Examining the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) Tool s Application within Florida's Local Health Departments 2011-2012 Environmental Public Health Leadership Institute Fellow: Julianne Price, R.S., B.S. Statewide PACE Coordinator; Florida Department of Health 1900 27 th St. Vero Beach, FL 32960 772-794-7445 Julianne_Price@doh.state.fl.us
EXECUTIVE SUMMARY: In 2011, the Florida Department of Health (FDOH) began undergoing an agency reorganization which proposed structural changes in its Division of Environmental Health (DEH). Historically, the DEH has been focused on programmatic and regulatory functions related to environmental health. A significant shift occurred in 2003, when a community environmental health assessment tool called the Protocol for Assessing Community Health in Environmental Health (PACE EH) was adopted by the FDOH to focus on a core public health component: assessment. The DEH supported the environmental health initiatives by circulating excesses in surplus revenue from permit fees back to county health departments to fund projects. Although FDOH has received national acclamation and won numerous awards for their PACE EH initiatives, approximately half of counties still have not chosen to conduct PACE EH assessments. Why is it difficult to fully implement and strengthen the Protocol for Assessing Community Excellence in Environmental Health across Florida despite the many obvious successes at the local level? Furthermore, how does PACE EH fit in with the current reorganization of the FDOH? To determine the root cause of the problem, data was gathered by polling each of Florida s sixty-seven county health departments to determine what prevented them from executing the PACE EH and whether they had ever performed an Environmental Public Health Performance Standard (EPHPS) self assessment. Two thirds of the health departments completed the survey. The results indicated that Environmental Health Managers perceived lack of funding and staff to be primary factors. The majority of health departments had never performed an EPHPS self assessment. It was evident that the FDOH DEH culture in county health focused primarily on enforcement and regulatory duties, rather than assessment functions. A clear need to improve the balance between enforcement and utilizing assessment more to engage communities to be empowered to work with local governments and stakeholder to solve issues was apparent. Becoming a partner in redeveloping a community instead of serving as an enforcer needs to be examined as a viable shift to start solving long standing community identified issues that have gone long ignored, only to be periodically band-aided with enforcement measures, but not permanently solved. INTRODUCTION/BACKGROUND: In the early days of statehood, Florida residents experienced poor sanitation, lack of mosquito control, and unregulated food practices that caused about 40 percent of the population of Jacksonville to flee the city due to a yellow fever epidemic which sickened a third of residents who stayed and killed over 400. Other epidemics of yellow fever and cholera affected the state almost annually, one of which almost killed the entire town of St. Joseph in 1841. Medical care was not widely available for the ill and therefore, weaker people died, but not before transmitting disease to many others. Numerous people who survived were carriers and continued to pass on the diseases to others due to poor sanitary practices and conditions. As a response to the deadly epidemics, widespread illnesses, and subsequent deaths of so many people, Florida's state health department was created in 1889. The main function of the state health department was to control infectious diseases. As the management and eradication of diseases improved, life expectancy increased and the focus of public health shifted to chronic
disease conditions such as obesity, heart disease, poor nutrition, and exposure to carcinogens in the environment. (1) In 2011, the Institutes of Medicine (IOM) issued recommendations that state and local governments form health councils to craft community health improvement plans in union with the private sector. The report stressed the importance of diagnosing community health hazards, enforcing public health laws and evaluating population-based services and suggested state health agencies ensure they have enough funding and staffing to provide 10 Essential Public Health Services. In 2003, The FDOH decided to adopt and encourage environmental health divisions in local health departments to utilize assessments such as PACE EH to determine what factors were negatively affecting and influencing communities health. The FDOH DEH utilized the PACE EH tool and to date, approximately 45 environmental health assessments have been performed in communities across the state, led by local health departments. To enhance this effort, the FDOH applied for a federal grant in late 2010 to improve the agencies public health infrastructure. Mini-grants were offered to all local health departments for community health improvement planning and assessments. Problem Statement: Florida continues to experience unprecedented growth. Despite the recent economic recession Florida continues to attract new residents, increasing the burden on schools, highways, water supplies, and open spaces. Throughout the state a number of communities exist in third world conditions without potable water and functioning sewage disposal systems. PACE EH has been identified as a possible solution to community issues that have slipped through the cracks or are simply deemed problems too large to solve. The FDOH has a long history with this process, dating back to membership on the project s steering committee