In 2011, the New Orleans Health Department (NOHD) launched a dramatic organizational transformation using the newly established national public health accreditation framework as a guide for action. The goal was to transform a local health department, housed under what an external consultant determined to be one of the “least competent city government(s)” in the country, into a high-performing organization, capable of impacting the city's significant health challenges at the population level. Strategies to accomplish this goal included cutting redundant or poorly performing services, reorganizing into a department capable of fulfilling core public health functions, and building a strong infrastructure rooted in continuous quality improvement.
The NOHD used the Public Health Accreditation Board (PHAB) standards and measures to guide the restructuring of the department, with a focus on addressing multiple determinants of health through cross-sector engagement.1 The rapid and successful transformation was made possible by (1) strong local political leadership; (2) community vision and support; (3) foundation funding to support dedicated staff and programs; (4) technical assistance from a public health institute; and (5) national institutional guidance.
In 2 years, the NOHD successfully stabilized the business and programmatic functions of the department, restored trust with key stakeholders and the community, transitioned away from direct clinical services, created a performance management and quality improvement system, completed a community health assessment and community health improvement plan, and developed an agency strategic plan. Having completed the prerequisites as part of the transformation, the NOHD applied for accreditation in February 2013 and will submit the remainder of the documentation in summer 2013. This report describes the role of the accreditation framework in the NOHD's transformation into a high-performing local health department capable of addressing complex population health issues in New Orleans (Table 1).
After Hurricane Katrina, New Orleans rebuilt many of its essential urban systems lost in the flood, including establishing a network of neighborhood-based community health centers. Traditionally, the health department focused on ensuring access to care for low-income populations through a safety net of city-operated primary care clinics. However, with the purposeful emergence of new quality, affordable community health centers able to serve everyone irrespective of ability to pay, the need for city clinics was diminishing. At the same time, New Orleans was in severe need of a 21st-century local health department capable of tackling serious population-level challenges, including violence, obesity, and infant mortality compounded by long-standing poverty, low levels of education, and poor infrastructure.
In January 2011, Mayor Mitch Landrieu appointed a new health commissioner to lead the department's transformation. The commissioner was joined by a deputy director who focused on establishing a strong administrative backbone to ensure successful execution of transformation goals.
The NOHD partnered with the Louisiana Public Health Institute to lay out the vision for a modern department focused on population health, to be achieved through accreditation-based performance improvements and community engagement. Baptist Community Ministries, a local foundation, provided funding for a transformation manager to oversee daily operations and progress against set targets, as well as a consultant from CommonHealth ACTION to provide strategic guidance. The Louisiana Public Health Institute served as the fiscal intermediary to expedite hiring and financial processes. The team used the accreditation framework as a blueprint to shape the department's transformation, including the strategic planning, reorganization, and capacity-building efforts required to build the foundation for new population health programs with a clear focus for success.
In March 2011, the NOHD created a workgroup including representation from across program areas charged with creating a strategic plan for the department's transformation based on the beta version of the PHAB measures. The 2011 plan outlined a series of strategic initiatives (eg, Assess Local Resources & Formalize Partnerships, Establish Emergency Preparedness Capacity, Strengthen Administrative Capabilities, Achieve Financial Sustainability, Implement a Workforce Development Program). The team mapped all of the PHAB measures to at least one of the initiatives and finalized the plan in July 2011 when PHAB released version 1.0. The NOHD used the results of the strategic planning process to develop a reorganization plan that produced a stronger administrative core and laid the groundwork for population health programs. Moving forward, the standards and measures provided guidance as the NOHD implemented the plan.
In addition to internal cooperation, accreditation and transformation demanded intensive collaboration with partners. The NOHD leveraged public health expertise along with technical assistance from a variety of sources to align its transformation efforts with national best practices and drive accreditation forward.
