HEALTH PARTNERSHIPS DIVISION | FEBRUARY 2016
PPMRS Instructions for Reporting in 2016
Local Public Health Act Performance Measures
USING INSTRUCTIONS
These instructions provide step-by-step assistance for reporting into
PPMRS in 2016, on 2015 data for Local Public Health Act performance
measures. The questions in these instructions are designed to not break
across pages; you may notice this as you navigate through and make
notes. To make best use of these instructions, you should:
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Use these instructions prior to sitting down to enter data into
PPMRS. The worksheets are structured just like the data entry
process in PPMRS, to assure the best possible data for
improvement activities within your community health board
and across Minnesota’s public health system
Share these instructions with everyone in the community
health board that has a role in reporting on Local Public Health
Act performance measures
In multi-county community health boards, identify the most
appropriate response(s) in consultation with directors and/or
supervisors of individual local health departments within the
community health board
IN THESE INSTRUCTIONS

Assure an Adequate LPH Infrastructure:
Capacity Measures from National
Standards

Assure an Adequate LPH Infrastructure:
Minnesota-Specific Measures

Promote Healthy Communities and
Healthy Behaviors

Prevent the Spread of Communicable
Diseases

Protect Against Environmental Health
Hazards

Prepare for and Respond to
Emergencies

Assure Health Services
Instructions for reporting on other areas of
These instructions replace previously available instructions for reporting.
public health responsibility can be found in a
The 2016 PPMRS instructions are based on PHAB Standards and Measures
companion document, online: Help: Local
v. 1.5, but are not intended to serve as a substitute for PHAB guidance. If
Public Health Act Performance Measures.
you would like to learn more about each measure and requirement, refer
directly to Public Health Accreditation Board: Standards and Measures
Version 1.5. PHAB language is prescriptive, and frequently uses “must;” to fully meet a measure; this language is used below.
REPORTING INTO REDCAP
In 2016, community health boards will report Local Public Health Act performance measures into PPMRS using a new
system called REDCap. MDH anticipates that REDCap will be easier for community health board staff to use, allow
community health board staff to access their own data, permit community health boards to use one system to report across
multiple MDH programs (SHIP, PPMRS, and more), and be simpler for MDH to administer and maintain.
User guides are available online to help you navigate REDCap, and a February 2016 webinar also provides an overview of
the process:
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Help: Local Public Health Act Performance Measures
February 2016: How to Navigate REDCap
WWW .HE AL TH .S T A TE . M N. U S/ PP MR S
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RESULTS AND ANALYSIS
As in the previous reporting cycle, MDH will use the data submitted to produce system-wide summary reports and reports
tailored to each community health board. The SCHSAC Performance Improvement Steering Committee will use data to
monitor system-level performance on these measures, identify system strengths and gaps, and recommend top
opportunities for system improvement. MDH will also use system data from all community health boards to guide technical
assistance and training.
For suggestions from peers on how to use your community health board’s data for improvement, visit Using Data to Tell
Your Story.
QUESTIONS
MDH Health Partnerships Division, Public Health Practice Section
651-201-3880 | health.ppmrs@state.mn.us
www.health.state.mn.us/ppmrs
Public Health Accreditation Board
www.phaboard.org
HOW TO USE INSTRUCTIONS
1. COMPLETE WORKSHEET
Complete the worksheet for each measure, checking the requirements your community health board has in hand, noting
each requirement’s time frame, and recording examples as desired.
Relevant time frames for the 2015 reporting period are below:
Less than 14 months old: 11/1/2014 – 12/31/2015
Less than two years old: 1/1/2014 – 12/31/2015
Less than three years old: 1/1/2013 – 12/31/2015
Less than five years old: 1/1/2011 – 12/31/2015
2. RECORD YOUR DECISION
Select whether your community health board can Fully Meet, Partially Meet, or Not Meet each measure. A multi-county
community health board should report on the lowest level of capacity of its individual health departments (see below).
3. SUMMARIZE
Use the reporting summary on pp. 4-6 to review and enter your data into the reporting system.
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Measure number and at-a-glance text
Full measure text
Context and significance
Note whether measure was part of previous key subset of measures (2013-2015)
Worksheet: Requirement(s), time frame(s), and example(s) needed for each measure
You complete: Check each requirement box you can meet, based on time frame and example(s)
You complete: Use text boxes to note example(s)
You complete: Use extra space to record notes as needed
You complete: Choose the appropriate response from the drop-down menu
Reporting instructions for single-county/city community health boards
Reporting instructions for multi-county community health boards
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2016 PPMRS REPORTING SUMMARY
Use the table below as a summary of your community health board’s capacity to meet national standards, for quick data entry
into the reporting system. Starred measures were reported by your community health board in previous reporting cycles.
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Key Subset
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1.1.2
Domain, Standard, and Measure Description
Community Health Assessment
Cannot
Meet
Partially
Meet
Fully
Meet
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A local community health assessment
1.2.2
Communication with Surveillance Sites
Communication with surveillance sites
1.3.1
Data Analysis and Conclusions
Data analyzed and public health conclusions drawn
**
1.4.2
Community Summaries, Fact Sheets
Community summaries or fact sheets of data to support public
health improvement planning processes at the local level
**
2.1.4
Collaborative Partnerships for Investigation
Collaborative work through established governmental and
community partnerships on investigations of reportable diseases,
disease outbreaks, and environmental public health issues
**
2.2.3
After Action Reports
Complete After Action Reports
**
3.1.2
Health Promotion Strategies
Health promotion strategies to mitigate preventable health
conditions
3.1.3
Factors for Specific At-Risk Populations
Efforts to specifically address factors that contribute to specific
populations’ higher health risks and poorer health outcomes
3.2.2
Organizational Branding Strategies
Organizational branding strategy
3.2.3
External Communications Procedures
Communication procedures to provide information outside the
health department
3.2.5
Variety of Publicly Available Information
Information available to the public through a variety of methods
5.1.3
Policies’ Impact on Public Health
Informed governing entities, elected officials, and/or the public of
potential intended or unintended public health impacts from
current and/or proposed policies
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Key Subset
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5.2.3
Domain, Standard, and Measure Description
Collaborative CHIP Implementation
Cannot
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Partially
Meet
Fully
Meet
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Elements and strategies of the health improvement plan
implemented in partnership with others
**
5.2.4
Monitor and Revise CHIP
Monitor the strategies in the community health improvement plan,
and revise as needed, in collaboration and with broad participation
from stakeholders and partners
**
5.3.3
An Implemented Strategic Plan
Implemented community health board strategic plan
**
6.3.4
Compliance Patterns from Enforcement
Patterns or trends identified in compliance from enforcement
activities and complaints
7.1.1
Assessing Health Care Availability
Process to assess the availability of health care services
7.1.2
Identifying Populations Facing Barriers
Identification of populations who experience barriers to health care
services
**
7.1.3
Identifying Gaps and Barriers to Health Care
Identification of gaps in access to health care services, and barriers
to the receipt of health care services
7.2.1
Developing Strategies to Improve Access
Process to develop strategies to improve access to health care
services
**
7.2.2
Implementing Strategies to Increase Access
Implemented strategies to increase access to health care services
**
7.2.3
Cultural Competence in Increasing Access
Implemented culturally competent initiatives to increase access to
health care services for those who may experience barriers to care
due to cultural, language, or literacy differences
**
8.2.1
Workforce Development Strategies
Workforce development strategies
8.2.2
Competent Workforce
A competent community health board workforce
**
9.1.1
Engagement in Performance Management System
Staff at all organizational levels engaged in establishing and/or
updating a performance management system
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9.1.2
Domain, Standard, and Measure Description
Performance Management System/Policy
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Partially
Meet
Fully
Meet
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Performance management policy/system
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9.1.3
Implemented Performance Management System
Implemented performance management system
**
9.1.4
Process to Assess Customer Satisfaction
Implemented systematic process for assessing customer
satisfaction with community health board services
**
9.1.5
Staff Involvement in Performance Management
Opportunities provided to staff for involvement in the community
health board’s performance management
**
9.2.1
Established Quality Improvement Program
Established quality improvement program based on organizational
policies and direction
**
9.2.2
Implemented Quality Improvement Activities
Implemented quality improvement activities
10.2.3
Communicated Research Findings
Communicated research findings, including public health
