Missoula Public Health OFFICIAL RECORD OF PROCEEDINGS

Missoula Public Health oakicsei ty Health Department

OFFICIAL RECORD OF PROCEEDINGS

Missoula City-County Board of Health

SEPTEMBER 17, 2015

Board Members Present: Ed Childers, Teresa Henry, Debbie Johnston (Vice Chair), Ross Miller (Chair), and Dr. Garon Smith

Members Excused: Jean Curtiss, Dr. Tom Roberts

Staff Present: Administration: Ellen Leahy, Julie Mohr, and Kathy Potwin; and Environmental Health: Jim Carlson, Alisha Johnson, and Shannon Therriault for Items 1 - 3; Health Promotion: Cindy Hotchkiss and Helen Russette for Items 5 - 7; and Health Services: Kate Siegrist for Item 1

Legal Counsel Present: Erica Grinde (Civil Attorney, County Attorney's Office)

Others Present: Leila Haack (Kiwanis); Callie Aschim; Danielle Beaudin; Bradley Daniel; Michael Dean; J. A. Edwards; Curtis Engelstad; Jeff Gutierrez; Malcolm Lowe; Dale Mayer; Tim Moats; Dan Monahan; Nicole Taranto; Jess Wrightson; MSU College of Nursing (Missoula Campus) students—Rick Alton, Annelise Baker, Scott Boyd, Bethany Buescher, Shelby Burkardt, Mariana Covaci, Alexandra Duncan, Ryan Durkin, Brittany Gessaman, Sarah Hanson, Amanda Studemen, Bethany Humphreys, Lindsay Jenson, Sarah Katterhagen, Ashton Keeler, Heidi Kelley, Katherine Morozumi, Kellie Nix, Alyson O'Brien, Jordan Snow, Vanessa Vail, and Andrew Vale; Christy Buttler Nelson (MSU Teaching Professor); and Ron Scholl (Cameraman, Missoula Community Access TV)

Meeting Called to Order: Ross Miller (Chair) called the meeting to order at 12:16 p.m.

ITEM 1 KIWANIS' PRIORITY ONE DONATION TO THE JOAN FISCHER FUND

Director Leahy introduced Leila Haack, a member of the Downtown Kiwanis Club, who was present on their behalf to give a donation of $950 to the non-profit Joan Fischer Fund, which is not under the Board's authority but is used for the benefit of health department clients. Joan Fischer was a Public Health Nurse (PHN) at the health department. In that capacity, she was in a position to identify the needs of parents and children and often gave personal resources to help.

Joan's husband William was instrumental in Ms. Haack becoming a Kiwanian. Although she never met Joan, she knows other members of the family. The Kiwanis reach out through their Priority One program to use funds raised from a pancake breakfast fundraiser to address the needs of younger children in the community. The Kiwanis are pleased to choose the Joan Fischer Fund is one of four recipients to receive an award. Ms. Haack spoke of the importance of this opportunity for the Kiwanis partner with the health department and others to support the success of the community—and to keep the story of Joan Fischer's service alive in order to help children. Ms. Haack explained that the Kiwanis also have an event "Cribbage for a Cause", in which they raise money to help eliminate tetanus worldwide—another public health concern. In memory of Joan's love of gardening, she distributed fresh garden produce and fruit.


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Mr. Miller applauded Ms. Haack and the Kiwanis Club for their support of the community.

Teresa Henry explained the presence of the Montana State University (MSU) College of Nursing (Missoula Campus) students who, as part of their education on public health, are required to attend one of the monthly series of Health, Air Pollution Control and Water Quality District Board meetings.

ITEM 2 HEARING AND POSSIBLE ACTION ON PROPOSED REVISIONS TO HEALTH CODE, REGULATION 4 FOOD ESTABLISHMENTS AND TO FEES

➢ Attachment A, "Regulation 4 – Food Service Establishments (Proposed Changes for Public Comment – August 19, 2015)"

➢ Attachment B, "Memo from Shannon Therriault, RS to the Board of Health regarding the Food Service Rules and Fees (September 9, 2015)"

➢ Attachment C, "Memo from Alisha Johnson, RS and Shannon Therriault, RS to Missoula Food Service Businesses regarding the Proposed Changes to the Montana Health Code (August 25, 2015)"

➢ Attachment D, "Regulation 4 – Updates for Food Services and Proposed Fees" (PowerPoint presentation)

➢ Attachment E, "Memo from Shannon Therriault, RS to the Board of Health regarding the Interim Temporary Food Service Permit Fees (September 9, 2015)"

➢ Attachment F, "Interim Fees for Temporary Food Services" (PowerPoint presentation)

Mr. Miller convened the hearing.

