The role of health departments in delivering the 10 essential public health services (EPHS) is important to fulfilling public health's mission to ensure the conditions in which people can be healthy.1,2 This mission has never been one that can be achieved by health departments acting alone.1,2 However, recent public health program cuts and job losses have highlighted a need for increased collaboration between health departments and their system partners.3 The 2010 passage of the Patient Protection and Affordable Care Act also generated new opportunities for health departments to work with system partners to improve the public's health.4,5

For the past decade, the National Public Health Performance Standards (NPHPS), versions 1 and 2, have offered tools to assess the performance of state and local public health systems (PHS) on the 10 EPHS.6,7 In 2013, these NPHPS were revised (version 3) to provide health departments and their system partners with an updated tool for assessing and improving performance within the context of existing organizational challenges and a constantly changing landscape of public health services. With the release of NPHPS version 3 and the 2011 launch of a national public health agency accreditation system by the Public Health Accreditation Board (PHAB), both agency and system performance improvement tools now exist.

The 2013 NPHPS revision addressed 4 major priorities: streamlining the assessment process; enhancing systems-building and partner engagement features; promoting performance and quality improvement; and strengthening linkages with PHAB accreditation. Developed through a practice-driven process, NPHPS version 3 materials were field tested during the fall of 2011 and released in the spring of 2013.

Streamlining the NPHPS resulted in simpler assessment instruments. This was achieved, in part, through a reduction in the number of scored assessment questions: version 2 state and local instruments had 466 and 326 questions, respectively, whereas version 3 state and local assessments have considerably fewer questions at 115 and 108, respectively. This reduction in the number of assessment questions enabled field test participants to spend the majority of their assessment time discussing how their organizations contribute to the EPHS and identifying related strengths, weaknesses, and opportunities for improvement. Participants found that while this shift to a highly discussion-oriented assessment process takes a similar amount of time to implement as version 2, it allowed for a more substantive information exchange among partners (S.D., unpublished data, January 2012).

The importance of systems building among the PHS partners cannot be emphasized enough, given the complex array of entities that comprise the system and the changing social, political, and economic contexts in which public health services are delivered. The diversity of PHS partners includes such entities as hospitals, community health centers, transportation agencies, churches, housing authorities, private foundations, civic organizations, and grassroots advocacy groups. NPHPS version 3 provide sample lists of PHS partners for each EPHS to aid in identifying and engaging partner participants prior to the assessment.

In completing the assessments, PHS partners participate in facilitated conversations to uncover organizational activities related to EPHS delivery and the extent to which different entities work together to ensure that services meet the needs of their community/state. For example, in one community, service providers who identified workforce shortage as a concern learned for the first time about the local community college's efforts to assess workforce needs and tailor curricula to meet local workforce demands.

In addition to streamlining and systems building, the NPHPS were revised to help PHS identify areas to focus improvement efforts, set improvement goals, and develop an action plan for achieving these improvement goals. NPHPS version 3 assessments include a Strengths-Weaknesses-Opportunities-Priorities (SWOP) worksheet for each EPHS to help PHS capture valuable qualitative data. NPHPS postassessment materials also provide guidance for identifying and implementing quality improvement activities.

An NPHPS assessment results in both quantitative and qualitative data that may be used for performance and quality improvement. Quantitative scores for each EPHS are a self-assessment by the participants of how well the PHS is implementing each service compared with optimal levels. The quantitative score helps system partners identify a focus area for improvement, whereas qualitative comments may provide rationale, details, and ideas for action. Qualitative information identified via the SWOP worksheet may include the following: resources that can be used to address priority areas; reasons why the system performs well in some areas and not in others; opportunities to reduce duplication and inefficiencies; opportunities to pool resources; hypotheses about what types of strategies and activities might be effective; and desired outcomes of improved system performance.

A final and important use of NPHPS assessments is to assist health departments preparing for or maintaining PHAB accreditation status. Both NPHPS and PHAB standards reflect significant alignment with one another, with both being based on the same EPHS framework; NPHPS version 2 informed PHAB standards development.8 This complementary relationship between NPHPS and PHAB is strengthened through the 2013 NPHPS revision in which version 3 tools were adapted to further complement the PHAB national accreditation program for public health agencies.

There are 3 scenarios in which the NPHPS assessment process and results may be useful in preparing for accreditation. First, there is an explicit connection with PHAB accreditation where NPHPS are referenced within PHAB's standards and measures documentation guidance.9 Specifically, NPHPS are provided as an example of a tool or process to meet the following 3 PHAB measures: Measure 1.1.1 (state/community health assessment); Measure 4.1.2 (models of community engagement); and Measure 5.2.1 (community health improvement plan).9

Second, NPHPS may be used to identify and document the health department's participation in, or contribution to, other PHS activities where collaboration is necessary to meet PHAB standards. The NPHPS assessment process and its related documentation may be used to identify where, and with whom, the partnerships necessary to meet PHAB standards exist.

Third, health departments may use the NPHPS process to identify potential quality improvement opportunities and/or solutions that support PHAB Standard 9.2, in which agencies must "...develop and implement quality improvement processes."9 Results from the NPHPS SWOP analysis may help health departments identify quality improvement projects, as well as potential solutions to address weaknesses noted through the accreditation process.

Summary

NPHPS version 3 provide a mechanism for engaging system partners in state/community health improvement and, potentially, health system transformation. The 2013 NPHPS revision resulted in important changes to these assessment tools to complement the PHAB standards and measures in this new era of public health accreditation. The resulting NPHPS tools provide a means for the public health agency and the system in which the agency operates to collect valuable performance information that contributes to the health assessment and improvement processes that are foundational to public health agency accreditation and may be used to catalyze quality improvement efforts at both the agency and system levels.

The revised NPHPS also offer a valuable method for the PHS to identify the important contributions of system partners to the health and well-being of their citizens. This is particularly relevant for communities undertaking Mobilizing for Action through Planning and Partnerships10 or State Health Improvement Plan processes.11 In these cases, communities may use NPHPS data, along with information about community health status, forces of change, and community assets, to develop a comprehensive understanding of public health issues and identify strategic action steps for improving overall health in a community/state.

Understanding the roles of all players (or stakeholders) is critical to transforming the nation's PHS. Using NPHPS, health departments and their partners may assess PHS performance and begin to understand their organization's role within this ever-evolving system. Public health agencies may use the resulting information to help achieve or maintain accreditation status; whereas the PHS may use the NPHPS assessment process to develop plans for realizing efficiencies, sharing resources, filling service gaps, reducing duplication of services, and identifying other improvements.

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