implications
11.1.2
Ethical Issues and Decisions
Ethical issues identified and ethical decisions made
11.1.4
Policies Appropriate to Specific Populations
Policies, processes, programs, and interventions provided that are
socially, culturally, and linguistically appropriate to specific
populations with higher health risks and poorer health outcomes
**
12.2.1
Communication with Governing Entity RE: Responsibilities
Communication with the governing entity regarding the
responsibilities of the community health board and of the
responsibilities of the governing entity
**
12.3.1
Information Provided to Governing Entity
Information provided to the governing entity about important
public health issues facing the community, the community health
board, and/or the recent actions of the community health board
**
12.3.3
Communication with Governing Entity RE: Performance
Communication with the governing entity about the community
health board performance assessment and improvement
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1.1.2
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COMMUNITY HEALTH ASSESSMENT
Full text of measure: A local community health assessment.
A thorough and valid community health assessment is a customary practice and core function of public
health, and also is a national standard for all public health departments. Since the passage of the Local
Public Health Act in 1976, Minnesota community health boards have been required to engage in a
community health improvement process, beginning with a community health assessment.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A local community health assessment that includes:
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Data and information from various sources and how the data were obtained
Demographics of the population
Description of health issues and specific descriptions of population groups
with particular health inequities
Description of factors that contribute to specific populations’ health challenges
Description of existing community assets or resources to address health issues
Must include qualitative data, quantitative data, primary data, and secondary data. Must also
include multiple determinants of health, especially social determinants.
Time Frame
One Example
☐2
Requirement 2
Time Frame
☐3
Less than five years old
1.
Opportunity for the local community at large to review, contribute to the assessment
Less than five years old
Two Examples
1.
2.
Requirement 3
The ongoing monitoring, refreshing, and adding of data and data analysis
Must be neighborhood/community-specific in order to understand health inequities and factors
that create them.
Time Frame
Less than 14 months old
If the community health assessment is more than two years old, the examples must be from two
different years (one of which is less than 14 months old).
Two Examples
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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1.2.2
COMMUNICATION WITH SURVEILLANCE SITES
Full text of measure: Communication with surveillance sites.
Communicating with surveillance sites about their responsibilities ensures sites are providing timely,
accurate, and comprehensive data.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
One Example
☐2
Requirement 2
The identification of providers and public health system partners who are surveillance
sites reporting to the surveillance system
Less than 14 months old
1.
Trainings/meetings held with surveillance sites regarding reporting requirements
including reportable diseases/conditions, and reporting time frames
Must include when the meeting was held, who attended the training, and what topics were
covered.
Time Frame
☐3
Less than 14 months old
Two Examples
1.
2.
Requirement 3
Surveillance data received concerning two different topics
Examples must be on two different topics, from two different occasions, itemized by surveillance
site.
Time Frame
☐4
Less than 14 months old
Two Examples
1.
Requirement 4
The distribution of surveillance data
Time Frame
Two Examples
2.
Less than 14 months old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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1.3.1
DATA ANALYSIS AND CONCLUSIONS
Full text of measure: Data analyzed and public health conclusions drawn.
Valid analysis of data is important for assessing a health problem’s contributing factors, magnitude,
geographic location(s), changing characteristics, and potential interventions, and for designing and
evaluating programs for continuous quality improvement.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Analysis of data and conclusions drawn with the following characteristics:
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The inclusion of defined timelines
A description of the analytic process used to analyze the data or a citation of
another’s analysis
The inclusion of the comparison of data to other agencies and/or the state or
nation, and/or similar data over time to provide trend analysis
One example must be the analysis of qualitative data; the other must be of quantitative data.
Time Frame
Less than 14 months old
Analysis must be conducted within 14 months; data may be older.
☐2
Two Examples
1. Analysis of qualitative data:
Requirement 2
Review and discussion of data analysis
2. Analysis of quantitative data:
Must document the review of data analysis selected for Requirement 1, above
Time Frame
☐3
Two Examples
1.
Requirement 3
Analysis of data that demonstrates the use of information and data from multiple
databases or data sources
Time Frame
One Example
☐4
Less than 14 months old
Requirement 4
Time Frame
Two Examples
2.
Less than five years old
1.
Aggregated primary and secondary data and the sources of each
Less than 14 months old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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1.4.2
COMMUNITY SUMMARIES, FACT SHEETS
Full text of measure: Community summaries or fact sheets of data to support public health
improvement planning processes at the local level.
Public health data must inform the development of public health policies, processes, programs, and
interventions. Community health boards must share data with other organizations to inform and support
others’ health improvement efforts.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Community health data summaries or fact sheets
Local health data summaries are not the same as a community health assessment.
Time Frame
☐2
Less than five years old
Two Examples
1.
2.
Requirement 2
Distribution of health data summaries to public health system partners, community
groups, and key stakeholders
Must include two examples of distribution of issue-specific data summaries, or one example of
provision of comprehensive data.
Time Frame
Example(s)
Less than five years old
1.
2 (if needed).
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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2.1.4
COLLABORATIVE PARTNERSHIPS FOR INVESTIGATION
Full text of measure: Collaborative work through established governmental and community
partnerships on investigations of reportable diseases, disease outbreaks, and environmental public
health issues.
The ability to conduct timely investigations of suspected or identified health problems is necessary for
the detection of the source of the problem, the description of those affected, and the prevention of the
further spread of the problem. When public health or environmental public health hazards are
investigated collaboratively, community health boards can better recognize and rectify problems, thus
helping prevent further disease outbreaks or illness.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Partnerships with other governmental agencies/departments and/or key community
stakeholders that play a role in investigations or have direct jurisdiction over
investigations
The agreement must state or show that the partner plays a role in investigation.
Time Frame
☐2
Less than five years old
Two Examples
1.
2.
Requirement 2
Working with partners to conduct investigations
Must be from two different investigations of reportable diseases or environmental public health
investigations.
Time Frame
☐3
Less than five years old
Two Examples
1.
2.
Requirement 3
Laboratory testing for notifiable/reportable diseases
The list of public health laboratory services provided must include such testing.
Time Frame
One Example
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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2.2.3
AFTER ACTION REPORTS
Full text of measure: Complete After Action Reports (AARs).
Community health boards must be able to act on information concerning health problems and
environmental public health hazards that was obtained through public health investigations, and contain
or mitigate those problems and hazards in coordination with other stakeholders. After Action Reports
(AARs) can demonstrate a community health board’s ability to do this.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Protocol describing the processes used to determine when events rise to significance
for the development and review of an AAR
Must address infectious disease outbreaks, environmental public health hazards, natural
disasters, and other threats.
Time Frame
One Example
☐2
Requirement 2
Less than five years old
1.
A list of all events that occurred, including outbreaks and environmental public health
risks
Must include events that met and did not meet the level of significance to require an AAR.
Time Frame
One Example
☐3
Requirement 3
Less than five years old
1.
Completed AAR for two events
Examples must be for two separate events. Completed AARs must report what worked well, what
issues arose, what improvement in protocols are indicated, and recommended improvements.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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3.1.2
HEALTH PROMOTION STRATEGIES
Full text of measure: Health promotion strategies to mitigate preventable health conditions.
Health promotion aims to enable individuals and communities to protect and improve their own health.
Community health boards must establish strategies to promote health and address preventable health
conditions.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
One Example
☐2
Requirement 2
A planned approach for developing and implementing health programs
Less than five years old
1.
Development and implementation of health promotion strategies
Must show how the strategies:





Are evidence-based, rooted in sound theory, practice-based evidence, and/or
promising practice
Were developed with engagement of the community
Focus on social and environmental factors that create poor health, discourage good
health, or encourage individual behavioral factors that negatively impact health
Use various marketing or change methods
Were implemented in collaboration with stakeholders, partners, and the community
Examples must be from different program areas, one of which addresses a chronic disease
program.
Time Frame
☐3
Less than five years old
Two Examples
1. Chronic disease program:
2.
Requirement 3
Engagement of the community during the development of a health promotion strategy
One example must come from one of the two program areas from Requirement 2, above. Must
include process and results.
Time Frame
☐4
Less than five years old
Two Examples
1. From Requirement 2 (above):
2.
Requirement 4
Implementation of strategies in collaboration with stakeholders, partners, and/or the
community
One example must come from one of the two program areas from Requirement 2, above.
Time Frame
Two Examples
Less than five years old
1. From Requirement 2 (above):
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
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3.1.2
HEALTH PROMOTION STRATEGIES
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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3.1.3
FACTORS FOR SPECIFIC AT-RISK POPULATIONS
Full text of measure: Efforts to specifically address factors that contribute to specific populations’
higher health risks and poorer health outcomes.
Differences in population health outcomes are well documented. Factors that contribute to these
differences are many and varied and include the lack of opportunities and resources, economic and
political policies, discrimination, and other aspects of a community that impact on individuals’ and
populations’ resilience. These differences in health outcomes cannot be effectively addressed with
programs and interventions; they require engagement of the community in strategies that develop
community resources, capacity, and strength.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Identification and implementation of strategies to address factors that contribute to
specific populations’ higher health risks and poorer health outcomes, or health
inequity, including:



Time Frame
Two Examples
Analysis of factors that contribute to higher health risks and poorer health
outcomes of specific populations and the development of health equity
indicators
Public health efforts to address identified community factors that contribute
to specific populations’ higher health risks and poorer health outcomes and to
impact health equity indicators
Internal policies and procedures to ensure programs address specific
populations at higher risk for poor health outcomes
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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3.2.2
ORGANIZATIONAL BRANDING STRATEGY
Full text of measure: Organizational branding strategy.
Branding can help to position a community health board as a valued, effective, trusted leader in the
community, by communicating what a community health board stands for and what it provides that is
unique and differentiated from other agencies and organizations.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A community health board brand strategy
Can be a single policy/plan or a set of policies/plans. Must include provisions/steps to:






Time Frame
One Example
☐2
Requirement 2
Time Frame
Two Examples
Ensure that community health board staff have a clear understanding and
commitment to the brand of the community health board
Communicate the community health board’s brand in a targeted manner (customized
to different stakeholders)
Integrate brand messaging into organizational communication strategies and external
communications
Use a common visual identity (logo) to communicate the community health board’s
brand
Display appropriate signage inside and outside the community health board facility
Link the branding strategy to the community health board’s strategic plan
Less than five years old
1.
Implementation of the community health board’s branding strategy
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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3.2.3
EXTERNAL COMMUNICATIONS PROCEDURES
Full text of measure: Communication procedures to provide information outside the health
department.
Consistent communication procedures and protocols ensure reliability in the management of
communications on public health issues, and that information is in an appropriate format to reach target
sectors or audiences.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Procedures for communications that include:





Dissemination of accurate, timely, and appropriate information for different
audiences
Coordination with community partners for the communication of targeted
and unified public health messages
A contact list of media and key stakeholders
A designated staff position as the public information officer
Responsibilities and expectations for positions interacting with the news
media and the public including, as appropriate, any governing entity members
and any community health board staff member
Can be one procedure or a set of procedures.
Time Frame
One Example
☐2
Requirement 2
Less than two years old
1.
Implementation of communications procedures
Examples must be from different program areas, one of which addresses a chronic disease
program.
Time Frame
Two Examples
Less than two years old
1. Chronic disease program:
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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3.2.5
VARIETY OF PUBLICLY AVAILABLE INFORMATION
Full text of measure: Information available to the public through a variety of methods.
Community health boards need to be able to present information to different audiences through a
variety of methods.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A website or web page that contains information on:







24/7 contact number for reporting health emergencies
Notifiable/reportable conditions link or contact number
Health data
Links to public health-related news
Information and materials from program activities
Links to CDC and other public health-related federal, state, or local agencies,
as appropriate
The names of the CHS administrator and leadership team
The community health board may have its own website, or be a part of another domain or
governmental website.
Time Frame
One Example
☐2
Requirement 2
Time Frame
Two Examples
Less than two years old
1.
Other communication strategies for informing the public about public health issues or
functions
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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5.1.3
POLICIES’ IMPACT ON PUBLIC HEALTH
Full text of measure: Inform governing entities, elected officials, and/or the public of potential
intended or unintended public health impacts from current and/or proposed policies.
Community health boards must provide policy makers and the public with sound, science-based, current
public health information that must be considered in setting or supporting policies. This includes policies
that may not be health-specific, but could impact the public’s health.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Information provided to policy makers and/or the public about potential public health
impacts of policies that are being considered or are in place
Examples must address two different items of those listed below:



