1.1The Structure of Public Health in Pennsylvania

ABSTRACT

A competent and skilled public health workforce is crucial in delivering the ten essential services of public health. Recognizing this, the Public Health Accreditation Board has incorporated workforce development and training into its national accreditation standards for State, Local, and Tribal Health Departments. Currently, the Allegheny County Health Department is in the pre-application phase of accreditation. Achieving accreditation status will ensure that the health department maintains standards related to population health. In June 2014, the Allegheny County Health Department administered a self-assessment of the Core Competencies for Public Health Professionals to its entire workforce to identify the training needs of the staff. The results of the survey will provide important, baseline data upon which a workforce development and training plan can be developed in accordance with accreditation standards. Through initial analysis of the assessment, it is recommended that the Allegheny County Health Department focus its efforts on public health policy, cultural competency, and the identification of community stakeholders. In addition, deputy directors and department managers will review assessment data relevant to their staff and identify trainings that can support the achievement of program-specific goals. Developing a training plan that supports the diversity of programs at Allegheny County Health Department will be a challenge; however, utilizing this type of evidence-based approach will best prepare its workforce to address current and future public health issues.

TABLE OF CONTENTS

preface

1.0case site

1.1The Structure of public health in pennsylvania

1.1.1Act 315: Pennsylvania’s Local Health Administration Law

1.2The allegheny county health department

1.3population the allegheny county health department serves......

2.0issue at hand

2.1domain 8 of accreditation: Maintain a competent public health workforce

2.2accreditation at the allegheney county health department

3.0literature review

3.1Workforce development defined

3.2Workforce development in the united states

3.2.1History of Workforce Development

3.2.2Workforce Development and Accreditation

3.2.3Methods for Workforce Development

3.3The importance of investing in the public health workforce

4.0methods

4.1development of survey

4.2determination of methods of analysis

4.3administration of survey

4.4analysis of survey responses

4.5determination of Training priorities

4.6next steps

5.0RECOMMENDATIONS

5.1Public health policy

5.1.1Reason to Address

5.1.2Recommended Trainings

5.2Cultural competency

5.2.1Reason to Address

5.2.2Recommended Trainings

5.3IDENTIFICATION OF STAKEHOLDERS

5.3.1Reason to Address

5.3.2Recommended Trainings

6.0conclusion

Appendix A: ORGANIZATIONAL STRUCTURE OF ALLEGHENY COUNTY HEALTH DEPARTMENT

Appendix B: ALLEGHENY COUNTY HEALTH DEPARTMENT TRAINING NEEDS ASSESSMENT SURVEY QUESTIONS

Appendix C: ALLEGHENY COUNTY HEALTH DEPARTMENT TRAINING NEEDS ASSESSMENT SURVEY SUMMARY OF DATA ANALYSIS

Appendix D: ALLEGHENY COUNTY HEALTH DEPARTMENT TRAINING NEEDS ASSESSMENT SURVEY AND THE TEN ESSENTIAL SERVICES OF PUBLIC HEALTH

appendix e: SCREENSHOT OF TRAIN TOOL

bibliography

List of tables

Table 1: Allegheny County Health Department number of employees by years in current position

Table 2: Allegheny County Health Department number of employees by program

Table 3: Training needs assessment survey average domain response

Table 4: Training needs assessment survey question findings

List of figures

Figure 1: State public health structure within the United States agency

Figure 2: Allegheny County Health Department percent of employees by years in current position

Figure 3: Allegheny County Health Department percent of employees by program

Figure 4: Location of Allegheny County Pennsylvania

Figure 5: Analysis of training needs assessment survey data breakdown

Figure 6: Training needs assessment survey average domain response

Figure 7: Training needs assessment survey average domain response

Figure 8: Ten Essential Services of Public Health

Figure 9. Allegheny County Health Department Organizational Structure

preface

I would like to take this opportunity to thank my advisor Gerald M. Barron, MPH for all of his support in identifying a case site for my essay and for his encouragement. I would like to thank Ronald Voorhees, MD MPH for his support through my practicum experience at the Allegheny County Health Department and for agreeing to be a reader of my essay.

I would also like to thank the Allegheny County Health Department for providing me with the opportunity to participate in their accreditation and workforce development and training efforts. I would especially like to thank Jamie Sokol, MPH my mentor at the health department and to whom I owe much of my success in identification of an essay topic and writing this essay.

