KWF: This was our attempt to connect with people that we know who are in leadership positions, some within the department and some outside the department. The outsiders were people who do a lot of business with the department and who are dependent on a vital Department of Health to advance their own issues. We conducted about 40 interviews with people: agency leadership, non-governmental, nonprofit, local governmental leaders, our local health department, our Department of Human Services in Allegheny County, and also people who were in some key positions in the Department of Health, and in Aging and Welfare. This is not meant to be a scientific survey. We were really looking to prepare some recommendations for a new administration to try and make vital the Department of Health.

KWF: I think it’s more about the careful selection of people to perform various key tasks and to provide leadership within the department than it is about new money. There are quite a few people we interviewed who felt that the distribution of resources—local and regional versus state—was awry and was not making it possible for people who actually are providing service or care, working in the regional offices, to be anywhere near minimum staff requirements. Leadership—choosing the right people for the right job and giving them support, setting accountability goals and asking the department to enlist the current staff to achieve measurable goals—doesn’t require new money. There is also the opportunity for redistributing the funds that are there. Getting a reasonable measure of collaboration among the key departments at the state level does not require new money. It just has not been done well.

KWF: The health department does collect a great deal of data. I think they’ve really improved, particularly in epidemiology, their data capacity over the last eight years. Having data is the beginning to improvement that’s evidence-based, so we’re impressed with that. We’re very impressed with the data that the state collects through the Pennsylvania Health Care Cost Containment Council. Those data are a rich source of all kinds of information, measurements and accountability, and we have no clear idea why the collaboration between the Department of Health and PHC4 isn’t even closer. The fact that all these data exist, both internal to the department and external but accessible, is a real strength. There’s a lot of talent within the department. I think the department has proven itself capable recently to adapt rather rapidly to challenges such as the West Nile virus and Homeland Security. They were able to keep the tobacco settlement funds focused on health and spread among research, education and treatment. I think most people have respected the process by which the department has been distributing these monies. I think there’s some promising movement toward better quality and safety accountability. The new Patient Safety Authority is governed by the physician general, who is part of the health department. The long term care demonstration project was very creative and well-conceived; I think it was a beginning toward change in our really antiquated regulatory apparatus. It’s a new experiment to have a non-physician secretary working with another appointee, the physician general, and I think their ability to get along and work collaboratively was quite excellent.

KWF: Although the department has access to wonderful data, I think the department is really not data-driven. A lot of the data don’t get used. They don’t get shared with people out in the local communities. The data don’t drive decision-making, as far as we can tell. For example, the PHC4 data: if you look at their data on diabetes, it’s very clear in certain areas of various counties the health sector managing diabetes poorly. That would be enough to call for concerted process improvement techniques to improve the performance of local clinicians and institutions in areas where you’re seeing disproportionate loss of eyesight, hospitalizations and limb amputations. These data are pretty compelling if you look at them and a health department should be in an emergency mode to respond to that. I don’t find that that’s really done.

I think managed care oversight has shriveled up. I think the regulatory apparatus, both for acute care facilities and long term care facilities, is antiquated. Everyone knows there’s probably not a cause-effect relationship for many of the things we regulate, and there are many redundancies in our regulatory apparatus. Institutions will tell you about things that JCAHO comes in and inspects them for, then a couple of weeks later the state comes in and checks on the same thing. The state has some conflicting regulatory requirements producing mixed messages that are sometimes at odds with inspectors from other agencies. Regulations don’t get updated. Almost every institution we interviewed said much of what they are asked to report is costly, time-consuming and has little impact on safety or quality.

The Department can and must improve care to underserved populations. Much more could be done by the department to ensure that we have a statewide network of good providers of physical, mental and dental services who work together, share patient information and take mutual responsibility for patient well-being. There are too many huge gaps in services; instead of concerted, sustained, measured improvement efforts, we have one initiative after another. These are our natural partners—community health centers, outpatient clinics, practices in rural areas—and we have to figure out how to support them to do their job well. When we look at our data we know we’re definitely not getting the job done. Our informants within the department as well as outside report that the department is really a lot of little fiefdoms and, unless something that’s overarching like 9/11 or West Nile Virus snaps them out of their business-as-usual and rather isolated existence, you don’t get the full court press that a department with so much talent could deliver.

We lack a statewide unified emergency response system for counties, cities, municipalities and rural areas. There’s a lot of opportunity for the state to provide leadership. We heard from many interviewees that our state is not drawing down its share of federal money available to regions and localities. It was once more of a priority at the department level and then it seemed to kind of wither away. That money is available, we’re entitled to it and we’re not drawing it down.

KWF: We’d like to believe that organizations that are mission-driven can erase practices that aren’t productive. We really need to build community within the Department of Health that is mission-focused—whether it is addressing the sad state in which certain chronic conditions like diabetes are being managed in parts of our Commonwealth, or a unified emergency response system. If somebody would task the department to use all the resources at its disposal to do something that has a measurable impact at the community level, I think you’d have a much better functioning department. There’s a whole series of things we could task the department to do—set up imperatives and say, "These are our outcome expectations for the department." One could certainly be a thorough review of the regulatory system. The state could form a special commission to do it. It should be very clear that certain things that would improve the health of the people of the Commonwealth need to occur within a certain timeframe and that somebody’s watching and will reward it if it’s accomplished. I would expect a higher level of prevention for conditions that result from diabetes that aren’t being managed by standard protocols. We could better engage patients to manage chronic conditions. The department has tools at their disposal and they should be implemented. We have protocols now for treating diabetes. They’re established, they’re accepted, we know they work and there’s been a lot of evidence. Put them in place. Require them. Inspect them. Promulgate them to help statewide education of clinicians. The state has both the ability to reward and also to respond when groups are not following best practice. You could go through some of the Rendell Administration’s priorities and pick a few of them. Charge the department to focus on these goals that are top priority.

To maximize federal revenue streams, assign someone in the department as a top priority to understand what the opportunities are for state funding and be really creative, with a knowledge of policy and legislative apparatus. There are funds available and Pennsylvania should always be an applicant for money that will strengthen the capacity of local organizations to deliver health care.

KWF: I’m assuming that one of the reasons the governor formed it was to come up with some reasonable solution to the malpractice issue. The malpractice system now is just so dysfunctional. It’s driven up the cost of health care. It’s driving physicians out of certain specialties. But most important, as it now exists, it is an impediment to process improvement and quality goals, it is achieving very little for patient safety and it is costing us a great deal of money. I’m very interested in the department asking some broad questions about what state programs we have that will really stimulate quality and safety and best practice within our health care system. I think the Office of Health Care Reform could ask important questions about how well we use our current health outcomes data. We have a lot of data. Some of it may or may not be timely enough, but the use of data to drive quality and safety is a key part of health care reform. I’d love to also know why many of our institutions collect these data for the Pennsylvania Health Care Cost Containment Council and don’t use them. The real answer to bringing down the cost of malpractice is to have health care systems that perform as well as possible in terms of safety and best practice. We have a long way to go. I think another thing we need to do is to find better ways to address our workforce issues. It’s just not sufficient to keep crying wolf. We shouldn’t have this gap between supply and demand.