Time Frame
Two Examples
Impact statement or fact sheet that is science-based and addresses current or
proposed policies
The distribution of correspondence, emails, briefing statements, or reports on policy
impacts
A presentation of evaluations or assessments of current and/or proposed policies
Less than two years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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5.2.3
COLLABORATIVE CHIP IMPLEMENTATION
Full text of measure: Elements and strategies of the health improvement plan implemented in
partnership with others.
The community health improvement plan is only useful when implemented, and provides guidance for
priorities, activities, and resource allocation. A community health board must implement its community
health improvement plan in partnership with others.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A process to track actions taken to implement strategies in the community health
improvement plan
Can be one process or a group of processes.
Time Frame
One Example
☐2
Requirement 2
Less than five years old
1.
Implementation of the plan
Examples must identify a specific achievement and describe how it was accomplished.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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5.2.4
MONITOR AND REVISE CHIP
Full text of measure: Monitor the strategies in the community health improvement plan and revise as
needed, in collaboration and with broad participation from stakeholders and partners.
Health improvement plans are dynamic. Community health boards must monitor the community health
improvement plan, identify tasks and timelines for progress, develop changes in collaboration with
partners and stakeholders, and report on progress made in implementing strategies from the plan.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Report on progress made in implementing strategies in the community health
improvement plan
Must be an annual report.
Time Frame
Less than 14 months old
If the plan was adopted within the year, a report of a previous plan would be suitable, or detailed
plans for assessment and reporting.
One Example
☐2
Requirement 2
Time Frame
1.
Review and revision, as necessary, of the community health improvement plan
strategies based on results of the assessment
Less than 14 months old
If the plan was adopted within the year, a report of a previous plan would be suitable, or detailed
plans for assessment and reporting.
One Example
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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5.3.3
AN IMPLEMENTED STRATEGIC PLAN
Full text of measure: Implemented community health board strategic plan.
A strategic plan sets forth what a community health board plans to achieve, how a community health
board will achieve those plans, and how a community health board will monitor progress (e.g., annual
reports of progress toward goals and objectives in the strategic plan). It provides a guide for making
decisions on resource and policy priorities.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Progress towards achievement of the goals and objectives contained in the plan
Reports developed since the plan’s adoption must show that the community health board has
reviewed the strategic plan and has monitored and assessed progress toward goals and
objectives. The reports must include how the targets are monitored. If the plan has been adopted
within the year, progress reports of a previous plan or detailed evaluation plans could serve as
examples.
Time Frame
Two Examples
One example must be less than 14 months old; the other may be older
1. Less than 14 months old:
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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6.3.4
COMPLIANCE PATTERNS FROM ENFORCEMENT
Full text of measure: Patterns or trends identified in compliance from enforcement activities and
complaints.
A community health board has a role in ensuring that public health laws are enforced—either by using
its authority to enforce, or working with those who have the legal authority to enforce. In either case, a
community health board needs to know about enforcement activities and violations in its jurisdiction,
since violations and enforcement can impact the public’s health. Community health boards must be able
to complete standard and consistent enforcement actions.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Enforcement programs’ annual reports summarizing complaints, enforcement
activities, and compliance
Examples must be from two different enforcement programs. If the community health board
operates an enforcement program that is out of compliance with state law or is under sanctions
or a performance improvement plan, one of the examples must be from that program.
Time Frame
☐2
Less than 14 months old
Two Examples
1.
2.
Requirement 2
Debriefings or other evaluations on enforcement for process improvements
In some cases, the community health board may have little or no authority to conduct
enforcement actions. In those cases, the community health board must coordinate and share
information with agencies that do have public health-related enforcement authority.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.1.1
ASSESSING HEALTH CARE AVAILABILITY
Full text of measure: Process to assess the availability of health care services.
Collaborative efforts are required to assess the health care needs of the population of a tribe, state, or
community. Health care services, for access planning purposes, focus on primary care, particularly
preventive primary care and chronic disease management, and include: clinical preventive services,
emergency services, urgent care, occupational medicine, ambulatory care (primary and specialty), and
dental treatment.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A collaborative process to assess availability of health care services
Must include the involvement of the health care system.
Time Frame
One Example
☐2
Requirement 2
Time Frame
☐3
Less than five years old
1.
The sharing of comprehensive data for the purposes of assessing the availability of
health care services and for planning
Less than five years old
Two Examples
1.
Requirement 3
Consideration of emerging issues in public health, the health care system, and health
care reimbursement
Time Frame
Two Examples
2.
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.1.2
IDENTIFYING POPULATIONS FACING BARRIERS
Full text of measure: Identification of populations who experience barriers to health care services.
It is important for a community health board to identify populations in its jurisdiction that experience
perceived or real barriers to health care. Assessing capacity and access to health care includes the
identification of those who are not receiving services, and understanding the reasons that they are not
receiving needed care or experiencing barriers to care.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
One Example
☐2
Requirement 2
A process for the identification of unserved or underserved populations
Less than five years old
1.
A report that identifies populations who are unserved or underserved
This report could be a section of a larger report that includes other topics, a separate report, or
part of the community health improvement plan.
Time Frame
One Example
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.1.3
IDENTIFYING GAPS AND BARRIERS TO HEALTH CARE
Full text of measure: Identification of gaps in access to health care services, and barriers to the receipt
of health care services.
It is important for community health boards to understand the gaps in access to health care, so that
effective strategies can be put into place. Community health boards must have reports of data analysis
from across the public health system, which identify gaps in access to health care services and causes of
access gaps.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
One Example
☐2
Requirement 2
The process or set of processes used for the identification of service gaps and barriers
to accessing health care services
Less than five years old
1.
Reporting the analysis of data from across the collaborative process (see Measure
7.1.1) that identifies the gaps in access to health care services and the causes of gaps
in access or barriers to care.
Reports must include:




Assessment of capacity and distribution of health care providers (will show
geographic gaps in the availability of health care providers)
Availability of health care services
Identification of causes of gaps in services and barriers to receipt of care
Results of data gathered periodically concerning access
These data collection efforts do not have to be administered by the community health board, but
the results must be considered in the assessment of gaps in access and barriers to care.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.2.1
DEVELOPING STRATEGIES TO IMPROVE ACCESS
Full text of measure: Process to develop strategies to improve access to health care services.
Partnering with other organizations and agencies allows community health boards to address the
multiple factors that contribute to poor access, and to coordinate strategies. A community health board
does not need to have convened or led the collaborative process, but must have participated in the
process.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A coalition/network/council working collaboratively to reduce barriers to health care
access or gaps in access
Must demonstrate involvement of representatives of providers of health care services. The
collaborative process and development of strategies in this measure can be done in conjunction
with Measure 7.1.1, and the same collaborative process/partnership can be used.
Time Frame
One Example
☐2
Requirement 2
Time Frame
Two Examples
Less than five years old
1.
Strategies developed by the coalition/network/council working through a collaborative
process to improve access to health care services
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.2.2
IMPLEMENTING STRATEGIES TO INCREASE ACCESS
Full text of measure: Implemented strategies to increase access to health care services.
Many factors influence health care access. Community health boards can use their local knowledge of
these factors to act collaboratively and implement strategies to increase access.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Collaborative implementation of mechanisms or strategies to assist the population in
obtaining health care services
Must show strategies to improve access to services for those who experience barriers.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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7.2.3
CULTURAL COMPETENCE IN INCREASING ACCESS
Full text of measure: Implemented culturally competent initiatives to increase access to health care
services for those who may experience barriers to care due to cultural, language, or literacy differences.
Cultural differences can present serious barriers to receipt of health care services, and must be
addressed in strategies if those strategies are going to be successful. Community health boards must be
able to incorporate cultural competence, language, or literacy efforts to address the health care service
needs of populations who experience barriers to access in health care.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Initiatives to ensure that access and barriers are addressed in a culturally competent
manner
The initiatives may be developed by the community health board or in collaboration with others.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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8.2.1
WORKFORCE DEVELOPMENT STRATEGIES
Full text of measure: Workforce development strategies.
Workforce development strategies can ensure that staff development is addressed, coordinated, and
appropriate for a community health board’s needs.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Workforce development plan
The workforce development plan must:




Address the collective capacity and capability of the community health board
workforce and its units
Address gaps in capacity and capabilities and include strategies to address them
Be responsive to the changing environment and include consideration of areas where
the technology advances quickly such as information management and (digital)
communication science
Be responsive to the changing environment and include considerations of areas where
the field is advancing; for example, emergency preparedness training, health equity,
and cultural competence
The plan must include:



Time Frame
One Example
☐2
Requirement 2
Time Frame
Two Examples
An assessment of current staff competencies against the adopted core competencies
Training schedules and a description of the material or topics to be addressed in the
training curricula to address gaps in staff competencies
A description of barriers/inhibitors to the achievement of closing gaps or addressing
future needs in capacity and capabilities and strategies to address those
barriers/inhibitors
Less than two years old
1.
Implemented workforce development strategies
Less than two years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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8.2.2
COMPETENT WORKFORCE
Full text of measure: A competent community health board workforce
As in all organizations, a community health board’s success depends on the capabilities and performance
of its staff. In order for a community health board to function at a high level, it must take action to
maximize staff capabilities and performance.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
☐2
Recruitment of qualified individuals for specific positions
Less than five years old
Two Examples
1.
2.
Requirement 2
Recruitment of individuals who reflect the population served
Examples of the evidence of the efforts of the community health board are key, not the success
or failure to achieve the desired applicant pool.
Time Frame
☐3
Two Examples
1.
Requirement 3
Retention activities
Time Frame
☐4
Less than five years old
1.
Requirement 4
Position descriptions, available to staff
2.
Less than three years old
Two Examples
1.
Requirement 5
A process to verify staff qualifications
Time Frame
One Example
☐6
2.
Two Examples
Time Frame
☐5
Less than five years old
Requirement 6
2.
Less than two years old
1.
Verified qualifications for all staff hired
Reviews include tracking required recertification.
Time Frame
Two Examples
Less than two years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
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8.2.2
COMPETENT WORKFORCE
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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9.1.1
ENGAGEMENT IN PERFORMANCE MGMT. SYSTEM
Full text of measure: Staff at all organizational levels engaged in establishing and/or updating a
performance management system.
An effective performance management system engages leadership, management, and staff in its
development and implementation.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
☐2
Community health board leadership and management supportive and engaged in
establishing and/or updating a performance management system
Less than five years old
Two Examples
1.
Requirement 2
Community health board staff at all other levels engaged in establishing and/or
updating a performance management system
Time Frame
Two Examples
2.
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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9.1.2
PERFORMANCE MGMT. SYSTEM/POLICY
Full text of measure: Performance management policy/system.
A performance management system encompasses all aspects of using objectives and measurement to
evaluate programs, policies, and processes; identify and manage opportunities for improvement; and
achieve outcome targets.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
An adopted performance management system
Must include:




Time Frame
One Example
Performance standards, including goals, targets and indicators, and the
communication of expectations
Performance measurement including data systems and collection
Progress reporting including analysis of data, communication of analysis results, and a
regular reporting cycle
A process to use data analysis and manage change for quality improvement and
towards creating a learning organization
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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9.1.3
IMPLEMENTED PERFORMANCE MGMT. SYSTEM
Full text of measure: Implemented performance management system.
Use of a process to evaluate and report on achievement of goals, objectives, and measures set by the
performance management system is critical to improving effectiveness and efficiency.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A functioning performance management committee or team
This does not have to be a separate group that deals only with performance management, but
may be a function of a standing community health board committee.
Time Frame
One Example
☐2
Requirement 2
Less than five years old
1.
Goals and objectives
Must include identified time frames for measurement. One example must be from a
programmatic area, and the other from an administrative area.
Time Frame
☐3
Less than five years old
Two Examples
1. Programmatic:
2. Administrative:
Requirement 3
Implementation of the process for monitoring the performance of goals and objectives
Must show the monitoring of performance toward the two objectives cited above in
Requirement 2.
Time Frame
☐4
Less than five years old
Two Examples
1.
2.
Requirement 4
Analysis of progress toward achieving goals and objectives and identification of areas
in need of focused improvement processes
Must show that performance of the two objectives identified in Requirement 2, above, was
analyzed according to the time frames.
Time Frame
☐5
Less than five years old
Two Examples
1.
2.
Requirement 5
Identification of results and next steps
Must show that performance results, opportunities for improvement, and next steps for the
identified goals and corresponding objectives were documented and reported.
Time Frame
☐6
Less than five years old
Two Examples
1.
2.
Requirement 6
A completed performance management self-assessment
Must reflect the extent to which performance management practices are being used.
Time Frame
One Example
Less than five years old
1.
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9.1.3
IMPLEMENTED PERFORMANCE MGMT. SYSTEM
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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9.1.4
PROCESS TO ASSESS CUSTOMER SATISFACTION
Full text of measure: Implemented systematic process for assessing customer satisfaction with
community health board services.
Customer focus is a key part of a community health board’s performance management system. A
community health board must have the capacity to assess its process to measure the quality of customer
relationships and service.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Collection, analysis, and conclusions of feedback from two different customer groups
Customers must be from two different programs. Special effort to address those who have a
language barrier, are disabled, or are otherwise disenfranchised must be included.
Time Frame
☐2
Less than five years old
Two Examples
1.
2.
Requirement 2
Results and actions taken based on customer feedback
Must relate to the examples in Requirement 1, above.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
9.1.5
STAFF INVOLVEMENT IN PERFORMANCE MGMT.
Full text of measure: Opportunities provided to staff for involvement in a community health board’s
performance management.
Staff must understand what a performance management system is, and how evaluation integrates with
performance management. Community health boards must provide staff with development
opportunities help to assure broad engagement in the performance management system.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Staff development in performance management
Targeted staff includes those who will be directly working on performance measure monitoring
and analysis, and/or serving on a quality team that assesses the community health board’s
implementation of performance management practices and/or system.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
9.2.1
ESTABLISHED QI PROGRAM
Full text of measure: Established quality improvement program based on organizational policies and
direction.
Implementing a quality improvement program is an important requirement of a performance
management system, and a quality improvement plan helps create the infrastructure required to make
and sustain quality improvement gains. This plan is guided by a community health board’s policies and
strategic direction (found in mission and vision statements), in its strategic plan, and in its community
health improvement plan.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
A written quality improvement (QI) plan
The plan must address:









Time Frame
One Example
Key quality terms to create a common vocabulary and a clear, consistent message
Culture of quality and the desired future state of quality in the organization
Key elements of the quality improvement effort’s structure
Types of quality improvement training available and conducted within the organization
Project identification, alignment with strategic plan and initiation process
Quality improvement goals, objectives, and measures with time-framed targets
The community health board’s approach to how the quality improvement plan is
monitored: data are collected and analyzed, progress reported toward achieving
stated goals and objectives, and actions taken to make improvements based on
progress reports and ongoing data monitoring and analysis
Regular communication of quality improvement activities conducted in the community
health board
Process to assess the effectiveness of the quality improvement plan and activities
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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9.2.2
IMPLEMENTED QI ACTIVITIES
Full text of measure: Implemented quality improvement activities.
Performance management system concepts and practices serve as the framework to set targets,
measure progress, report on progress, and make improvements. Community health boards must use QI
activities to improve processes, programs, and interventions.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Quality improvement activities based on the QI plan
One example must be from a programmatic area, and the other from an administrative area.
Examples must demonstrate:







How staff problem-solved and planned the improvement
How staff selected the problem/process to address and described the improvement
opportunity
How they described the current process surrounding the identified improvement
opportunity
How they determined all possible causes of the problem and agreed on contributing
factors and root cause(s)
How they developed a solution and action plan, including time-framed targets for
improvement
What the staff did to implement the solution or process change
How staff reviewed and evaluated the result of the change, and how they reflected and
acted on what they learned
Examples must demonstrate ongoing use of an improvement model, including showing the tools
and techniques used during application of the process improvement model.
Time Frame
☐2
Less than five years old
Two Examples
1. Programmatic:
Requirement 2
Staff participation in quality improvement activities based on the QI plan
Time Frame
Two Examples
2. Administrative:
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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FE B R UA R Y 20 16
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
10.2.3 COMMUNICATED RESEARCH FINDINGS
Full text of measure: Communicated research findings, including public health implications.
Public health research provides the knowledge and tools that people and communities need to protect
their health. However, research findings can be confusing and difficult to translate into knowledge that
steers action toward improved public health. Community health boards can communicate the facts and
implications of research so that individuals and organizations are informed and knowledgeable, and can
act accordingly.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
The communication of research findings and their public health implications to
stakeholders, public health system partners, and/or the public
That is, research conducted and published by others, outside of the community health board.
Audiences would be especially appropriate if involved in or affected by the research. The
research must have been evaluated by experts to provide valid implications—for example, peerreview for publication in journals. Distribution of findings must include the state health
department and tribal health department(s) with which the community health board
coordinates.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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FE B R UA R Y 20 16
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
11.1.2 ETHICAL ISSUES AND DECISIONS
Full text of measure: Ethical issues identified and ethical decisions made.
Efforts to achieve the goal of protecting and promoting the public’s health have inherent ethical
challenges. Employer/employees relations may also raise ethical issues. Understanding the ethical
dimensions of policies and decisions is important for the provision of effective public health and public
health management. Defining and addressing ethical issues must be handled through an explicit,
rigorous, and standard manner that uses critical reasoning.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Strategies for decision-making relative to ethical issues
Must provide for opportunities for input from affected stakeholders. Must also provide for best
evidence available, and for opportunities to evaluate decisions as new information becomes
available.
Time Frame
One Example
☐2
Requirement 2
Time Frame
One Example
Less than five years old
1.
Ethical issues reviewed and resolved
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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11.1.4 POLICIES APPROPRIATE TO SPECIFIC POPULATIONS
Full text of measure: Policies, processes, programs, and interventions provided that are socially,
culturally, and linguistically appropriate to specific populations with higher health risks and poorer
health outcomes.
A community health board needs to cultivate social, cultural, and linguistic competence in working with
its own employees, and in providing public health programs to populations in its jurisdiction.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Policy or procedure for the development of interventions and materials that address areas
of health inequity among the specific populations and are culturally and linguistically
appropriate for the population the community health board serves in its jurisdiction
A policy or procedure must ensure that social, cultural, and linguistic characteristics of the
various populations groups of the population it serves are incorporated into processes,
programs, and interventions.
Time Frame
One Example
☐2
Requirement 2
Less than five years old
1.
Processes, programs, or interventions provided in a culturally or linguistically
competent manner
Examples must come from two different program areas of the community health board.
Time Frame
☐3
Two Examples
1.
Requirement 3
Assessment of the community health board’s cultural competence and knowledge of
health equity
Time Frame
One Example
☐4
Less than five years old
Requirement 4
Time Frame
One Example
2.
Less than five years old
1.
Health equity and cultural competency training provided to community health board
staff
Less than five years old
1.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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12.2.1 COMMUNICATION WITH GOVERNING ENTITY (1)
Full text of measure: Communication with the governing entity regarding the responsibilities of a
community health board and of the responsibilities of the governing entity.
The governing entity is accountable for a community health board achieving its mission, goals, and
objectives, to protect and preserve the health of the population within its jurisdiction. Governing entities
significantly influence community health boards through policymaking, and can greatly influence
whether a community health board is fulfilling its responsibilities. A community health board must
educate the governing entity about public health responsibilities.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Communication with the governing entity regarding the responsibilities of the
community health board


Communication with the governing entity about its operational definitions
and/or statements of the public health governing entity’s roles and
responsibilities
The orientation process for new members of the governing entity
Examples will be based on the model of governance in place for the community health board.
Part A
Time Frame
Two Examples
Part B
Time Frame
One Example
Communication with the governing entity about its operational definitions and/or
statements of the public health governing entity’s roles and responsibilities
Less than five years old
1.
2.
The orientation process for new members of the governing entity
Less than five years old
3.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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FE B R UA R Y 20 16
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
12.3.1 INFORMATION PROVIDED TO GOVERNING ENTITY
Full text of measure: Information provided to the governing entity about important public health
issues facing the community, a community health board, and/or the recent actions of a community
health board.
Public health governing entities exercise a wide range of responsibilities, which demand that the
governing entity is well-versed in public health and in the work of a community health board.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Time Frame
Two Examples
Communication with the governing entity regarding important public health issues
and/or recent actions of the community health board
Less than two years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all parts of the requirement.
Partially Meet: Your CHB can meet some parts of the requirement, but not all.
Cannot Meet: Your CHB cannot meet any parts of the requirement.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all parts of the
requirement.
Partially Meet: If any single member department in your CHB can only meet some
parts of the requirement (but not all), your CHB should enter “partially meet,” even if
other member departments can meet all parts of the requirement.
Cannot Meet: If any single member department in your CHB cannot meet any parts of
the requirement, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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L O C A L P U B L I C H E A L T H A C T P E R F O R M A N C E M E A S U R E S : C AP AC I T Y M E A S U R E S FR O M NAT I O N AL ST A N D AR D S
12.3.3 COMMUNICATION WITH GOVERNING ENTITY (2)
Full text of measure: Communication with the governing entity about community health board
performance assessment and improvement.
Public health governing agencies exercise a wide range of responsibilities, which demand that the
governing entity is well-versed in public health and in the work of a community health board. A
community health board must communicate with the governing entity on assessing and improving the
overall performance of a community health board.
Your community health board reported on this measure in previous reporting cycles.
WORKSHEET
☐1
Check each box if your CHB can meet a requirement’s time frame and number of examples, below.
Requirement 1
Communication with the governing entity concerning assessment of the community
health board’s performance
Examples will be based on the model of governance in place for the community health board.
Time Frame
☐2
Less than five years old
Two Examples
1.
2.
Requirement 2
Communication with the governing entity concerning the improvement of the
community health board’s performance
Examples will be based on the model of governance in place for the community health board.
Time Frame
Two Examples
Less than five years old
1.
2.
Additional Notes
REPORTING
Our CHB can
_____ meet
this measure
How should our CHB report? Use the drop-down menu at left to record your answer
Single-County
or City CHB
Fully Meet: Your CHB can meet all requirements.
Partially Meet: Your CHB can meet some requirements, but not all.
Cannot Meet: Your CHB cannot meet any requirements.
Multi-County
CHB
Fully Meet: Every member health department in your CHB can meet all requirements.
Partially Meet: If any single member department in your CHB can only meet some
requirements (but not all), your CHB should enter “partially meet,” even if other
member departments can meet all requirements.
Cannot Meet: If any single member department in your CHB cannot meet any
requirements, your CHB should enter “cannot meet,” even if other member
departments can meet some or all.
MDH HE A L TH PA R TN E R S H IP S D IV IS ION
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