1.0 case site

1.1The Structure of public health in pennsylvania

Public health infrastructure varies from state to state. Local agency responsibility can be independent or shared with the state health agency (National Association of County and City Health Officials, 2014). Health departments within a state can be centralized (state governed), decentralized (locally governed), or a mix of the two agency (National Association of County and City Health Officials, 2014). As shown in Figure 1, Pennsylvania’s structure is mixed.

(Source: National Association of County and City Health Officials, 2014)

Figure 1: State public health structure within the United States agency

The financing of public health and public health staff within a state also vary among states. It is estimated that from 2008-2013, local health departments in the United States lost approximately 28,000 total employees, approximately a 12% decrease in FTEs (National Association of County and City Health Officials, 2014). Although the amount of funding a state receives depends on the economic status of the state, about 50% of the funding for states come from the federal government, through grants, cooperative agreements, and contracts (Salinsky, 2010). In 2009, 76% of state health departments and 55% of local health departments reported cuts within the past 12 months (Meyer and Weiselberg, 2009). In Pennsylvania, the median annual per capita local health expenditure is less than $20 (National Association of County and City Health Officials, 2014). Such losses in funding and staff have significantly reduced the number of initiatives and programs that a community can implement, and they must find ways to insure that the programs and interventions within the state are improving the health status of the community in which they serve.

1.1.1Act 315: Pennsylvania’s Local Health Administration Law

Act 315 and its amendments guide health departments within Pennsylvania. Since its establishment in 1951, provisions and amendments have been made to strengthen the act. These include (Pennsylvania Department of Health, 2013):

Steps to establish a health department in Pennsylvania
Act 12, which adds environmental health support
Provisions to chapters 13, 15, 17, and 27

Additionally, Act 315 provides communities with (Pennsylvania Department of Health, 2013; Local Health Administration Law):

The authority to establish local health departments to serve their residents
The process of how to establish a local health department
Financial administration guidance
Documentation of powers and duties of local health departments, the director, and board of health
Local health department jurisdiction
State funding to recognized health departments to deliver public health services

Health departments within Pennsylvania, under Act 315, are required to address administrative and supportive services, personal health services, and environmental health services (Pennsylvania Department of Health, 2013).

1.2The allegheny county health department

The Allegheny County Health Department was founded in 1957 (Allegheny County Health Department, 2014) and today serves the over 1.2 million residents of Allegheny County Pennsylvania. A Board of Health governs the Allegheny County Health Department, its nine members receiving their appointments from the County Chief Executive and approved by the County Council (Allegheny County Health Department, 2013). During their four-year appointment, these members advise the County Health Director (and appoint one if needed) and perform the following duties (Allegheny County Health Department, 2013):

Formulate rules and regulations for the prevention of disease
Formulate rules and regulations for the prevention and removal of conditions which constitute a menace to health
Formulate rules and regulations for the promotion and preservation of the public health

The Allegheny County Health Department is one of only 6 county and 4 municipal health departments in Pennsylvania (Pennsylvania Department of Health, 2013). The mission of the Allegheny County Health Department is “to protect, promote, and preserve the health and well-being of all Allegheny County residents, particularly the most vulnerable” (Allegheny County Health Department, 2014). The workforce of the health department strives to fulfill the mission of the health department through programs and interventions aimed at improving health and well-being.

The health department employs 349 individuals, not including contractors (as of September 30, 2014). Demographics of health department employees are not available because the health department is an equal opportunity employer. Based on a self-assessment, it is possible to determine the number of years individuals working at the health department have been in their current role (Figure 2 and Table 1) and distinguish which programs individuals work in (Figure 3 and Table 2). Appendix A provides a current organizational structure of the Allegheny County Health Department.