in the mid-1990s. The FDOH mission statement for PACE EH is to engage and empower residents to collectively solve environmental health problems and improve their quality of life. The Florida Department of Health is the only state agency in the nation that has made it a priority to support PACE EH projects. Funding is derived from surplus budget when available; however, there is no permanent or dedicated funding source. Over 45 PACE-EH projects throughout the state have yielded significant results; however, less than half of the local health departments in Florida have not performed a PACE EH assessment. Why has it been so difficult to implement and strengthen PACE EH across Florida in light of the many successes at the local level? Behavior Over Time Graph: To assess this problem, variables were identified and charted to look at trends: Level of PACE tool utilization- this variable indicates the annual number of PACE EH initiatives that occurred in FL
EH Community Issues- this variable represents the level of EH issues present in a community (i.e.- substandard housing, contaminated land and water, substandard septic systems, safety, and built environment barriers) Level of enforcement- this variable indicates the amount of enforcement (regulatory) action taken to address EH violations Variables Over Time Variable value 20 15 10 5 0 2003 2006 2009 2012 Year Level of PACE tool Utilization EH Community Issues Level of Enforcement When PACE EH utilization was at its peak, the amount of environmental health community issues was at its lowest. An explanation for this is that PACE EH is actually solving or addressing long standing community environmental health issues. When PACE EH activity decreases, enforcement increases. This is due to a short term fix of an environmental health issue in a community by using a singular enforcement action to correct the problem. The decrease in enforcement is projected for 2012 based on legislation that is currently proposed. If you do not manage culture, it manages you, and you may not even be aware of the extent to which this is happening. Edgar Schein, professor MIT Sloan School of Management Thus far, the variables and reasons for local health departments not administering PACE EH have been outlined, but the structure and culture influences of the FDOH must also be considered. In the following diagram, one can observe how the culture of our DEH places an emphasis on enforcement activity to solve environmental health issues. Looking at the bigger picture of the organizational culture, a deduction could be made that the history and tradition of the organization tends to focus on regulatory activity. In interviews with local environmental health leaders, they discussed how their divisions programmatic structure revolves around enforcement and the fees they collect for enforcement and permitting activity. Program evaluations primarily take place for regulatory functions within the department.
Causal Loop Diagrams and applicable Archetypes: Shifting the Burden Diagram: Reflections of EH Culture and PACE EH tool Why are we even doing PACE? It s not a requirement Quick Fixes: Enforcement O B Side Effect: Perceived need to seriously take on PACE EH Side Effects: Resources available for long term Problem Symptom: Community EH Issues R Side Effects: Mistrust of Government B Gaining trust is taking too much time! This is not traditional EH Long-term Solutions: PACE EH S
Project Logic Model:
PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES: Program Goal: To increase the usage of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) tool to address long standing environmental health issues in impoverished communities in Florida. Health Problem: The number of indigent communities with environmental health issues exists in all 67 counties in Florida. Community identified issues that plague residents range from contaminated land and water, substandard septic systems, safety, and built environment barriers. Outcome Objective: By September 30, 2012 increase county health department participation with PACE EH by at least 20% of the 2010 baseline. Determinant: The number of completed PACE EH interventions that result from county health department participation will create improved health outcomes. Quantitative data from tangible solutions to the community identified issues will be reported as well as written report deliverables on what actions were achieved and the improvements realized. Impact Objective: By December 31, 2011 100% of the county health departments will have been offered funding and technical assistance to perform a PACE EH intervention. Therefore, numerous communities will benefit from improved environmental health as long standing issues will have been addressed and/or solved. Contributing Factors: 1. Lack of understanding on the importance, effectiveness and health benefits of the PACE EH tool. 2. Lack of staff capacity to perform an environmental health assessment spanning a time frame of 12-18 months. 3. Reliance on enforcement as a solution of environmental health issues by county health departments. Process Objectives: 1. By July 15, 2011, make contact with all 67 county health department EH Administrators to seek necessary information pertaining to discovering why they are not adopting and implementing PACE EH in their counties. Event: Survey distribution to county health department EH Administrators Activities: Develop questions that gather data which will reveal obstacles to performing PACE EH Conduct a formal survey to gather data from EH Managers in a uniform fashion. Compile results and analyze the data. 2. By December 31, 2011, provide all 67 county health departments with the resources they need to perform a PACE EH intervention. Event: Offer grant funding and technical assistance to all health departments Activities:
Conduct monthly technical assistance calls. Ensure funding is given to health departments desiring to do PACE EH Train new coordinators in skills needed to perform duties. 3. By December 31, 2012, achieve enabling over half of our FL counties (a 20% increase) to have either begun or completed a PACE EH initiative. Event: Analyze deliverable of grant and data to determine whether this objective has been met. Activities: Present findings in a power point presentation to summarize successes. Determine if project was successful. Develop a PACE EH business plan to continue successes of increased participation and implementation by county health departments. METHODOLOGY: In order to discern why environmental health divisions within local health departments were not implementing PACE EH, a survey was sent to all the health departments in 67 counties in Florida. The survey consisted of five questions and 38 of the state s local health departments completed the survey.
Determining the root cause for why all local health departments haven t implemented PACE EH was necessary to determine and ascertain the sustainability of PACE EH. The survey data indicated that over two-thirds of responders had never performed an Environmental Public Health Performance Standard (EPHPS) self assessment to determine performance gaps in services they administer locally. This result illustrates that local health departments may not even be aware that they have a performance and service delivery gap in the area of assessment. Events and Activities Related to this project, I was able to utilize local projects funding from central FDOH office for county health departments to try an EPHPS self assessment. During July- September 2011, the Indian River County Health Department s Environmental Health Division (IRCHD EHD) and five other local health departments in Florida each performed an assessment of their environmental public health system. Utilizing a system based approach, the assessment involved a wide range of participants from programs such as environmental quality, civic organizations, laboratories, nonprofits, local government, and community development. By performing the EnvPHPS assessment, Environmental Health realized that our focus tends to be on enforcement and regulation. While this is a very important service we perform, our scores on the other essential services, combined with the feedback from stakeholders indicate we need to take a broader, more holistic approach to environmental health. Feedback from counties who did the assessment often commented that staff is laser focused on their individual specialties and did not look at how their programs fit in with the system or how they are related to the community. By
performing the EnvPHPS assessment and engaging in quality improvement activities, our division has had the opportunity to examine how our services balance with the national standards that are being set in environmental health so that locally, we can align our services and capacity to be able to deliver quality services and to operate at maximum efficiency. Next steps are to implement action plans by accomplishing measurable objectives and strategies that were collectively developed by environmental health staff. RESULTS: Survey data collected from environmental health managers reveals that respondents feel there is a lack of funding and staff to perform assessments such as PACE EH. This survey was distributed shortly after the FDOH offered funding to all 67 local health departments for the purposes of improving performance and health outcomes through assessment work. Funding was offered to all health departments in 2010-2011 yet lack of funding was cited as a reason that inhibits them from performing PACE EH. As time and staff were also identified a top factors standing in the way of local health departments taking on a PACE EH assessment, then one can deduct that because funding was offered and could be used to hire staff or to pay existing staff for time spent on assessment activity, that these two factors also are negated by the auspices of the respondents perception that there are a lack of resources. Conversations with county Environmental Health Managers revealed that many wanted to perform PACE EH, but their county Health Department Administrator decided grant monies awarded to them would be allocated to projects other than PACE EH. One could deduct that a lack of education and information regarding the applicability of PACE EH and importance of the core public health function of assessment to local county environmental divisions could be the ultimate root cause for the lack of PACE EH activity. People often accuse environmental health of being just in the business of enforcing laws. And these are really important laws that we are enforcing; however, environmental health also has a role in the other services, which PACE EH can help to bring about. In late 2011, national standards were developed for the accreditation of local health departments. Standards and criteria for accreditation are fundamentally based on the 10 essential services. Although there have been a few health departments that participated in beta testing for the accreditation, most environmental health staff remain unaware of how PACE EH fits in with accreditation. The diagram below illustrates the essential services that PACE EH fulfills. For example, the first broad category of services is assessment. It s an assessment of the community s environmental health so it involves monitoring health. Additionally, PACE EH fulfills the assessment requirement that local health departments must have performed in order to earn accreditation.
