In examining the public's attitudes and behaviors concerning public health, a paradox emerges. Rates of asthma cases among children are increasing. Reports of food and water related illness outbreaks are on the rise. Local and state health agencies are receiving increasing complaints of indoor air problems in homes and schools. Harmful or toxic products in people's homes are being improperly stored, used, and disposed. Yet the general public assumes our drinking and recreational waters are safe. People are eating out in restaurants in increasing numbers and assume the food they eat is safe. Families purchase many household items such as cleansers, pesticides, or medicines without giving a second thought to possible adverse effects from the misuse of these products.

How can this paradox be explained? Is it a failure to communicate risks properly? Is it that the public has unquestioning faith in the government to protect them from harm? Whatever the response to these complex questions, public health agencies are engaged on both sides of this paradox. We in public health agencies intuitively believe that what we do is vital to improving the health of our communities. And further, we believe that the community supports us in what we do. The question is how do we confirm that to be true?

A starting point for public health agencies, and others involved in the work of public health, might be to ask some basic questions:

• Do we consider environmental factors to be an important determinant of health status?

• Are we positioned to respond strategically to a community-based, data-driven, policy-focused, and system-oriented way of thinking?

• Are we in sync with what the community and policymakers perceive or expect of government for health protection?

• Does our workforce understand our mission and the principles and values on which we practice?

Communicating the roles and responsibilities and the successes of local or state health agencies has always been challenging. This is true in part because all agencies have unique fiscal, political, social, and administrative challenges. It is also a challenge because of the difficulty in measuring prevention activities and because of the broad range of activities that health jurisdictions carry out.

Performance Measures Create Accountability

One way agencies are beginning to examine these challenges is through the use of performance measures to illustrate how local or state health agencies are achieving health outcomes. Simply put, a performance measure is a quantitative indicator that can be used to track progress toward an agreed upon objective. Performance measures are important because they hold the public health system accountable.

Many benefits arise from the use of performance measures. The measures communicate to policy makers and the public the purpose and philosophy of public health. They also provide public health workers a clear understanding of what is expected of them. Use of performance measures provides an opportunity to develop performance-based contracts, "setting the bar" for all jurisdictions to achieve. Policymakers gain context from performance measures, allowing them to make data-driven decisions. Performance measures are also a valuable means of illustrating the interrelationships of the various components of public health, including environmental health.

The involvement of outside interests in the development and use of performance measures for environmental health issues is crucial. This involvement ensures commitment and sustainability on standards that affect others and avoids duplication of activities. External groups or agencies can also be rich sources of helpful data. Examples of outside interests might include local, state, or federal regulatory agencies such as local building or planning departments; state environmental agencies including fish and wildlife or agriculture; and federal agencies involved in worker safety or consumer protection. Other examples come from community interests such as elected officials, economic development councils, religious institutions, school districts, or neighborhood planning groups.

Private and business interests should also be included in the standards development process. They are often the direct recipients of the services health agencies provide. Examples from that sector include restaurant associations, water purveyors, and on-site sewage disposal designers or installers. The involvement of nearby universities and colleges can also be helpful in providing resources or input into the standards development process.

Currently, the National Association of County and City Health Officials (NACCHO) is completing work on a program to develop a protocol for community environmental health assessment. This protocol describes the importance and methodology of including stakeholders outside of public health in the development of public health policy. This "Protocol for Assessing Community Excellence in Environmental Health" will be completed later this year and should be helpful in the development of performance measures by health agencies (for more information on this initiative see "Turning the Tide" on page 8).

Practical Application of Performance Measures: Washington State

Currently there is work in Washington State to develop a set of standards to define a basic level of public health protection for its citizens. This work is a collaborative effort by the State Department of Health and the 34 local health jurisdictions in the state. The standards will reflect the core functions of public health and use the Ten Essential Services as a framework for reference. The aim will be to provide clear, simple, and non-technical standards to describe what every jurisdiction in the state of Washington needs to do. The standards will not address the question of who should execute them or how they should be met. Rather, the standards will describe what should be done.

Environmental health will be an important component of the standards development process. A team of public health officials will discuss developing environmental health standards such as: "Maintain a 24-hour capability to respond to environmental health emergencies." Measures to determine whether that standard was met will also be developed. For example: "A written list of responsibilities for personnel responding to an environmental health emergency."

Setting Performance Measures at the Local Level

Local government policymakers are also expressing the desire for clarity of outcomes and results. The Seattle-King County Department of Public Health has been working on developing a set of performance measures in response to a county mandate. This effort requires the Department to use data rather than simply report them, to improve management responsibilities rather than to control them, and to measure performance rather than to merely count activities. Similar to the state experience, environmental factors were viewed as important considerations in the development of health standards. The development of environmental health vision and value statements was also an important part of this process and was a significant step in reaffirming the importance of environmental health as a part of public health.

Two examples of standards to control and reduce the exposure of individuals and communities to environmental hazards included: "To decrease the risk of food-related illnesses in food service establishments" and "to decrease the amount of personal exposure to household and small quantity hazardous wastes." The measures to determine the accomplishment of these standards included: Changes in average food inspection scores for critical item violations, and changes in the pounds of hazardous material entering our county's landfill and public sewer systems.

Performance measures are key parts of public health improvement plans
There is much diversity in the size of the local health jurisdictions in Washington State and the communities that each serves. The development of state and local health performance measures has been sensitive to this diversity, and reaching consensus on standards and measures has been challenging. Much work still needs to be completed on the development of appropriate standards to measure environmental health outcomes. But until we complete this work, we will continue to struggle with demonstrating how we are making a difference in the public's desire for clean water, safe food, and healthy homes, schools, and workplaces.

Carl S. Osaki is the Chief of Environmental Health with the Seattle-King County Department of Public Health, a member of the Washington State Board of Health, and a Clinical Associate Professor in the School of Public Health and Community Medicine, University of Washington. He has been active in the development and execution of Washington State's Public Health Improvement Plan. Carl is also a member of NACCHO's work group on the Commuity Environmental Health Assessment initiative.