Figure 2: Allegheny County Health Department percent of employees by years in current position

Table 1: Allegheny County Health Department number of employees by years in current position

Allegheny County Health Department
Number of Employees By Years
In Current Position / Response Count / Percent (%)
Less than 1 year / 49 / 14.8
1-5 years / 76 / 22.9
5-10 years / 70 / 21.1
10-15 years / 34 / 10.2
15-20 years / 24 / 7.2
Over 20 years / 79 / 23.8

Figure 3: Allegheny County Health Department percent of employees by program

Table 2: Allegheny County Health Department number of employees by program

Allegheny County Health Department
Number of Employees By Program / Response Count / Percent (%)
Administration / 30 / 9.0
Air Quality / 46 / 13.9
Chronic Disease and Injury Prevention / 2 / 0.6
Dental / 5 / 1.5
Directors Office/Leadership Team / 3 / 0.90
Epidemiology and Biostatistics / 8 / 2.4
Food Safety / 24 / 7.2
Housing and Community Environment / 26 / 7.8
Infectious Diseases/STD / 41 / 12.3
Legal / 3 / 0.9
MIS / 2 / 0.6
Maternal Child Health / 31 / 9.3
Other / 10 / 3.0
Preparedness / 3 / 0.9
Public Drinking Water/Waste Management / 33 / 9.9
Public Health Laboratory / 14 / 4.2
Public Information, Health Information and Publications / 4 / 1.2
WIC / 47 / 14.2

It is important to note that most of the individuals working in the health department work in regulatory roles and very few provide administrative support.

To better prepare employees to achieve the ten essential services of public health, the health department currently offers a limited set of trainings to employees. These trainings include:

Required Preparedness Trainings
Incident Command System 100 and 700
Points-of-Dispensing
American Heart Association CPR
American Heart Association First Aid
Hazmat Awareness (environmental health staff only)
Non-Required Preparedness Trainings
Personal Preparedness
Swift Water Awareness
Incident Command System 300/400 (for certain staff only)
Health Department Wide Trainings
HIPAA
New Staff Orientation
Public Health 101

Additional trainings are needed to improve the competencies and capabilities of the workforce at the Allegheny County Health Department.

1.3population the allegheny county health department serves

Allegheny County is located in Southwestern Pennsylvania (Figure 4). Historically, Allegheny County and the City of Pittsburgh were major players in manufacturing and soon became a major port city due to the strategic location of rivers and location of the early towns on the riverbanks (Allegheny County Pennsylvania, n.d). In 1852, the Pennsylvania Railroad opened up Allegheny County and Pittsburgh to continued trade and Allegheny County soon became known for its steel and iron industries (Allegheny County Pennsylvania, n.d).

(Source: Pennsylvania Department of Transportation, 2014)

Figure 4: Location of Allegheny County Pennsylvania

As of 2013, the estimated population of Allegheny County Pennsylvania is 1,231,527 (United States Census Bureau, 2014). Of these individuals, 81.3% identify as white (79.9% identify as white not Hispanic or Latino), 13.3% identify as black, 0.2% identity as American Indian and Alaska Native, 3.2% identify as Asian, 1.9% identify as two or more races, and 1.8% identity as Hispanic or Latino (United States Census Bureau, 2014). In Allegheny County, the median household income from 2008-2012 was $50,644, with 12.7% of the population living below poverty level (United States Census Bureau, 2014). In Allegheny County, 5.2% of the individuals are under the age of 5, 19.2% are under the age of 18, 17.1% are 65 years of age or older, 51.9% of individuals are female, and 48.1% individuals are male (United States Census Bureau, 2014).Educational attainment estimates from 2008-2012 are listed below (United States Census Bureau: American FactFinder, 2014):

Less than 9th grade: 2.1%
9-12 grade, no diploma: 5.3%
High school graduate: 31.5%
Some college, no diploma: 17.2%
Associate’s degree: 8.8%
Bachelor’s degree: 20.8%
Graduate or professional degree: 14.3%

2.0 issue at hand

The Public Health Accreditation Board (PHAB) notes “accreditation using the PHAB standards and measures can help a health department achieve performance excellence” (Public Health Accreditation Board, 2013b). The PHAB began working with health departments towards accreditation in September of 2011, with accreditation beginning in 2013 (Centers for Disease Control and Prevention, 2013). Accreditation of health departments is a voluntary program and signifies a health department is meeting national standards (Centers for Disease Control and Prevention, 2013). According to the PHAB, as of September 16, 2014, 54 health departments in the United States have received national accreditation (Public Health Accreditation Board, 2013a). National accreditation of health departments, although spearheaded by the PHAB, is supported by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation (Centers for Disease Control and Prevention, 2014a). Benefits and impacts of accreditation include (Centers for Disease Control and Prevention, 2010):

