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San Diego County’s Health and Human Services Agency
It Cannot Demonstrate That It Employs the Appropriate Number of Public Health Nurses to Efficiently Serve Its Residents

Report Number: 2017-124

Response to the Audit

San Diego County's Health and Human Services Agency

July 2, 2018

Ms. Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Dear Ms. Howle:

Audit Report 2017-124 validates the County of San Diego’s (County) position that 1) the County effectively addresses the public health needs of its residents, through its public health nursing programs; 2) appropriately used its draft surge plan to address a county-wide hepatitis A outbreak; 3) uses the civil service framework to fill its nursing vacancies; and 4) has adequate financial resources for its public health nurses.

This audit originated at the request of Senator Ben Hueso who, on August 14, 2017, made the following assertions in his written request to the Joint Legislative Audit Committee:


“The consistent lack of adequate staffing levels of public health nurses contributes to persistent health related problems in communities and can lead to a public health crisis if not remedied.”

“[S]taffing deficiencies place our community in jeopardy and significantly limit healthcare access for underserved and at-risk populations.”

“[M]any foster youth fail to receive basic health screenings and routine medical visits as a result of the chronic understaffing of public

“As a result of the ongoing shortage of public health nurses, HHSA has been slow to respond to the Hepatitis A outbreak.”


Nothing in the audit report supports any of these statements.


Furthermore, we disagree with any claims that the County cannot sufficiently demonstrate that it needs more, or less, public health nurses—and our positive outcomes speak for themselves. San Diego County has among the highest outcomes in numerous measures and we are one of only twelve counties in California accredited by the Public Health Accreditation Board receiving the highest possible ranking on 94 out of 100 assessment measures. Finally, although the report reinforced the positive outcomes by the County in its public health nursing program and hepatitis A response, the title of the audit report does not reflect this. Instead, the title implies that the County does not employ an adequate efficiency metric and, as a result, county residents are not appropriately served. The title does not acknowledge that a standard metric does not yet exist in California. As such, we are prepared to help the State develop an efficiency metric that could be used throughout California in order to create standardized tools for all statewide jurisdictions. The County will be contacting statewide organizations to pursue next steps related to this recommendation by your department.


Agency Director

c:  Helen Robbins-Meyer, Chief Administrative Officer

County of San Diego Health and Human Services Agency (HHSA) Response to the California State Audit Report 2017-124 entitled San Diego County Health and Human Services Agency: It Cannot Demonstrate That It Employs the Appropriate Number of Public Health Nurses to Efficiently Serve Its Residents

Finding 1: The Health Agency Cannot Sufficiently Demonstrate Whether It has the Appropriate Number of PHNs
Recommendation 1: To better ensure and demonstrate that it efficiently meets public health needs of at-risk county residents and that it employs the appropriate number of PHNs in the right locations to address those needs, the Health Agency should measure and assess PHN efficiency. Specifically, the Health Agency should direct the Chief Nursing Officer to begin developing and implementing PHN efficiency measures by January 1, 2019. The measures could address such factors as caseload, case complexity, and overtime.

The County of San Diego Health and Human Services Agency (HHSA) disagrees with the recommendation.

HHSA is effectively providing public health services through our nurses to the residents of San Diego County as demonstrated by our outcomes when compared to statewide standards. No finding in the Audit Report disputes this. HHSA asserts that the outcomes associated with our PHNs, coupled with a reasonable overtime rate, is evidence of the County’s efficiency.

Currently, the State does not provide standard measures for efficiency. A uniform statewide measure could allow all 58 counties to have comparable measures and share best practices. HHSA is interested in exploring a statewide effort to establish efficiency standards for consistency across California.

In the absence of statewide efficiency measures, we place a high priority on outcomes to demonstrate our level of success in addressing the public health needs of our residents. For example, we provide timely health screenings and routine medical visits for the children in our Foster Care system. As stated in the Audit Report, in 2016-2017, 97% of foster children received timely preventive health examinations and 91% of foster children received timely preventive dental examinations in San Diego County. These results were achieved after the County conducted a comprehensive quality improvement project.

Administrators, managers and supervisors who oversee PHNs are responsible for on-going evaluation of practice and services, including monitoring caseloads. In particular, HHSA’s Foster Care program has a robust process for monitoring PHN caseload. As of October 2015, the Heath Care Program for Children in Foster Care (HCPCFC) developed a work plan and established a workgroup to address caseload and PHN assignments. As a result, HCPCFC meets with the regional leadership to discuss caseloads, caseload methodology, and to address concerns and challenges on a regular basis. PHN overtime is regularly monitored by the units, sections or branches to ensure they are meeting their own operational needs. As the Audit Report illustrates, “overtime data revealed that PHNs’ overall overtime hours over the last three fiscal years were generally reasonable” with few outliers.