Staff Presentations: Alisha Johnson (Environmental Health Specialist, Environmental Health Division) presented the department's proposal to revise Regulation 4 of the Missoula City-County Health Code—including changes to fees.

The health department has proposed the changes because the state rule adopted new retail food regulations, adopting the 2013 FDA Food Code by reference. In addition, the 2015 Legislature made changes to the state statute pertaining to temporary food services, cottage foods, and mobile food carts, which go into effect October 1, 2015.

As documented in detail or referenced in Attachments A through D, key language changes, will: • Establish consistency with the state rule and statute, address high-risk violations, update

citations of rule or law, update authority language, and clarify "gray" areas. • Address certified food protection manager requirements. • Introduce and solidify mobile design standards. • Address registration and compliance protocol for cottage foods.

Temporary Food Services (TFS) will no longer be licensed by the Montana Department of Public Health and Human Services (DPHHS), but will be permitted on the local level. Proposed revisions to the Health Code will:

• Incorporate a new definition from law. • Allow new operational times. • Introduce three types of permits—recurring events, multi-day events, and single-day

events.


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• Make adjustments to clarify responsibilities of the event coordinator. • Set higher fees for operating with a permit. • Reorganize information in subsections. • Remove sections covered by rules. • Add information on wild mushrooms, wholesale foods, and circumvention language.

Other proposed revisions change to modern regulatory terms, use of the singular tense, and clean-up to decrease logistical issues.

Discussion: Mr. Miller called for questions from the Board.

In response to questions from Debbie Johnston, Alisha Johnson confirmed the following: • Cottage food is not defined in Regulation 4 because it is defined in state statute. • Under this regulation, many vendors at Saturday markets, who are selling prepared food

products, would be permitted for a temporary, multiple-recurring event. Not all vendors would be permitted because in state statute there are exemptions for certain kinds of prepared foods.

• The permit would be issued one time, at the beginning of the season. • The permit is per event, so if issued, for example, for the Saturday Farmers' Market at a

particular location, the permit is not valid for a Thursday event at another location.

Teresa Henry requested changing the wording in the definition of "Establishment" in 4(B) (Attachment A, page 4-2) by replacing "and" with "or"—otherwise is reads as though an establishment must be a retail food service establishment and a wholesale food establishment rather than one or the other. Ms. Johnson: Okay.

Mr. Miller, Ms. Grinde, Ms. Johnston and Teresa Henry posed numerous questions to Ms Johnson and gave comments regarding the definitions related to self-contained and self-sufficient mobile food establishments.

• Mr. Miller asked whether "mobile" as used in the definition of "Self-Contained" in 4(G) and "Self-Sufficient in 4(H) (Attachment A, page 4-3) is the same as a "mobile food establishment" as defined in the Montana Code Annotated (MCA). Upon learning from Ms. Johnson that it is the same and the definition is in MCA, he requested replacing "mobile" in 4(G) and 4(H) with "mobile food establishment."

• Ms. Grinde asked, for the sake of clarity, to cite the state law or rule that defines a "mobile food service."

• Mr. Miller asked for clarification regarding the difference between a self-sufficient mobile food establishment versus one that is self-contained. Is a self-sufficient mobile food establishment basically "self-contained" plus more? Ms. Johnson confirmed he was correct. "Self-contained" means everything is on board and it is a fixed structure; things are mounted as is. "Self-sufficient" means there is no need for an additional facility to make any of the food. It is a full service kitchen on wheels. Based on feedback provided by Ms. Grinde, Ms. Johnson indicated the language in the definitions for "self-sufficient" and "self-contained" can be revised to clarify that a self-sufficient mobile food service is a self-contained mobile food service that does not have to rely on a commissary. A mobile food service must be self-contained but you whether it is self-sufficient depends


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on how it is constructed. It is possible to have a self-contained mobile food service that relies on a commissary and thus is not self-sufficient—or it could be both.

Mr. Miller asked for clarification regarding information in the section on Mobile Food Service in 8(A) and 8(E)(1) in Attachment A on page 4-8. In 8(A), it says a mobile food service must be self-contained. In 8(E) it says a mobile food service must obtain a temporary food service permit if: (1) It is not self-contained. Does this mean that, at minimum, the mobile food service must be self-contained? Perhaps this will be clarified when the definitions are revised for clarity. Ms. Johnson said the problem is that sometimes mobiles will expand beyond what was originally approved. Even though they are a licensed mobile food service, they will arrive on site with a completely different setup; thus, they no longer meet the definition of self-contained mobile food service. At that point they need to be permitted as a temporary food service. Ms. Johnson will review the language. Debbie Johnston said it made sense to her: an operation is a mobile food service until it no longer is self-contained and then it requires a temporary food service permit.

