevalence of disease in target population.
*Adapted from: McLees A, Nawaz S, Young A, Thomas C. (2013, April). Defining and Measuring Quality Improvement in Public
Health. Panel presentation at the 2013 PHSSR Keeneland Conference, Lexington, KY. http://www.publichealthsystems.org/
uploads/docs/KC13_2D_McClees.pdf.
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