The County, for its part, will bring this recommendation to the attention of our statewide associations to explore if a case complexity/acuity tool would be a valuable resource for all public health departments in California. Moving forward, we fully support and look forward to participating in a State-driven effort to establish uniform efficiency standards across California.

Finding 2: The Health Agency Implemented Its Draft Surge Plan to Respond to the Recent Hepatitis A Outbreak.
Recommendation 2: To better ensure that its PHNs are prepared for future public health emergencies, the Health Agency should distribute its surge plan to its PHNs and train them on its protocols.

The County of San Diego Health and Human Services Agency (HHSA) agrees with this recommendation.

We will continue to distribute the Public Health Personnel and Infrastructure Surge Capacity Plan (Surge Plan) and train our public health nurses. During the hepatitis A outbreak, the draft Surge Plan was implemented and the appropriate PHNs received training on their roles and responsibilities. Consistent with the County of San Diego Hepatitis A After Action Report, the County is committed to ensuring public health staff members are trained in emergency management structures and roles to enhance their readiness to respond to a public health emergency. The 2018 Surge Plan contains guidance for ensuring all necessary individuals are provided training at regular intervals. The County currently provides quarterly trainings for nurses as well as annual mass care/shelter trainings and ‘Point of Dispensing’ trainings. Additional trainings are provided on an as-needed basis.

As mentioned in this report, neither the County of San Diego Hepatitis A After Action Report nor the 2017/2018 San Diego County Grand Jury Report, dated May 17, 2018, had any concerns with the use of PHNs in responding to the hepatitis A outbreak. Further, the San Diego County Grand Jury commended Public Health Services and PHNs for the creation of the innovative ‘foot team’ approach for providing vaccinations for unsheltered individuals living in difficult-to-reach areas. As a result of the collaborative effort of County PHNs and community health care partners, 162,253 hepatitis A vaccinations have been administered countywide, as of June 6, 2018.


To provide clarity and perspective, we are commenting on the response to our audit report from the Health Agency. The numbers below correspond to the numbers we placed in the margin of the Health Agency’s response.


As we state here, because the Health Agency does not consistently use available information such as case assignment data to measure PHN efficiency and assess its PHN staffing assignments, it cannot demonstrate that it employs the appropriate number of PHNs to efficiently serve its residents. In addition, as our report indicates here, a large percentage of PHNs from two programs who responded to our survey reported that their caseloads were too high for them to effectively accomplish their jobs. Finally, as we report here, the Health Agency’s chief nursing officer, who is responsible for planning, coordinating, implementing, and evaluating countywide nursing standards and practices, agreed during our audit that the Health Agency cannot demonstrate its PHN staffing level is appropriate.


We stand by the title of our report. As we indicate herehere, and here, the Health Agency does not use available information such as case assignment, caseloads, or overtime data to monitor PHN efficiency and assess staffing. Consequently, it cannot demonstrate that it employs the optimal number of PHNs or allocates them in the right locations to efficiently serve county residents. Such efficiency is required under San Diego County’s Code of Administrative Ordinances and the strategic plan for the Health Agency’s Public Health Services programmatic department.


We acknowledge here and here that currently there are no required or generally accepted standards for measuring and assessing PHN caseloads and workloads. However, the California departments of Social Services and Health Care Services have developed caseload benchmarks for Foster Care and Children’s Services that the Health Agency could use to monitor the adequacy of its PHN staffing until it develops its own efficiency measures.


It is because there are no statewide efficiency measures for PHNs that we recommend San Diego County develop and implement its own. We believe that the Health Agency’s development of its own efficiency measures is the most expeditious way to ensure it employs the optimal number of PHNs in the right locations to best serve county residents. Therefore, we stand by our recommendation that the Health Agency should direct its chief nursing officer to begin developing and implementing PHN efficiency measures by January 1, 2019.


Evidence we obtained during our audit did not support the Health Agency’s claim that its Foster Care program has a “robust process” for monitoring caseloads. As we report here, the Health Agency does not require its managers to monitor each PHN’s caseload. Furthermore, as we note here, the chief nursing officer confirmed that the Health Agency does not collect or analyze PHN workload information from its programs and regions. Although the Health Agency provided summary PHN caseload information aggregated by region and unit for the Foster Care program and described how regional office staff discuss their caseloads, it provided no information regarding how program administrators monitor PHN caseloads across regions or programs—which would be an indication of the efficiency of a program’s PHN staffing. We stand by our conclusion as stated here that the Health Agency does not consistently use available information—including caseloads—to measure PHN efficiency and help assess PHN staffing assignments.

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