Public Comment: Mr. Miller asked members of the audience to give a show of hands if they planned to give public comments and noted the Board reserved the right to limit comments to ten minutes per person if necessary to conduct all of the Board's business. If more individuals want to give comments, it will still be possible to submit written comments through September 30, 2015. Mr. Miller opened the public comment portion of the hearing

Nicole Taranto (Owner, Bao Chow food cart) is a mobile food service vendor who uses a TFS setup for different events around town that exceed the food we put out with the mobile cart. When she first got a TFS, she was told through the Health Department that she did not need a TFS permit if she added a table to set up condiments. However, if she was going to use the same table to set out prepared food that needs to be time- or temperature-regulated, then it is a temporary food service. She said she did not know this because the code does not say this. She asked for clarification as to the distinctions that determine when a mobile food service must be considered a TFS and licensed as such.

She also remarked on how language in the code about attached equipment adds to the confusion regarding distinctions between mobile food services versus temporary food services and the permitting requirements. The definition for "self-contained" says equipment has to be attached to the mobile setup. If her table is not attached does that mean her setup is not considered to be a mobile food service and it is a TFS—regardless of what is placed on the table? If the table is not connected to the food cart, why is it not considered to be a TFS since the setup is no longer self-contained? Ms. Johnson said in order to make a determination, the department's plan review looks at the vendor's mobile and facility and what the vendor plans to do. The concept is that the vendor is one facility that moves and cannot leave behind anything that requires temperature control or necessary equipment. If the vendor sets up an array of individual tables, the level of risk increases. Determining the effect of using a free-standing table is tied to what is essential to the operation in order to protect public health.

Bradley Daniel (Bao Chow) also asked for clarification of the definition of "attached." He asked how and to what extent appropriate items have to be attached? Ms. Johnson proposed revising the language to define or explain what is meant by "attached" in "attached equipment" and to


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explain that a mobile food service can set up a free-standing table with a cash register, napkins or non-TCS foods and still be considered a mobile food service.

Malcolm Lowe (Loose Caboose – Farmers Market/Clark Fork Market) asked how many days are allowed for a reoccurring event. Ms. Johnson said in the state statute, the definition of a reoccurring event no longer limits the event to 21 days: it can occur up to 45 days.

Kim Kaufman (Commercial Department, EXIT Realty) asked how the assignment of the permit fee for a small versus a large temporary food service is determined. What are the criteria used to assign the fee for one category versus the other. Ms. Johnson said the determination is defined at the state level and is based on the number of employees. It is not in the local code. Small establishments have no more than two employees working at a time. If three or more employees are working at the same time, it is considered a large establishment.

Jeff Gutierrez (Montana Food Bank Network) asked for clarification regarding the Food Protection Manager requirements and licenses as they relate to Emergency Food Providers. If a provider can show good manufacturing processes and critical access points, etc., where will they fall under the new requirements? Ms. Johnson said the requirement for a Certified Food Protection Manager (CFPM) does not apply to wholesale establishments. When it comes to retail organizations, including food banks that give food directly to the consumer, the requirement for a Certified Food Protection Manager requirement is applied based on the level of risk. If you are going beyond a pre-packaged temperature-controlled food or a pre-packaged non-temperature controlled food—or doing something more, like heating up a hot dog, then you need a Certified Food Protection Manager. Ms. Johnson confirmed e confirmed that if the establish is doing repack or transporting product from a retail establishment—if they are a Food Circle Program—a CFPM is required.

Mr. Gutierrez asked how the labeling requirements affect Food Circle Programs. Ms. Johnson

explained the full list of ingredients must be listed with the food—and the allergens. the rule requires the full list of ingredients listed with the food--and the allergens. That said, there is a variance section in the rule. You have the option to propose something else, which the health department may or may not be able to approve.

Mr. Miller called for additional comments. Director Leahy reiterated that the written comment period is open until September 30, 2015.

Mr. Childers asked for clarification regarding the definition of small versus large TFS. Is this based on people working there at one time or is it based on full-time equivalents (FTEs)? Ms.

Johnson said it is based on the maximum number of employees working at any one time. A caveat is that the state is looking at revamping rules based on risk level so this may change. The department may come back to the Board later on and propose different regulations based on that, or different fees based on that.

Director Leahy and Ms. Grinde discussed with Mr. Miller and Ms. Johnston that the Board needs to clearly identify when the hearing closes, which will determine when the Board is last able to take


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additional public comment. If the hearing is continued to the October 15th meeting, the Board can take additional public comment at that time and still take action if ready to do so.

