Michael
Pratt,
MD,
MPH
Sherri
McDonald,
RN,
MPA
Patrick
Libbey
Mark
Oberle,
MD,
MPH
Arthur
Liang,
MD,
MPH
Local
Health
Departments
in
Washington
State
Use
APEX
to
Assess
Capacity
Drs.
Pratt,
Oberle,
and
Liang
are
with
the
Centers
for
Disease
Con-
trol
and
Prevention.
Dr.
Pratt
is
a
medical
epidemiologist
in
the
Health
Interventions
and
Transla-
tion
Branch,
Division
of
Chronic
Disease
Control
and
Community
Intervention,
National
Center
for
Chronic
Disease
Prevention
and
Health
Promotion.
Dr.
Oberle
is
a
Medical
Officer
and
Dr.
Liang
is
in
the
Epidemiology
Program
Office.
Ms.
McDonald
is
the
Assistant
Director
and
Mr.
Libbey
is
the
Director
of
the
Public
Health
and
Social
Services
Department,
Thurston
County,
WA.
Tearsheet
requests
to
Michael
Pratt,
MD
MPH,
Health
Interventions
and
Translation
Branch,
Division
of
Chronic
Disease
Control
and
Community
Intervention,
National
Centerfor
Chronic
Disease
Prevention
and
Health
Promotion,
Centersfor
Disease
Control
and
Prevention,
Mailstop
K-46,
4770
Buford
Highway,
Atlanta,
GA
30341-3
724;
tel.
404
488-5522;fax
404
488-5964.
SYNOPSIS
THE
ASSESSMENT
PROTOCOL
for
Excellence
in
Public
Health
process
was
carried
out
in
the
state
of
Washington
to
assess
local
heafth
department
capacity
and
to
identify
their
self-perceived
strengths
and
weaknesses.
Staff
from
24
of
the
32
local
health
departments
in
Washington
completed
organizational
capacity
assessments.
Fifty
percent
or
more
of
the
health
departments
identified
the
following
eight
indicators
as
strengths:
legal
authority,
public policy
and
implementation,
budget
development,
financial
reporting
and
administration,
audit,
financial
documenta-
tion,
organization
and
structure
of
program management,
and
policy
board
pro-
cedures.
Seven
indicators
were
identified
as
weaknesses
by
50%
or
more
of
the
respondents:
legal
counsel,
mission
and
role,
data
collection
and
analysis,
planning
and
development,
evaluation
and
assurance
of
community
health
assessment,
community
heafth
assessment
and
planning,
and
community
heafth
policy.
The
results
of
the
assessment
highlight
the
traditional
organizational
and
ser-
vice
delivery
strengths
of
the
local
heafth
departments
and
point
out
weaknesses
in
their
ability
to
assess
community
heafth
and
to
develop
communitywide
heafth
policy.
Te
here
are
nearly
3,000
local
health
departments
spread
across
the
United
States'.
Relatively
little
effort
has
been
devoted
to
the
study
of
local
health
departments
despite
their
critical
role
in
assuring
public
health.
Since
1945
a
handful
of
studies
have
listed
local
health
departments
and
described
their
jurisdictions,
staff,
structures,
and
patterns
of
service
deliveryl'.
It
is
difficult
to
discern
from
these
descriptive
studies
how
well
local
health
departments
are
carrying
out
the
three
core
functions
of
public
health
identified
in
the
Institute
of
Medicine's
1988
report
The
Future
of
Public
Health:
assessment,
policy
development,
and
assur-
ance5.
In
that
report,
the
Institute
of
Medicine
noted
that
local
health
depart-
ments
are
understaffed,
overworked,
and
focus
on
assurance
(service
delivery),
largely
at
the
expense
of
assessment
and
policy
development
functions.
In
response
to
these
observations,
the
American
Public
Health
Association,
the
Association
of
Schools
of
Public
Health,
the
Association
of
State
and
Ter-
ritorial
Health
Officials,
the
Centers
for
Disease
Control
and
Prevention
January/February
1996
*
Volume
I
lit
s
MA
.FM.
A N
L L
Public
Health
Reports
87
Scientific
Contribution
(CDC),
the
National
Association
of
County
Health
Offi-
cials
(NACHO),
and
the
United
States
Conference
of
Local
Health
Officers
collaborated
to
develop
the
Assess-
ment
Protocol
for
Excellence
in
Public
Health
(APEXPH
or
APEX)6.
The
APEX
process
was
designed
to
assist
local
health
departments
in
assessing
and
improving
their
own
organizations
and
in
working
with
the
local
community
to
assess
and
improve
the
health
status
of
the
citizenry.