PACE EH and Accreditation Readiness: Essential Services And improve the leadership skills of your EH staff while you do it! The process may also inform how you fulfill existing mandates Engage in policies and other actions needed to address key issues Assess community environmental health Empower residents to identify EH issues and actions Bridge the gap between residents, local government & other stakeholders Figure 1: Osaki, Ten Essential Environmental Public Health Services National Goals Supported National Strategy to Revitalize Environmental Public Health Services: This project supports Goal I, Build Capacity. Goal I is to strengthen and support environmental public health services at the state, tribal, territorial, and local levels. This project builds the capacity at all levels by utilizing a common methodology (PACE EH) to collectively solve a problem, empower a local community, and ultimately, achieve a solution to a long standing environmental hazard or issue. This project supports Goal VI, Create Strategic Partnerships. Goal VI emphasizes the fostering of interactions among agencies, organizations, and interests that influence environmental public health services. PACE EH was developed primarily by two national agencies, the Centers for Disease Control and National Association for County and City Health Officials. As a state agency, the FDOH administers PACE EH in local county health departments. County health department staff facilitates communication between stakeholders and residents to achieve action that they continue to utilize even after PACE EH is complete. In the truest sense, PACE EH forges strategic partnerships between levels of governments, private and public sectors, different agencies, cultures, and geographical divides.
PACE EH also embodies Goal III, Foster Leadership. The objective of this goal is to foster strong leadership to enhance environmental public health services. FDOH has won many national awards for its application of PACE EH as an innovative method for solving environmental health issues and has remained committed to supporting the program since 2003. PACE EH is cited in the National Strategy to Revitalize Environmental Public Health Services: Environmental public health professionals need to recognize and address the unique needs, beliefs, and practices of communities. PACE-EH 12 is an excellent tool to use in tackling this problem because it fosters collaboration among public health agencies and their communities to assess the environmental public health needs of the community. (2) 10 Essential Environmental Health Services The project content addresses gaps in Essential Services: 4.1A, 4.2A, 5.1A, 5.2B, 5.2C, and 5.3A and the PACE EH tasks and Essential Services further correlate as shown in the chart below. Essential Environmental Health Services Monitor health status to identify community environmental health problems Diagnose and investigate environmental health problems and health hazards in the community PACE-EH Task # 4-9 5-9 Activities Associated with PACE-EH Tasks Assessing the environmental health needs of the community Assessing the environmental health determinants in the community Investigating the occurrence of environmentally related events Enforce laws and regulations that protect health and ensure safety 11-13 Protecting residents from exposure to contaminants and hazardous surroundings Link people to needed environmental health services and assure the provision of environmental health services when otherwise unavailable 12 Implementing an environmental health program Managing resources and developing sound organizational structures Assure a competent environmental health workforce 1 Assess skills and capacities of environmental health workforce Provide appropriate training to build capacities in coalition building, data collection and analysis, etc.
