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When We Have Data We Can Count on, Everyone WINS

Tilson, Hugh MD, MPH, DrPH

Journal of Public Health Management and Practice: November/December 2015 - Volume 21 - Issue - p S173–S174
doi: 10.1097/PHH.0000000000000290
Guest Commentary

This commentary provides evidence of the value of current comprehensive cross-sectional data to inform public policy for the public health workforce.

Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

Correspondence: UNC Gillings School of Global Public Health, Campus Box 7469, Chapel Hill, NC 27599 (

The author declares no conflicts of interest.

The articles in this (very) special supplement of the Journal of Public Health Management & Practice provide ample evidence of the value of current comprehensive cross-sectional data, carefully chosen, well-reported, and thoroughly analyzed, to inform public policy for the public health workforce.

Following closely upon the releases of a new nationally representative data set of state health agency central office employees and a large pilot data set of local and regional health department employees,1 the Public Health Workforce Interests and Needs Survey (PH WINS) provides powerful in-depth looks extending and explaining the findings of the enumeration surveys. As such, PH WINS gives us even better “data we can count on.”2

Does it matter?

Well ...

Public health matters.

The workforce, which delivers on the promise of public health, matters.

Investments in both matter.

And evidence-based investments ... targeted and constructive ... matter greatly!

So: YES!

The Profile studies conducted by the Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials have taken on new importance as the organizations and their sponsors (notably the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation), have understood the importance of a consistent, longitudinal, dynamic, and continuing approach to collection of workforce data; these constitute the new public health workforce surveillance systems. Grounded in good public health epidemiology principles, the data set leaders have adopted consistent definitions (“case definitions” to borrow from public health practice)2 and extended our understanding of the taxonomy issues.3 Furthermore, they have deployed consistent data collection instruments and analyses. The result is that for the first time public health policy advocates and decision makers can view solid evidence about the composition, variability, and dynamics of the workforce and can target interventions accordingly. The conclusions are stunning. The workforce is “graying” and eligible for retirement; key elements of the workforce are vastly underrepresented; important specialties are depleted by attrition and budget cuts; and the ability of the workforce to respond to current and future threats to the public health is diminished.

PH WINS was conceived by the de Beaumont Foundation and ASTHO to provide more granular, detailed data about some of the root causes of these trends and the impact on the workforce, current and potential, of shortages, on the one hand, and efforts at improvement, on the other. In 2013, the team sponsoring and directing the project called upon a set of experts in the field (plus me) to advise on what we don't know about workforce from the existing surveys, what we need to know, and how we might best go about finding it out. The resulting methodology chosen for the survey4 was deployed and resulted in the remarkable array of important insights in the pages of this Journal of Public Health Management & Practice supplement. Among the most startling and important are that at least a quarter of the workforce intends to leave their agency; say they will retire before 2020. Job satisfaction is high at around 79%, although organizational satisfaction is lower at 65% and pay satisfaction is lower still at 48%. Only 44% of staff said they were “proficient” or “expert” in all the skills they felt were “somewhat important” or “important” in their day-to-day work.1

Public health agency accreditation is a critical force driving public health delivery today, with strong support from the national public health opinion leadership organizations. The oversight board for this accreditation, the Public Health Accreditation Board (PHAB), has made workforce improvement one of its cardinal principles, and has embedded standards and metrics for continuous improvement for the workforce in its accreditation policies and practices. Notable among these is the establishment of a separate “domain” for accreditation, to “assure a high functioning public health workforce” (domain 8), and to “maintain a high functioning organization” (domain 11).

Key among expectations from PHAB for agency workforce initiatives are maintenance of competencies commensurate with roles, training, and continuing education opportunities, and creation of a culture of continuing quality improvement. Thus, the responses to questions in PH WINS about the impact, importance, and emphasis on a “culture of quality improvement” are also highly informative of these efforts and the appropriateness of including them in accreditation standards. Notable are the observations that a quarter of agency staff who reported that applying quality improvement concepts in their day-to-day work was somewhat or very important felt they were a “beginner” or “unable to perform” the task. About 17% of the central office workforce has never heard of the national trend toward a culture of quality improvement. Among those who had, 96% thought it was somewhat or very important to the field, 70% thought it impacted their day-to-day work a “fair amount” or a “great deal,” and 55% thought it should receive more emphasis in the future.1

These findings will inform evaluation efforts of PHAB in examining the impact of the accreditation expectations upon the sector and define areas for improvement among agencies aspiring to and maintaining accreditation.

Just as the periodic, sporadic efforts at workforce enumeration have matured into a strategic and ongoing effort at surveillance at the organizational levels, surely this complementary effort at understanding the workforce at the personal level must be incorporated into the epidemiologic spirit of surveillance: perhaps these surveys will be repeated periodically, therefore becoming a proper, ongoing, representative sample of the workforce at the local level. Dare I ask for similar enumerations about the workforce at the national level as well? The evidence from PH WINS makes one eager to know more! Perhaps, that is the basis for a separate commentary!

The world of Public Health Services and Systems Research has also enjoyed the strong support of the CDC and the Robert Wood Johnson Foundation to build our insights into the dynamic nature of the workplace (in which the workforce labors, after all!). A critical next step for all of these efforts will be to create the data sets that will allow linkage between the detailed attributes of the workforce and the similarly detailed characteristics of the organizations.

Coupled with the overall findings of the ongoing workforce surveillance efforts, these explanatory findings must galvanize the sector to action for expansion, enhancement, and continuous improvement of the public health workforce. It really matters! And as we apply the findings and upgrade our workforce, everyone WINS!

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1. Sellers K, Leider JP, Harper M, et al. Highlights from the Public Health Workforce Interests and Needs Survey: the first nationally representative survey of state health agency employee. J Public Health Manag Pract. 2015;21(suppl 6):S13–S27.
2. Tilson HH. Turning the focus to workforce surveillance: a workforce data set we can count on. Am J Prev Med. 2014;47(5)(suppl 3):S278–S279.
3. Boulton ML, Beck AJ, Coronado F, et al. Public health workforce taxonomy. Am J Prev Med. 2014;47(5)(suppl 3):S314–S323.
4. Leider JP, Bharthapudi K, Pineau V, Lui L, Harper E. The methods behind PH WINS. J Public Health Manag Pract. 2015;21(suppl 6):S28–S35.
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