Leveraging

Commentary
Leveraging the Revised National Public Health
Performance Standards to Meet Today’s
Ever-Changing Public Health System Landscape
Teresa Daub, MPH, CPH; Sonal Doshi, MPH, MS; Julia Joh Elligers, MPH; Denise Pavletic, MPH, RD;
Trina Pyron, MA
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T

he 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 ver-

sion 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

Author Affiliations: Centers for Disease Control and Prevention, Office for
State, Tribal, Local and Territorial Support, Division of Public Health
Performance Improvement, Atlanta, Georgia (Mss Daub, Doshi, and Pyron);
National Association of County & City Health Officials, Washington, District of
Columbia (Ms Elligers); and Association of State and Territorial Health Officials,
Arlington, Virginia (Ms Pavletic).
The authors thank the National Public Health Performance Standards (NPHPS)
version 3 work groups and field test sites, for their contributions throughout
the NPHPS revision process, and Valeria Carlson, for her contribution to this
commentary.
The findings and conclusions presented here are those of the authors and
do not necessarily represent the official position of the Association of State and
Territorial Health Officials, the National Association of County and City Health
Officials, or the Centers for Disease Control and Prevention.
The authors declare no conflicts of interest.

J Public Health Management Practice, 2014, 20(1), 135–137
C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright 

Correspondence: Teresa Daub, MPH, CPH, Centers for Disease Control and
Prevention, 4770 Buford Hwy NE, MS E-70, Atlanta, GA 30341 ([email protected]).
DOI: 10.1097/PHH.0b013e3182a7bdae

135
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136 ❘ Journal of Public Health Management and Practice
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

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Leveraging NPHPS in Today’s Public Health System Landscape

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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