In
the
state
of
Washington,
however,
considerable
interest
devel-
oped
in
using
APEX
to
provide
a
statewide
overview
of
local
health
department
capaci-
ties,
strengths,
and
weaknesses
as
perceived
by
their
staff.
This
study
was
designed
and
carried
out
by
the
Washington
State
0
Association
of
Local
Public
Health
Officers,
the
Depart-
ment
of
Health
and
CDC
to
assess
local
health
department
capacity
in
the
state
of
Wash-
S
ington
and
to
identify
strengths
and
weaknesses
of
local
health
departments.
Methods
The
current
APEX
manual
was
pilot
tested
by
more
than
40
local
health
departments
across
the
country.
The
manual
consists
of
three
sections:
Part
I,
Organizational
Capacity
Assessment;
Part
II,
The
Community
Process;
and
Part
III,
Completing
the
Cycle6.
These
sections
are
designed
to
guide
health
departments
through
self-assessment
and
community
assessment
and
through
the
development
of
action
plans
to
address
priority
problems.
The
initial
phase
of
the
Washington
APEX
pro-
ject
focused
solely
on
Part
I:
Organizational
Assessment.
The
organizational
capacity
assessment
requires
health
department
staff
to
describe
the
agency's
performance
in
terms
of
approximately
200
indicators
that
can
be
grouped
into
nine
broad
functional
areas:
Operational
authority
indicators
encompass
the
develop-
ment
and
enforcement
of
local
regulations,
intergovernmen-
tal
relations,
and
the
availability
of
legal
counsel
for
local
health
departments
to
address
issues
of
public
health
law.
Community
relations
includes
working
with
other
organiza-
tions
and
the
public
and
communicating
with
the
media
and
the
public.
Community
health
assessment
scores
reflect
the
existence
of
a
clear
mission
statement
and
the
collection,
analysis,
and
utilization
of
community
health
data
for
pro-
gram
evaluation
and
planning.
The
public
policy
development
indicators
also
involve
the
use
of
data
for
planning
and
pri-
ority
setting,
but
by
the
board
of
health,
citizens
advisory
groups,
and
local
government.
The
assurance
ofpublic
health
services
variables
measure
whether
personal
and
environ-
mental
health
services
are
available
in
the
community.
I
S
Other
variables
address
financial
management,
personnel
management,
program
management,
and
interaction
with
a
policy
board.
A
standardized
self-administered
questionnaire
was
de-
veloped
for
use
in
Washington
by
the
Washington
State
De-
partment
of
Health
(DOH),
the
Washington
State
Associa-
tion
of
Local
Public
Health
Officials
(WSALPHO),
CDC,
and
NACHO.
The
approximately
200
APEX
indicators
fit
into
the
32
broader
variables
listed
in
the
table.
An
organi-
zational
capacity
asssessment
team
from
each
participating
health
department
rated
their
department's
performance
on
these
variables
as
"acceptable,"
as
a
"strength,
or
as
a
"weak-
ness."
The
teams
included
members
of
senior
management
as
well
as
representatives
from
*
E
major
units
of
the
health
department.
DOH,
CDC,
and
NACHO
provided
the
local
health
a
3
departments
with
technical
assistance
and
training
in
con-
sensus
development
and
in
the
use
of
the
APEX
manual.
Rep-
resentatives
from
each
local
health
department
and
the
sponsoring
organizations
par-
ticipated
in
an
initial
two-day
meeting
to
orient
local
health
department
staff
to
the
APEX
process.
Health
departments
that
opted
to
partici-
pate
in
the
Washington
APEX
Project
attended
an
addi-
tional
fill-day
workshop
four
months
later
in
which
partici-
pants
discussed
and
adopted
a
standardized
approach
to
completing
the
questionnaire.
The
entire
process
was
coor-
dinated
by
WSALPHO.
DOH
staff
were
made
available
to
any
local
health
department
that
wanted
on-site
assistance.
The
data
were
aggregated
by
CDC
and
analyzed
by
WSALPHO,
DOH,
and
CDC.
Results
Twenty-four
of
the
32
local
health
departments
and
dis-
tricts
in
Washington
participated
in
the
study.
Both
large
and
small
health
departments
were
included
among
the
24.
Representation
from
the
western
(14
health
departments)
and
the
eastern
(10
health
departments)
regions
of
the
state
was
nearly
equal.
The
table
lists
the
percentages
of
health
departments
that
rated
their
performance
on
each
of
the
indicators
as
acceptable,
as
a
strength,
or
as
a
weakness.