Improvement of health departments and infrastructure
Valuable and measurable feedback on strengths and areas for improvement
Improvements to delivery of public health services and programs
Quality and performance improvement within all public health programs to better respond to health challenges
Increasing accountability and credibility

There are seven steps of accreditation (Public Health Accreditation Board, 2014):

Pre-application
Application
Documentation Selection and Submission
Site Visit
Accreditation Decision
Reports
Reaccreditation

There are 12 domains of accreditation (Public Health Accreditation Board, 2013c):

Domain 1: Conduct and Disseminate Assessments Focused on Population Health Status And Public Health Issues Facing the Community
Domain 2: Investigate Health Problems and Environmental Public Health Hazards to Protect the Community
Domain 3: Inform and Educate about Public Health Issues and Functions
Domain 4: Engage with the Community to Identify and Address Health Problems
Domain 5: Develop Public Health Policies and Plans
Domain 6: Enforce Public Health Laws
Domain 7: Promote Strategies to Improve Access to Health Care
Domain 8: Maintain a Competent Public Health Workforce
Domain 9: Evaluate and Continuously Improve Processes, Programs, and Interventions
Domain 10: Contribute to and Apply the Evidence Base of Public Health
Domain 11: Maintain Administrative and Management Capacity
Domain 12: Maintain Capacity to Engage the Public Health Governing Entity

2.1domain 8 of accreditation: Maintain a competent public health workforce

Domain 8 of the accreditation process focuses on building a competent workforce that is better prepared to deliver the ten essential services of public health. Domain 8 has two standards that are required of health departments (Public Health Accreditation Board, 2013c):

Encourage the Development of a Sufficient Number of Qualified Public Health Workers
Assess Staff Competencies and Address Gaps by Enabling Organizational and Individual Training and Development

Under these standards, the health department must provide documentation of the following to measure each standard (Public Health Accreditation Board, 2013c):

Relationships and/or collaborations that promote the development of future public health workers
Workforce development strategies
A competent health department workforce
Professional and career development for all staff
Work environment that is supportive to the workforce

2.2accreditation at the allegheney county health department

Currently, the Allegheny County Health Department is in the pre-application phase of the accreditation process. This requires collaboration among staff members within different bureaus of the health department. Although there are many domains that must be addressed to become accredited, this essay looks at the second bullet above and addresses the process of determining the training needs of staff based on a self-assessment of core competencies. The documentation required for the measure “workforce development strategies” must include a workforce development plan and demonstrate that the health department implemented workforce development strategies (Public Health Accreditation Board, 2013c). An interdisciplinary working group, comprised of roughly twenty staff across all bureaus, has been developed to identify appropriate documentation for accreditation measures. The Allegheny County Health Department aims to submit an application for accreditation prior to December of 2015 and submit necessary documentation prior to December of 2016.

3.0 literature review

3.1Workforce development defined

It is challenging to define workforce development within the context of public health due to the difficulties in even determining who is considered a public health professional. A public health worker can be interpreted to include those who are drivers within a health agency, transporting lab samples, or to include doctors who provide guidance to individuals on their health and behaviors that impact their health. A public health worker can be defined as an individual who “provide[s] essential public health services, regardless of the nature of the employing agency” (Beck et al, 2012), including those at public, private, and voluntary organizations (Turnock, 2003). This includes “all those engaged during a significant part of time in work that creates the conditions within which people can be healthy” (Tilson and Gebbie, 2004).

Interviews with leaders in public health indicated that (Miner and Allan, 2014):

“The public health workforce needs to be up-to-date in the practice of public health at the federal, state, and local levels
There are organizations, personnel, and strategies in place to make this happen
Public health academia should be more engaged in educating and training for public health practice with this increase practice engagement also benefitting academia
There is a sense of ‘now is the time’ for public health to be as an essential player in the health care system”

Workforce development in public health “reflects the multiple disciplines constituting the field of public health” (Kaufman et al, 2014). Workforce development is thought to be a solution to gaps in competencies for public health workers who do not have a public health degree, a group that makes up a large portion of public health workers in the United States (Miner and Allan, 2014). However, not having a degree in public health or a lack of formal public health training does not mean that the current public health workforce is unprepared (Turnock, 2003).