Mr. Miller asked for Board and staff feedback as to how long to continue the hearing. Dr. Smith

spoke in favor of keeping the hearing open through October 15th, giving the public a chance to respond to changes proposed today. Ms. Henry asked what the process will be if more public comments are given on October 15th and staff respond that day. Will the Board vote on changes at that time, or will the hearing be continued again to a later date? Ms. Therriault described the process usually employed by the department. Staff will prepare a document to address any written comments that come in through September 30th, as well as the comments given today. Based on changes proposed today, she confirmed staff will recommend additional changes at the October 15, 2015 meeting. Staff will provide the comments document to the Board a week in advance of the October meeting—which will also be available to the public via the Internet or by acquiring a copy at the department. Depending upon the Board's preference, the department may also send out an e-mail to all of the licensees. Previously a letter was sent to them but there will not be sufficient time to follow up by sending a letter via the mail. Interested parties may submit their e-mail address to the department or call the department to request updated documents.

Dr. Smith made a motion to continue the hearing until the Board's October 15, 2015 meeting.

Mr. Miller called for additional comments and asked how the department is affected logistically if the Board does not take action until October 15th but the changes in statute go into effect October 1st. Ms. Therriault said are scheduled to provide follow-up as Item 3 on the agenda. She will ask the Board to adopt interim fees today, which will go into effect on October 1st. Adoption of proposed interim fees does not have to go through the process of setting a public hearing, conducting the hearing, and then taking action. It is sufficient to include the request for action as an item on a publicly-noticed agenda and for the Board to allow public comment. This approach provides the public with an opportunity to comment but also addresses logistical issues if the interim fees are adopted today.

Ms. Johnston asked how this affects changes regarding temporary food services since licensing has moved from the state to local permitting but the Board has not adopted the proposed changes to the Health Code. Ms. Therriault explained there are TFS fee rules, which are in effect now. The department will be able to issue permits have temporary food ervice fees rules that are in effect now. Staff will be able to issue permits, but the process s not going to be as clean as when the proposed changes to the Health Code are adopted.

Motion: The Board of Health approved the motion to continue the hearing on proposed changes to Health Code Regulation 4 Food Service Establishments and changes to fees other than interim TFS fees to their October 15, 2015 meeting. The motion carried unanimously: Ayes – 5 (Childers, Henry, Johnston, Miller, and Dr. Smith); Nays – 0; Excused – 2 (Curtiss and Dr. Roberts).

ITEM 3 ADOPT INTERIM FEES FOR TEMPORARY FOOD SERVICE PERMITS

➢ Attachment F, "Interim Fees for Temporary Food Services (PowerPoint presentation)



Staff Recommendation: Ms. Therriault presented the recommendation to the Board to adopt interim fees for TFS permits. The 2015 Legislature passed House Bill (HB) 478, which moves TFS from state licensing to local permitting, effective October 1, 2015. The bill requires local health departments to charge a fee, which cannot exceed fees for retail food service licenses. The current fees are $85 for a small establishment in which no more than two people are working at a time. The fee is $115 for an large establishment where three or more people are working at a time. The proposed fees will only apply to "for profit" TFS; non-profit vendors are exempted by law from paying the permit fees.

The department recommends that the Board adopt interim fees today in order for them to be in place by October 1st. The Board has the ability to revise them as may be appropriate, along with other fee changes, at another time. Under the Health Code, fees may be adopted or changed at any regularly scheduled meeting of the Board, providing the action is scheduled on the Board publicly-noticed agenda and public comment is allowed.

Ms. Therriault recommended the following interim fees:

Small Establishment Large Establishment

Single Day Event: $65 $ 95 Multiple Day Event: $75 $105 Recurring Event: $85 $115

Right now, the department receives 90% of the license fees and DPHHS keeps 10%. Effective October 1st, 100% of the fees will stay at the local level so the department can offer a discount for shorter term events without causing a budget shortfall. The proposal provides for the department to continue to receive almost an equal amount of fee revenue. Ms. Therriault noted, that there may, however, be a reduction in the number of temporary food services because the new law allows the events to run longer.

Board Discussion: Dr. Smith suggested adding information to the fee schedule to identify the length of a multi-day versus a reoccurring event. Ms. Therriault agreed to do so and noted the definitions are included for adoption in Regulation 4.

Public Comments: Heather McDonald acknowledged that licensing will no longer be done at the state and TFS will be permitted locally. She knows many mobile units will go from county to county, which will now require obtaining permits from each county. She asked whether the department took this into consideration when proposing the fees. Ms. Johnson clarified that the proposed fees apply only to TFS. Fees for licenses for mobile food services will still be set and handled by the state.