Eight
indicators
were
identified
as
strengths
by
50%
or
more
of
local
health
departments:
legal
authority
to
carry
out
public
health
func-
tions,
implementation
of
Federal
and
state
policies,
author-
ity
and
procedures
for
budget
development,
financial
report-
ing
and
administration,
an
independent
financial
audit,
financial
documentation,
a
management
plan
providing
organization
and
structure
of
program
management,
docu-
January/February
1
996
*
Volume
I
I
I
88
Public
Health
Reports
Assessing
Capacity
Percent
of
local
health
departments
rating
APEXPH
indicators
as
a
strength,
acceptable,
or
a
weakness
Indkator
1.
Authority
to
Operate
A.
Legal
Authority................................................................................................
B.
Intergovernm
ental
Relations........................................................................
C.
Legal
Counsel...................................................................................................
II.
Community
Relations
A.
Constituency
D
evelopm
ent
.........................................................................
B.
Constituency
Education
................................................................................
C.
Docum
entation...............................................................................................
Ill.
Community
Health
Assessment
A.
M
ission
and
Role.............................................................................................
B.
Data
Collection
&
Analysis...........................................................................
C.
Resource
Assessm
ent....................................................................................
D.
Planning
and
D
evelopm
ent...........................................................................
E.
Evaluation
and
Assurance.............................................................................
IV.
Public
Policy
Development
A.
Community
Health
Assessment
and
Planning.........................................
B.
Com
m
unity
Health
Policy.............................................................................
C.
Public
Policy
&
Public
Health
Issues...........................................................
V.
Assurance
of
Public
Health
Services
A.
Public
Policy
Implem
entation.......................................................................
B.
Personal
Health
Services...............................................................................
C.
Involvement
of
Community
in
Public
Health
System............................
VI.
Financial
Management
A.
Budget
Development
&
Authorization......................................................
B.
Financial
Planning
&
Resource
Development...........................................
C.
Financial
Reporting
&
Adm
inistration........................................................
D.
Audita.
.
.
.....
E.
D
ocum
entation...............................................................................................
VIl.
Personnel
Management
A.
Policy
Development
&
Authorization........................................................
B.
Personnel
Administation
&
Reporting.......................................................
C.
Staffing
Plan
&
Developm
ent........................................................................
D.
Personnel
Policy
&
Procedure
Audit.........................................................
E.
Docum
entation...............................................................................................
Vil.
Program
Management
A.
O
rganization
&
Structure
.............................................................................
B.
Evaluation..........................................................................................................
C.
G
eneral
Inform
ation
System
s
......................................................................
D.
Shared
Resources...........................................................................................
IX.
Policy
Board
Procedures
.....................................................................................
Acceptable
Strength
54
13
21
17
25
13
29
50
25
38
54
67
4
0
8
4
4
0
8
21
29
50
67
21
17
21
42
46
so
42
8
58
17
65
63
58
33
33
17
8
29
58
0
4
21
58
38
50
67
29
42
26
33
33
54
54
54
46
46
38
54
58
71
25
Weakness
17
38
54
46
21
21
67
50
25
75
79
79
50
33
13
8
25
13
42
9
4
8
13
13
29
46
25
4
46
38
8
17
mented
operating
procedures,
and
policy
board
procedures.
Seven
indicators
were
identified
as
weaknesses
by
50%
or
more
of
the
respondents:
access
to
legal
counsel,
mission
and
role,
data
collection
and
analysis,
planning
and
staff
development,
evaluation
and
assurance
of
community
health
assessment,
community
health
planning,
and
developing
community
health
policy.
No
local
health
department
iden-
tified
community
health
assessment
and
planning
data
col-
lection
and
analysis,
or
program
evaluation
as
a
strength.
Health
departments
were
stratified
by
size
of
the
popu-
lation
served
(less
than
or
more
than
100,000),
budget
(above
or
below
$1
million),
number
of
employees
(<24,
25-49,>50),
and
region
(east
and
west).
We
used
the
2-
tailed
Fishers
exact
test
to
compare
each
of
the
indicators.
Only
one
statistically
significant
difference
was
observed
by
region.
Few
consistent
differences
were
evident
between
large
and
small
health
departments
as
defined
by
the
three
measures
of
size.
Intergovernmental
relations
were
identi-
fied
as
a
weakness
by
eight
(57.1%)
of
the
western
Wash-
ington
health
departments
while
only
a
single
eastern
January/February
1996
*
Volume
I
P
e
p
Public
Health
Reports
89
Scientific
Contribution
Washington
health
department
perceived
this
to
be
a
weak-
ness
(P
=
0.03).