Evaluate effectiveness, accessibility, and quality of personal and population-based environmental health services Develop policies and plans that support individual and community environmental health efforts Mobilize community partnerships to identify and solve environmental health problems Inform, educate, and empower people about environmental health issues Research for new insights and innovative solutions to environmental health problems and issues 13 10-11 1-3 1-13 12-13 Evaluating programs and developing quality assurance mechanisms Setting priorities for environmental health action Developing plans and strategies to address environmental health priorities Advocating for environmental health improvement, building constituencies, and identifying community resources Inform and educate the public about environmental health issues Select intervention and prevention activities for identified environmental health issues Conduct process and outcomes evaluations of selected activities Source: Island County Health Department, WA CONCLUSIONS: The culture of depending mainly on enforcement to solve community environmental health issues needs to change to meet current needs. As the shifts in decrease of regulation occur, the culture of public health will need to adapt by solving problems using other mechanisms. Communities need help meeting basic needs and right now the need is greater than ever for public health to assist. Accreditation and the development of the EPHPS s are opportunities for county health departments to align with a more holistic strategy to meet needs and align themselves with national objectives. The divisional silos that once separated governmental agencies, sectors, and divisions are weakening as the economy and politics dictate that we must work together across levels to accomplish goals and strategies efficiently to ensure the core services of public health are delivered. While learning from the past, we must look towards the future to utilize innovative solutions like PACE EH to solve broader, complicated community environmental health issues in a holistic way. "Environmental public health is one of the most vital and rapidly expanding fields of public health. The duties have moved far beyond that of the inspector or the regulator. The environmental public health specialist of the 21st century needs to be on the front lines of disease
prevention, using new and effective tools and methods to investigate the environmental causes of disease and mortality. - Dr. Richard Jackson, M.D., M.P.H. LEADERSHIP DEVELOPMENT OPPORTUNITIES: Julianne Price, R.S., B.S. The initial plans that I had for my EPHLI project were modified at the first meeting in Atlanta. I had grand ideas about breaking down silos and getting different agencies and levels of governments to work together like a finely oiled machine to improve our community s environmental health issues through assessment work. Early on, a supervisor named Meade Grigg listened to my project ideas and said, Culture trumps strategy every time. His words stuck in my head and as I tried to develop a strategy and utilize systems thinking, I realized it was the culture of our systems that needed to be changed. EPHLI really affirmed for me that my supervisor, Daniel Parker has a great vision for PACE EH and that local county health environmental health managers like Cheryl Dunn are good leaders who see value in assessment work and performance improvement. Leaders create the change in the culture and it takes time. While my EPHLI project did lead me to such reaffirmations and revelations about organizational culture, I think perhaps the most valuable part of the experience to me was the personal development and individual development plan. The data provided to us about our management style and personality types was extremely beneficial and led to substantial personal and professional growth.
ABOUT THE EPHLI FELLOW Julianne Price is the Florida Department of Health s Statewide PACE Coordinator and an Environmental Specialist at the Indian River County Department s division of Environmental Health. Julianne s diverse work history includes employment at Washington State Park Recreation Commission and working for Raytheon Technical Services, in Hohenfels, Germany, as an Operations Administrator. She is a graduate of the University of North Carolina at Asheville with a B.S. in Natural Resource Management from the Environmental Studies program. In 2008, she earned the accreditation as a Registered Sanitarian (R.S.) Her work has been published in two text books and numerous journals and earned her NACCHO s Jim Parker Award, two Promising Practices Awards, a Model Practice Award, four Davis Productivity Awards, ASTHO s Best Practice Award, and was featured in the Public Health Grand Rounds documentary. Julianne also founded and is the President of the housing nonprofit, Every Dream Has A Price, Inc. and was awarded the Governor s Point of Light Award for her volunteer efforts. The Governor hailed Julianne, saying She is an asset and hero in her community and is an example to others. Specific works: www.everydreamhasaprice.com http://www.doh.state.fl.us/environment/programs/pace-eh/pace-eh.htm
REFERENCES 1. http://www.doh.state.fl.us/planning_eval/phealth/history.htm 2. Centers for Disease Control and Prevention, A National Strategy to Revitalize Environmental Public Health Services, Atlanta, Georgia, Department of Health and Human Services, October, 2003.