No other public comments were given. Ms. Johnston made the motion for action.

Board and Staff Comments: In response to questions from Mr. Childers, Ms. Johnson and Ms. Therriault clarified details regarding the occurrences of recurring versus multi-day events.

Motion: The Board of Health approved the motion to adopt the interim fees for temporary food service permits now, in order to have fees in place by October 1st. The motion carried


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unanimously: Ayes — 5 (Curtiss, Henry, Johnston, Miller, and Dr. Smith); Nays — 0; Excused — 2 (Curtiss and Dr. Roberts).

ITEM 4 APPROVE AUGUST 20, 2015 MINUTES

Director Leahy encouraged the Board and staff to speak louder and clearly to support the process of recording minutes. Ms. Johnston made the motion for action.

Motion: The Board of Health approved the August 20, 2015 minutes with a correction to remove highlighted text from page 7. The motion carried unanimously: Ayes — 5 (Childers, Henry, Johnston, Miller, and Dr. Smith); Nays — 0; Excused — 2 (Curtiss and Dr. Roberts).

ITEM 5 ADOPT COMMUNITY HEALTH IMPROVEMENT PLAN: JULY 2015 —JUNE 2018

)=. Attachment G, "Community Health Improvement Plan for July 2015 — June 2018"

Staff Presentation: Director Leahy said the department is not asking the Board to adopt the Community Health Improvement Plan (CHIP) at this time, as the document is not fully completed. The document may be ready for adoption at the Board's October 15, 2015 meeting. Today, staff will review the two priorities set forth in the CHIP, identify which portions are still being finalized, and answer questions. This is the second cycle to develop a three-year CHIP. The CHIP workgroup met in full on September 11, 2015 for their final meeting prior to approval of the plan. During their next phase of meetings, they will monitor and track progress toward fulfilling the plan.

Cindy Hotchkiss (Director, Health Promotion Division) coordinates the CHIP project. She reminded the Board that the project came out of development of the Community Health Assessment (CHA), which the board adopted in December, 2014. Thereafter, the CHA workgroup continued to meet in order to select two key indicators for the CHIP. The determination was made after drawing on public comments given at meetings and solicited from the public by posting the CHA on the Internet.

The two key indicators are obesity and access to care. The focus for access to care includes mental, dental, and medical care, as well as maternal child health. The obesity indicator includes all age groups across the lifespan. The group addressing access to care is still trying to pull in evidence-based practices and background information on the strategies they intend to use. They will continue to meet two times per year. The group addressing obesity will continue to meet quarterly for the next three years to check in to see if anything new is happening, to confirm efforts are still on track, and to compile their yearly reports for the Board.

Director Leahy said the CHIP is still in draft form because the obesity group has not resolved whether there are sufficient resources in the community to commit to retaining the "older adult" plank for prevention. Ms. Hotchkiss clarified that the issue was resolved at meeting held late yesterday. Missoula Aging Services has agreed to take this on at the forefront. Parks and Recreation and the City Transportation Department will also continue to serve as primary community partners to address the "older adult" section on obesity. Director Leahy was pleased to learn of this decision.


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This year, the work groups looked for ways to focus on populations that tend to have health inequalities. They identified the "aging"—now appropriately called "older adults"—as one such population. The other cross-cutting population whose needs they want to address wherever possible in both priority areas is the Native American population. They were not able to develop a good organizational scheme for the CHIP that clearly emphasizes this intent.

Ms. Hotchkiss reminded the Board that the previous CHIP also had obesity and access to care as the priorities but the first focused primarily on childhood obesity and the latter focused on access to medical care. In choosing these indicators again for the new CHIP, it was decided to expand and include more areas of focus. Director Leahy reported one of the largest goals for "access to care" is to involve people across the community in Medicaid Expansion. Dr. Roberts participated as a member of this work group.

Director Leahy asked for questions and comments from the Board so staff can move forward to finalize the plan. She clarified that public health accreditation does not require the board to adopt the CHIP but, in the past, the department asked all of the agencies involved in the development of the CHIP to commit to the plan. For this reason, the department will ask the Board next month to adopt the plan, although it is really owned by numerous agencies—unlike the Strategic Plan, which is under the Board's jurisdiction. Ms. Hotchkiss offered for the Board to submit comments and suggestions on the plan to her via e-mail by October 1, 2015.

Discussion: Ms. Henry recommended revising the Table of Contents so that the 5th focus area under "Priority: Improve Access to Health Care" reads "Focus Area: Remove Barriers for Groups Experiencing Health Disparities" rather than "Focus Area: Remove Barriers to Care Through Provider Training" in order to be consistent and to be clear that the issue is about groups at risk for health disparity. Ms. Hotchkiss confirmed staff will make the change.