The
lack
of
an
understandable
mission
and
role
was
identified
as
a
weakness
by
88.9%
of
health
depart-
ments
serving
populations
of
100,000
or
more
and
by
53.3%
of
health
departments
serving
populations
under
100,000.
Large
health
departments
reported
a
weakness
in
the
area
of
evaluation
and
assurance
more
often
than
smaller
health
departments.
Neither
of
these
differences
reached
statistical
significance.
Data
collection
and
analysis
were
perceived
as
a
weakness
by
half
of
all
health
departments
and
as
acceptable
by
the
other
half.
Discussion
The
eight
indicators
identified
as
strengths
by
50%
or
more
of
health
departments
fit
into
four
broad
categories,
all
of
which
involve
basic
public
health
infrastructure:
1.
Health
departments
have
the
legal
authority
to
carry
out
regulatory
functions
and
routinely
do
so.
2.
Health
departments
are
adept
at
providing
direct
health
services
and
imple-
menting
policy
made
by
Federal
and
state
authori-
ties
(public
policy
imple-
mentation).
3.
Health
departments
have
well
developed
budgeting,
audit,
and
financial
man-
agement
capacities
and
view
themselves
as
excellent
cus-
todians
of
public
monies.
4.
Local
health
departments
have
well
defined
and
effective
means
of
communicating
with
their
boards
of
health.
The
basic
organizational
structure
and
operating
mechanisms
of
the
public
health
system
exist
and
appear
to
be
flourish-
ing
among
local
health
departments
in
Washington.
On
the
other
hand,
many
local
health
departments
rec-
ognize
a
number
of
significant
weaknesses,
which
fall
into
four
broad
areas:
1.
Inadequate
health
department
access
to
legal
counsel,
particularly
among
smaller
health
departments;
2.
Lack
of
clarity
about
their
mission
and
role;
3.
Lack
of
expertise
in
data
collection
and
analysis,
program
evaluation,
and
community
health
assessment;
and
4.
The
inability
to
use
data
effectively
to
guide
established
community
public
health
priorities
and
program
planning
and
policy.
Interestingly,
the
perceived
areas
of
strength
and
weak-
ness
varied
little
by
health
department
size
or
location
within
the
state.
The
respondents
expressed
an
across-the-
board
perception
of
excellence
in
service
delivery
and
basic
day-to-day
management
functions.
Perceptions
of
weak-
nesses
in
collecting,
analyzing,
interpreting,
and
applying
community
health
and
program-specific
data
were
equally
widespread
and
clear.
Both
large
and
small
health
depart-
ments
felt
that
they
had
difficulty
in
linking
their
assess-
ment
and
policy
development
functions.
Actual
capacity
in
data
assessment
may
vary
considerably
from
small
to
large
health
departments,
but
all
the
health
departments
per-
ceived
this
function
as
less
than
optimal.
The
results
of
the
APEX
process
in
Washington
State
are
concordant
with
previous
observations
of
local
health
department
capacities,
including
the
National
Profile
of
Local
Health
Departments
and
the
IOM
report
on
The
Future
ofPublic
Healthib.
All
32
local
health
departments
in
Washington
participated
in
the
National
Profile
of
Local
Health
Departments
in
1989
and
reported
being
active
in
personal
health
assurance
functions
and
services
such
as
immunizations,
child
health,
and
tuber-
culosis
control.
Nearly
all
of
the
local
health
departments
were
also
active
in
basic
assessment
functions,
such
as
com-
municable
and
reportable
disease
monitoring
and
vital
records.
Seventy-two
percent
of
(23
of
32)
local
health
departments
in
Washington
reported
activity
in
health
planning
and
priority
setting.
However,
staffing
patterns
clearly
indicated
that
assessment
and
policy
development
were
areas
of
weakness.
Only
three
(9%)
of
the
32
local
health
departments
reported
employing
a
full-
or
part-time
epidemiologist
or
statistician.
The
same
small
proportion
(9%)
of
health
departments
reported
having
a
health
plan-
ner
or
analyst
on
staff.
Specialists
in
both
epidemiology/sta-
January/February
1
996
*
Volume
I
I
I
Local
health
department
participation
in
the
Washington
State
APEXPH
Project
Sa
unk
Whatcom
heh
dremepartmn-t
A
Itsand
Gz
Ha_
osr
'
~~~~~~~~~~~~~~~~Whitmi
Participating
Columbia
health
departments
r-
N
o
n-parti
c
ipants
Sousth
west
Welsh
ington
HD
ID
90
Public
Health
Reports
Assessing
Capacity
tistics
and
health
planning
were
concentrated
in
a
few
large
health
departments.