As the NOHD put the direct service transition into action, the team met with leadership from the Centers for Disease Control and Prevention's Office for State, Tribal, Local and Territorial Support (OSTLTS), which offered technical assistance in a variety of forms that were crucial to the NOHD's ability to establish a population health focus. In addition to providing 2 temporary staff members to assist with records management and chronic disease program planning, the OSTLTS connected the department with capacity-building fellowship programs and provided extensive policy and legal technical assistance.
The National Association of County and City Health Officials (NACCHO) selected the NOHD as 1 of 12 accreditation preparation community health improvement demonstration sites. Through this project, the department received targeted technical assistance and access to multiple shared learning opportunities to complete 2 of the 3 accreditation prerequisites, including the first community health assessment in New Orleans in over a decade and a community health improvement plan. NACCHO later awarded the NOHD a second grant to support final accreditation preparation.
The Robert Wood Johnson Foundation and the Arkansas Coalition for Obesity Prevention provided technical assistance and seed funding to launch the NOHD's fitness and nutrition initiative, Fit NOLA. This marked the NOHD's first steps in a new role, addressing one of the identified community health improvement priorities.
Finally, with the city of New Orleans participating in the federal-local Strong Cities, Strong Communities (SC2) initiative, the NOHD was able to leverage federal technical assistance to implement key initiatives. This included intensive technical assistance from the US Substance Abuse and Mental Health Services Administration to develop a strategic improvement plan for behavioral health and the US Department of Health and Human Services to secure local health care data.
The successful transition of patients from city-run clinics to quality, affordable private community health centers marks one of the NOHD's most important early achievements. More than 98% of former city patients accessed care at another clinic within 9 months of the last city clinic closing, demonstrating sufficient local capacity to absorb the patient load. In the transition year, the NOHD saved taxpayers $700 000 and the city is saving more than $1 million annually. With confidence in the community health centers and resources freed from clinic operation, the NOHD could attend to population health issues.
Using PHAB measures for direction, the NOHD has established itself as a local convener, facilitating health improvement in the community by linking partners and leveraging resources through collaboration (Domains 1, 3, 4, 5, and 10). The department is leading progress in key population health areas—violence prevention, access to care (Domain 7), fitness, nutrition, and family health. Other areas of focus include emergency preparedness (Domains 1, 2, and 5) and improving the performance of the local public health system. Addressing the multiple determinants of health and driving policy development are pillars of the new population health framework.
Internally, the NOHD used the PHAB measures to inform the creation of a performance management program with indicators and targets for all program areas, design the needed administrative structure (Domains 9 and 11), and write an updated strategic plan based on the community health improvement process.
In February 2013, New Orleans was 1 of only 6 communities nationwide to receive an inaugural Robert Wood Johnson Foundation Roadmaps to Health Prize, recognizing the community's progress in health improvement. There are also promising trends for some local health indicators. Orleans Parish advanced 12 slots within Louisiana's 64 parishes, from 60 to number 48, in the County Health Rankings from 2012 to 2013.2
New Orleans was ready for this change. The department has unparalleled support from the mayor, city council, and community members eager to see improvements in the public's health. However, the process was not without challenges. The NOHD's aggressive transformation schedule in many cases outpaced the other progress taking shape throughout City Hall. Basic administrative processes at the city for releasing or hiring staff, contracting with businesses, and monitoring finances required intensive coordination and negotiation with other departments (ie, civil service, finance, legal) and progressed at a rate slower than anticipated. Patience, determination, and above all persistence were required to push through the reorganization, budget periods, and daily contract demands.
The department's limited staff capacity immediately after the direct service transition was a barrier to moving to the population level. Only 11 general fund (nongrant) staff members remained, and all were administrative or clerical in their scope. The NOHD was able to overcome this issue by leveraging the Centers for Disease Control and Prevention's capacity-building Public Health Associate and Prevention Service Fellowship programs as well as other federal technical assistance through OSTLTS and the SC2 program while it worked to hire permanent staff under a newly reduced budget.
Advice for Other Health Departments
The NOHD's advice and lessons learned from the transformation are summarized in Table 2.