The CHIP is set up in a new format, with the goal to track and report on progress on specific items over the three-year period in a way that everyone involved can understand.

Ms. Henry also recommended revising the Table of Contents to clearly show there are two focus areas—one related to children and the other related to adults. Director Leahy concurred but said there should be three focus areas. Ms. Hotchkiss explained this is one part of the CHIP that is still being edited. The three focus areas—children, adults, and older adults—will be listed.

Mr. Miller called for additional comments. There were none.

ITEM 6 ACTION ON PROPOSED STRATEGIC GOALS FOR STRATEGIC PLAN (FY 2016 - 2018)

)=. Attachment H, "Proposed Strategic Goals for FY 2016 – 2018 (July 1, 2015 through June 30, 2018)"

Director Leahy introduced the proposed strategic goals for the next strategic plan's 3 year cycle. She reminded the Board the proposed goals arose from the following activities:

• They are informed by the CHA, adopted by the Board in December, 2014. • They are informed by the CHIP, even though it has not yet been finalized and

formally adopted.



• The health department held three meetings over the summer to obtain input from staff, with over 80% of staff participating.

• The department's management team members were asked to bring proposed goals to the September 2, 2015 planning meeting. The Board appointed Ms. Johnston and Dr. Roberts to serve as a committee and to join staff at the planning meeting. The group drafted and chose the goal areas.

• A subgroup of staff refined several proposals in a follow-up session.

Staff Recommendation: Director Leahy recommended that the Board approve the strategic goal areas and then direct the department to write the work plan for the first year of the strategic plan, which will then be brought to the Board, possibly as early as the October 15, 2015 meeting.

• The work plan is written in one-year increments and each year is brought to the Board for approval. The intent is to bring the Year One plan to the Board for adoption on October 15th if there is room on the agenda.

• The Board is already aware there will be some language changes, particularly to the indicators which do not yet have baselines.

• Board questions and comments are welcomed in order to improve this document before managers write the work plan for the first year.

Discussion: Mr. Miller noted page 2 needs to be corrected to read, "E) Decrease completed suicides in Missoula County"—not listed as Item 2 under Section D. Director Leahy concurred.

Dr. Smith identified that the word "Indicator" is usually underlined throughout the document but is not on underlined on page 1, under A), 2) or on page 3, under E), 1).

Director Leahy provided an overview of the process used at the September 2, 2015 planning meeting. Ms. Johnston commented that it was a good process and commended Director Leahy for her leadership during the session. Mr. Miller thanked Ms. Johnston and Dr. Roberts for their participation on behalf of the Board.

Staff Request: Director Leahy requested that the Board adopt the proposed strategic goals and direct the department to bring forward the Year One Work Plan.

Board and Staff Comments: No comments were given.

Public Comments: No comments were given. Dr. Smith made the motion for action.

Motion: The Board of Health approved the motion to adopt the strategic goals and to direct staff to bring forward the Year One (FY 2016) work plan at a future meeting. The motion carried unanimously: Ayes – 5 (Childers, Henry, Johnston, Miller, and Dr. Smith); Nays –0; Excused – 2 (Curtiss and Dr. Roberts).

ITEM 7 REVIEW HEALTH DEPARTMENT PERFORMANCE MANAGEMENT INDICATORS

➢ Attachment I, "5-Step Friedman Approach to Select Performance Measures and the Logic of Public Health" (PowerPoint presentation)

➢ Attachment J, "MCCHD Performance Measures 2015 - 2017"


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Helen Russette (Performance Management/Quality Improvement Coordinator, Health Promotion Division) was introduced to the Board at their August meeting but, due to time constraints, her presentation on the health department's performance management indicators was postponed to today. Ms. Russette comes from the University of Montana's Masters in Public Health (MPH) program and was hired earlier this year on a half time basis.

The department sets performance management indicators and metrics, which tie to the yearly work plan for the Strategic Plan, and which are scrutinized as part of the public health accreditation process. Performance management measures are an important means of determining why an initiative may fail or years of work in the community may appear to show little movement forward. Ms. Russette has developed an approach for staff to use to identify the measures the department wants to follow, as well as the document format to use to track them.

Ms. Russette used Attachment I to explain the 5-step Friedman approach, chosen by the department as the process to use to choose the top performance measures. Ms. Hotchkiss commented that her staff completed this process for each of their programs. She described the ways in which doing so was very helpful. After staff identified what they wanted or needed to measure, Ms. Russette helped them create a data development agenda, which pinpoints the areas for which the department lacks the necessary data. The purpose is to establish what the department would like to measure more time and resources are available. Director Leahy said the ultimate purpose is to connect the PM in a direct and focused way with any Quality Improvement (QI) projects the department pursues in order to go successfully meet public health goals.