Although
completely
validating
self-
reported
measures
of
health
department
capacities
is
impos-
sible,
we
believe
that
the
consistency
of
the
findings
of
this
study
across
the
state
and
in
comparison
to
earlier
studies
suggests
that
its
findings
are
valid.
The
strengths
reported
by
local
health
departments
in
Washington
reflect
the
historical
strengths
of
the
public
health
system
in
the
United
States.
An
effective
public
health
system
has
been
developed
to
provide
limited
preven-
tive
services
to
those
most
in
need,
to
control
communicable
diseases,
and
to
ensure
public
sanitation.
The
infrastructure
needed
to
carry
out
these
functions
is
well
established.
Some
cracks
in
this
infrastruc-
ture,
such
as
inadequate
legal
services
may
appear
as
health
department
resources
are
stretched
too
thin
or
when
departments
tackle
more
com-
plex
health
issues.
Despite
these
vagaries,
local
health
departments
in
Washington
appear
to
do
a
good
job
of
car-
rying
out
traditional
public
health
functions.
The
nature
of
public
health
is
changing,
however,
and
local
health
departments
are
having
difficulty
adapting
to
new
roles.
Multifactorial
chronic
diseases
with
major
behav-
ioral
components
and
associated
with
complex
community
health
policy
issues
are
stressing
a
system
designed
to
deliver
basic
services
and
combat
communicable
diseases.
The
old
models
of
clinic-based
service
delivery
and
sanitary
regula-
tion
do
not
adapt
well
to
community
organizing
and
popula-
tion-based
interventions.
This
transition
has
probably
engendered
some
of
the
confusion
among
both
health
department
staff
and
the
community
at
large
as
to
the
mis-
sion
and
role
of
the
health
department.
Addressing
the
health
problems of
the
community
as
a
whole
is
a
very
different
mission
from
that
of
providing
lim-
ited
clinical
services
for
the
needy.
Local
health
departments
will
need
to
provide
leadership
to
bring
together
the
wide
variety
of
organizations
and
resources
that
can
contribute
to
assuring
the
community's
health.
A**
0
-
0
-
*
' '
0.
*
--
S
*
.0S.O
*6
.6
The
expanding
role
of
health
departments
into
new
areas
such
as
chronic
disease
prevention,
injury
control,
and
HIV-AIDS
has
greatly
complicated
assessing
community
health
and
developing
health
policy.
Local
health
depart-
ments
in
Washington
clearly
perceive
a
need
for
a
greater
capacity
to
collect,
analyze,
and
interpret
health
data
and
to
use
these
data
to
guide
policy.
Meeting
this
need
will
require
placing
trained
public
health
officers,
administrators,
and
epidemiologists
in
local
health
departments
or,
alternatively,
providing
training
and
technical
assistance
to
existing
public
health
staff.
In
either
case
this
will
require
commitment
of
public
resources
to
developing
assessment
and
planning
capacity
at
the
local
level.
Cre-
ative
combinations
of
support
and
staffing
may
be
needed
to
provide
these
skills
in
smaller
health
jurisdictions
that
do
not
have
the
population
or
economic
base
to
support
a
large
professional
staff.
The
results
of
the
Washington
APEX
Project
highlight
the
organizational
and
service
delivery
strengths
of
local
health
departments
and
point
out
the
need
to
redefine
their
role
in
assessing
the
health
of
their
communities
and
devel-
oping
community-wide
health
policy.
References
1.
National
profile
of
local
health
departments.
Washington,
DC:
National
Association
of
County
Health
Officials,
1990.
2.
Emerson H.
Local
health
units
for
the
nation:
a
report
of
the
Subcom-
mittee
on
Local
Health
Units,
Committee
on
Administrative
Practice,
American
Public
Health
Association.
New
York:
Commonwealth
Fund,
1945.
3.
Miller,
CLA,
et
al.
A
survey
of
local
public
health
departments
and
their
directors.
Am
J
Public
Health
1977;67:931-939.
4.
Mullan
F,
Smith
J.
Characteristics
of
state
and
local
health
agencies.
Baltimore
MD:
Johns
Hopkins
University
School
of
Hygiene
and
Public
Health,
1988.
5.
Institute
of
Medicine.
The
future
of
public
health.
Washington,
DC:
National
Academy
Press,
1988.
6.
APEXPH
Steering
Committee.
A-PEXPH
assessment
protocol
for
excellence
in
public
health.
Washington
DC:
National
Association
of
County
Health
Officials,
1991.
January/February
1996
*
Volume
I
I
Public
Health
Reports
91
