Assessing the Public Health System in Delaware

Assessment Results

Essential Public Health Service #6:
Enforcing Regulations that Protect Health and Safety

On November 15, 2006, an Assessment Team including representatives from the Division of Public Health (DPH), Henrietta Johnson Medical Center, Delaware Healthcare Commission, Department of Justice (DOJ), Department of Natural Resources and Environmental Control (DNREC), and the Delaware Healthcare Association listened to public testimony about how well Essential Public Health Service #6 is performed in Delaware based on the model National Public Health Performance Standards (NPHPS). Those providing public testimony included representatives from DPH, Delaware Food Safety Council, Christiana Care Health Services, Delaware Authority on Radiation Protection, and DNREC.

Following the testimony, the Assessment Team completed the NPHPS instrument on Essential Service #6: Enforcing Regulations that Protect Health and Safety.

This essential service model standard includes a state public health system that:

1. Assures that existing and proposed state laws and regulations reflect appropriate public health practices;
2. Encourages compliance with the health related laws and regulations through education and incentives;
3. Provides local governing bodies with assistance in developing health related laws and regulations; and
4. Reviews and makes improvements to enforcement procedures.

The Assessment Team examined four indicator categories for the essential service:

1. planning and implementation;
2. technical assistance and support;
3. evaluation and quality improvement; and
4. resources.

The team identified strengths and gaps in the Delaware’s public health system performance of these indicator areas.

The Assessment Team rated the Delaware public health system as having partially met the model standard in the area of planning/implementation, technical assistance/support, and resources.  Within planning/implementation, Delaware does an excellent job utilizing written guidelines to administer public health enforcement activities. As to resources, the Public Health System workforce is diverse with a high level of expertise and they have access to expertise in legislative and regulatory processes.

The Team identified noticeable gaps in evaluation/quality improvement. Gaps included:

1. no formal review of capacity to conduct enforcement functions within the state;
2. no formal review of the technical assistance provided to public health systems and state partners regarding enforcement; and
3. review findings do not necessarily lead to improvements.

The assessment team felt that Delaware does a good job of monitoring enforcement procedures to assure professional conduct of personnel.

Evaluation of the Assessment Process:

The overall evaluation results indicated that participants felt that it was beneficial to assess this essential service. The introduction and the background provided for the process were good. Scoring on a number of the instrument questions varied widely. Some questions were difficult to interpret and there was not sufficient time to fully discuss. Time was also limited in terms of sharing insights and suggestions for immediate improvement opportunities.

Sharing of “Take Away” Thoughts

The sharing of “take away” thoughts by the assessment team always provides good feedback. One team member shared that the model standard provides a good prototype of what the public health system partners need to be delivering to citizens. Another thought the tool was difficult to use but it provides a starting place, and the process overall helped identify areas for improvement. Some mentioned that the regulations are very important to protecting the public’s health, but the public often does not understand this. The value of the rules, regulations, and enforcement services are underappreciated by the public.

Priority List

Each member of the assessment team was asked to vote on a scale of 1 - 10 on the importance and priority of each of the four indicator categories with 10 being the highest priority. Below are the indicator areas with the priority scores and a summary of strengths (in italic) and gaps (in bold ) that were identified in the Delaware public health system. There was a lot of information that was shared and hopefully we captured the critical points.

6.1 Planning and Implementation (priority rank: 9)

• Delaware has good quality monitoring programs with extensive data.
• DPH has included stakeholders during the development and/or review of regulations.
• DPH has implemented a three year plan to review all environmental health regulations.
• Office of Health Facilities and Licensing networks with other states to obtain input on compliance and enforcement issues.
• Solicits input from stakeholders (LTC provides).
• DPH and other entities maintain a good relationship with DAG.
• The Immunization program can only collaborate to ensure standards are met but have no enforcement authority or capacity.
• Regulatory programs have mostly paper records making it difficult to monitor and assess data.
• Compliance enforcement is different than putting forth a law - DE enforcement of laws does not go through the general assembly.
• Stakeholders for many regulatory are not well organized
• Enforcement authority is lacking in the statute.
• The regulations are antiquated and in need of revision.
• There is a lack of incentive to comply with regulations.
• There is little training for workforce to increase their understanding of regulations.
• Regulations are antiquated and at times difficult to interpret.  