Ms. Russette also used Attachment I to explain how to apply the logic of public health. She explained how Attachment J is a tool designed to use a balanced score card approach to report on the performance measures the department has adopted in a way that shows how the data is trending from year to year. Currently, staff members are providing the goals for the baseline measures. Status columns at the right side of the score card are designed to show the status of a goal: the goal has been met; progress is being made and activities are on track to meet the goal; or progress is not on track toward meeting the goal. Thus, the indicator will show if there is a need for a quality improvement project. Some of the next steps could be to implement performance metrics (inputs) specific to the five steps of PM, to describe the outputs, efficiency, service quality, and outcomes, and/or to incorporate strategic planning objectives and measures, potentially including the Community Health Improvement Plan (CHIP).

Discussion: In response to a question from Dr. Smith regarding the green goal entry in Attachment J, Director Leahy confirmed the intent is to show the current status of efforts to meet a goal, which may or may not have already been met. If it has been met, we want to show when we are trying to hold that line. Ms. Russette confirmed the color formatting (green, red, and yellow) is intended to illustrate for Years 1 through 3 whether the goal has been met, the line is being held, or if changes move toward or drop away from meeting the goal. Yesterday, the department's PM/QI Committee discussed whether to use the term "goal" or "metric" or "benchmark" but did not reach a conclusion. Director Leahy said there are items which will start in the red and others which may start in the green.

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ITEM 8 MATERNAL CHILD HEALTH (MCH) ADVISORY COUNCIL UPDATE

For the benefit of the public, Ms. Henry explained the role of the MCH Advisory Council to support the Board of Health and described how members are chosen. She told the Board the Council has had some success over several meetings to increase membership. They received training on the Adverse Childhood Event (ACE) study at the July meeting. The Council and other agencies are examining how to partner to help members of the community to respond to adverse childhood events. The Council is conducting a needs assessment for the populations with whom they have contact. They will address issues related to access to childcare. They examined the Community Health Assessment and discussed priorities. A representative from Child Protective Services will speak at the next meeting about current programs and ways to reach children at risk for neglect and abuse before they suffer from adverse events.

ITEM 9 DIRECTOR'S REPORT AND ACCREDITATION UPDATE

Director Leahy said a skunk tested positive for rabies in Missoula County. Either a single skunk was involved in two events—or possibly separate skunks were involved. The first event involved a person, the skunk and feral cats. The next day an event involved a skunk and dogs. It has been 20 years since there has been report of a rabid skunk west of the Divide. The state veterinarian is in charge of rabies quarantine for animals and has issued a quarantine order for all of Missoula County, specifically for dogs, cats and ferrets. All of these animals should be immunized for protection against rabies. The order was written in a way, which the public may find to be unclear in explaining how they are impacted. For people who have unvaccinated dogs, cats or ferrets, these animals cannot be released from Missoula County for 60 days. This is not an easily enforceable or controllable situation.

As discussed with the state veterinarian's office, the department is focusing priority enforcement on agencies that normally would transfer animals, including shelters, dog breeders and pet shops. The department is working with these groups directly to make sure they are aware of the quarantine requirements. Under the second part of the order, if an animal is vaccinated and the vaccination occurred within the last 28 days, they cannot leave Missoula County until 28 days have passed. The vaccine needs that amount of time to build immunity. Director Leahy said the department would have preferred a more honed order, although the state veterinarian has been very expeditious. She allowed the department to join her in her press release, which was issued earlier today. Jim Carlson (Director, Environmental Health Division) was in charge of that.

Three of the four dogs that physically encountered the skunk were not current on their rabies shots so they will be subject to quarantine for six months. Director Leahy said this provides a reminder to pet owners of the importance of maintaining current rabies vaccinations for their dogs, cats, and ferrets. The cats involved in the other incident were part of a feral cat community being fed by someone, which is prohibited by the department's regulations. The individual has been advised not to feed feral cats. The cats will be trapped and euthanized because it is not within the department's ability to control the spread of rabies in a feral cat population. They are also trying to trap additional skunks to determine whether others test positive for rabies. (On a scientific note, the rabies culture is being checked by the Centers for Disease Control (CDC) to see if this is the strain that is known to be found in bats or if it is a skunk variety, meaning that we may have a more widespread problem in the skunk population.)


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Although the quarantine order is for the entire county, the department is focusing on the neighborhood in which the events occurred, which involved the skunk or skunks. Director Leahy had hoped this is what the quarantine order would do; however, according to state rules, the state veterinarian does not have that ability. The incidents took place in the area around Harper's Bridge road. The neighborhood was given notice of the quarantine.

In response to a question from Ms. Henry, Director Leahy clarified that, even when a quarantine order is not in effect, people need to keep the rabies vaccinations up to date for their dogs, cats, and ferrets. By statute, they are prohibited from taking dogs, cats, or ferrets whose rabies vaccinations are not current out of the county. If these animal's vaccinations are current, they are completely unaffected by this order. The department anticipates there will be many questions, due to the scope of the order. Also, this is the time of year when there normally are many encounters with skunks so they are trying to be prepared to address public concerns.

To have three or four unvaccinated dogs is an unfortunate teaching opportunity. One person is undergoing post-exposure rabies prophylaxis. In response to a question from Debbie Johnston, Director Leahy said the frequency with which a person needs to be revaccinated against rabies depends on their risk of exposure. She described the department's recommendations for Animal Control workers to be vaccinated or to have blood titers draw to ensure their antibodies are sufficiently high. Director Leahy noted that it would not be smart for the department had to begin immunizing humans because people failed to immunize the domestic animal population.

Influenza has arrived early: four counties, including Missoula, have confirmed cases. It appears to be type H2, which is covered in this year's vaccine. The department has received some of its vaccine and has started early with giving flu shots.

For the second time, First Lady, Michelle Obama, invited the Let's Move! Missoula initiative for preventing childhood obesity in our community to be represented at an event held yesterday at the White House. Commissioner Curtiss received the invitation and passed it along so that Lisa Beczkiewicz and Mary McCourt (Health Promotion Division) were able to attend.

The department is working on the backlog of meeting minutes for the Board, as well as looking at ways to prevent backlogs. Numerous drafts will be sent to the Board for review and approval.

Staff Proposal: Director Leahy made two proposals: 1) Limit reporting of the monthly journal report to the full citation and the findings, starting today; and 2) Allow staff to publish draft versions of the minutes via the Internet. The journal report is part of Missoula Community Access Television's (MCAT's) taping of each meeting. Director Leahy noted that one of the department's strengths on accreditation was the fullness and clarity of the minutes. Future discussion is needed to determine how to make it manageable to record the minutes without losing that quality.

Discussion: The proposal does not require official action and therefore does not require being posted for public notice or a motion by the Board. In response to a question from Mr. Childers, Director Leahy indicated that Mr. Best has not submitted specific requests for records. Ms. Mohr confirmed he has not contacted her. There was discussion regarding the potential consequences if a draft set of minutes were to contain a substantive error. Erica Grinde (legal counsel) said drafts

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can be posted as long as there is clear indication that they are drafts. It could be problem if minutes are not made available.

ITEM 10 JOURNAL REPORT; IDENTIFY VOLUNTEER FOR OCTOBER REPORT

➢ Smith, Philip J. et al, "Children and Adolescents Unvaccinated Against Measles: Geographic Clustering, Parents' Beliefs, and Missed Opportunities," Public Health Reports Volume 130, pp. 1-20, September-October, 2015, and available online at http ://www.publichealthreports. org/documents/Measl es 130 5 .pdf.

Director Leahy reported on a study in which the researchers concluded that negative parental beliefs do not account for the majority of scenarios in which children go unvaccinated for measles. Instead, they found that 74% of instances in which the children went unvaccinated for measles were due to missed opportunity. For example, there were occasions when children obtained other vaccinations but their healthcare providers overlooked given them their measles shot. Director Leahy said this highlights one opportunity for the department to address improving child vaccination rates. She will share this information with Sara Heinemann, the manager of the department's outpatient clinic.

Mr. Childers volunteered to provide the October journal report.

Mr. Miller (Chair), Ms. Johnston (Vice Chair) and Dr. Smith will all miss the October 15, 2015 meeting. Teresa Henry must be able to leave before 3 p.m. to teach a class. Dr. Smith or Ms. Johnston said they can participate via phone if necessary to secure the quorum for action items.

Follow-up: Ms. Mohr will confirm attendance for a quorum for the Board's October meeting.

ITEM 11 PUBLIC COMMENTS ON ITEMS NOT ON THE AGENDA

No comments were given.

ITEM 12 BOARD AND STAFF COMMENTS ON ITEMS NOT ON THE AGENDA

No comments were given.

ADJOURNMENT: Mr. Miller adjourned the meeting at 2:38 p.m.

Respectfully submitted,

Ellen Leahy Health Officer


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Documents

Missoula Public Health OFFICIAL RECORD OF PROCEEDINGS