6.2 Technical Assistance/Support (priority rank: 5)

• There is a longstanding collaboration with DNREC, EPA, DOE, DelDOT and DPH.
• State agencies have state-wide jurisdiction responsibility.
• DPH currently utilizes an inspection – compliance – education – enforcement model.
• The Food Protection Program provides technical support in compliance and enforcement to other State partners such as to DE Department of Agriculture and Department of Corrections.
• There is a long standing collaboration with other state agencies which use DPH as technical experts.
• DPH and other state entities provide technical assistance to the community such as training water system operators on regulatory compliance issues.
• DPH attempts to ensure that their regulated partners understand the regulations.
• Operations of state government are not user-friendly.
• Poor training at state level
• Supporting partners takes away from tactical work.
• Delaware Code is antiquated and does not reflect the 21^st century.
• Enforcement of regulations is difficult because the enforcement varies with every regulation.
• The Food Protection program does not train state partners in enforcement protocols.
• DPH staff does not receive periodic continuing education in enforcement protocols.
• Local governing bodies do not routinely request assistance from the Food Protection Program in developing ordinances.

6.3 Evaluation/Quality Improvement (priority rank: 8)

• Radiation Office has made improvements in operations
• The Office of Health Facilities Licensing and Certification (OHFLC) review existing regulations to ensure that they reflect current knowledge and practice.
• DPH has implemented a three year plan to review all environmental health regulations.
• The rate of growth in the new radiation facilities has accelerated with modernized imaging modalities such as new computed tomography (CT) scans.
• Technical assistance regarding enforcement in the Food Protection Program undergoes several levels of management review before the assistance is provided to state and local partners.
• All systems and processes within OHFLC have been revised, refined, prioritized, and organized.
• Personnel receive extensive on-the-job training to be able to complete their duties.
• The OHFLC assures that providers have the information and are equipped to comply with the laws and regulations.
• The Immunization Program conducts regular provider site visits to ensure proper vaccine storage.
• The Immunization Program ensures that all immunizations administered in DE are reported to the registry.
• The public health system has a tendency to be reactive rather than proactive; the system is weak and inconsistent in evaluating activities.
• DPH has not done a good job with tracking and evidence training.
• The process required to revise regulations is complex and does not facilitate inclusion of most recent changes in model Federal codes.
• The communication of information regarding enforcement actions taken in the field is not immediately available to program management.

6.4 Resources (priority rank: 10)

• Deputy Attorney General (DAG) provides the necessary legal counsel that is required to enforce laws and regulations.
• Resource allocations are reviewed as grants are applied for on a yearly basis
• There is a high level of expertise throughout the Public Health System.
• Staff is appropriately certified in their respected professional field.
• There is effective use of the resources that are available
• Delaware is not investing enough resources into laws/regulations and enforcement.
• The number of regulated facilities has grown by 50% while additional responsibilities on the inspection staff had increased, decreasing the staff hours available for field inspections of facilities.
• Insufficient capacity to create additional positions, upgrade equipment, and train staff at a level necessary to operate a modern radiation program
• Staff are not able to be proactive in survey activities because of a lack of resources.
• Sharing of limited resources is an issue.

Next Steps:

Participants mentioned several steps that should be taken:

• Disseminate results/information to as many public sectors as possible.
• Determine the status of Healthy DE 2010 to find out who, if anyone, is measuring the objectives and what should be done.
• Continue to work with the various interest groups to improve the public health system in Delaware.

The Division of Public Health anticipates convening a meeting in the first quarter of 2007 with all of the participants in each of the essential service assessments. Participants will be asked to prioritize the services and gaps, develop an implementation plan, and draft action steps with assigned responsibilities.

• Go back to 2006 Assessment Meetings and Summaries

Last Updated: Wednesday January 10 2007