What three items must a local or state health department produce within the two years prior to seeking accreditation?

In response to a call for improved quality and consistency in public health departments, the Public Health Accreditation Board (PHAB) is leading a voluntary public health accreditation initiative in the United States.

The public health department accreditation system will implement a comprehensive set of standards that set uniform performance expectations for health departments to provide the services necessary to keep communities healthy. Continuous quality improvement is a major component of PHAB accreditation, demonstrating a commitment to empower and encourage public health departments to continuously improve their performance.

The accreditation process was tested in 30 health departments around the country in 2009 and 2010, and was launched on a national level in September 2011 at the National Press Club in Washington, DC.

ACCREDITATION IS A WELL-established process for improving performance within organizations1 and takes place when a formal authority concludes that an organization meets predetermined standards.2 In the health care field, the Joint Commission and National Committee for Quality Assurance are long-standing, respected accreditation authorities recognized for establishing standards and advancing quality through accreditation of health care organizations.3,4 Initiatives undertaken in 4 states—North Carolina, Michigan, Missouri, and Illinois—have demonstrated the relevance and usefulness of similar accreditation systems in public health. 5–8 Important lessons have been learned from these programs about the need for and development of a national public health accreditation system. Nonetheless, despite state examples and the critical role of public health in the health of the nation, no national accreditation organization has been established to ensure public health department standards of performance, until now.

Public health department accreditation has become one of the most important initiatives in public health today, representing the culmination of many years of collaboration and research. Leading this initiative is the Public Health Accreditation Board (PHAB), a nonprofit organization dedicated to advancing the continuous quality improvement of state, local, tribal, and territorial health departments through accreditation.9 The goal of the PHAB, set by the Robert Wood Johnson Foundation and the Center for Disease Control and Prevention, is to ensure that 60% of the US population is served by an accredited health department by 2015.10,11 Achievement of this goal is expected to promote and protect the health of the public by advancing the performance of state, tribal, territorial, and local public health departments.9,12

We have provided an overview of the voluntary national accreditation program led by the PHAB, the current status of accreditation, and a roadmap for next steps that will be undertaken in the transformation of public health quality in the United States.

Opinions vary widely about what constitutes a public health department and what should be expected of it, despite several attempts to clarify these concepts.13 Accreditation can reduce this inconsistency by formulating a set of standards against which health department performance can be measured, along with recognition for agencies meeting the standards.14 These standards identify opportunities to improve management, develop leadership, and advance relationships within the community.15 Accreditation also documents the capacity of public health departments to carry out their 3 core functions16 and 10 essential health services,17 ensuring that they can meet the public health needs of their community.9

Significant progress has been made in developing a public health accreditation process during the past decade. In 2003, the Institute of Medicine recommended exploring public health accreditation as a way to improve accountability for public health departments and suggested that a national commission be appointed by the secretary of the Department of Health and Human Services to consider accreditation in public health.16 The following year, the Centers for Disease Control and Prevention identified accreditation as a key strategy for strengthening the public health infrastructure.18 Within 2 years, the Exploring Accreditation Project was formed to further investigate the case for public health accreditation.14 Most major public health associations contributed to the effort, including the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the National Association of Local Boards of Health, and the National Indian Health Board.14 State and local public health practitioners were also involved. The participants concluded, in a report released in 2006, that it was both desirable and feasible to move forward with establishing a voluntary national accreditation program, to be overseen by an independent accreditation board.14

The PHAB was incorporated in 2007 as a voluntary nonprofit organization to function as the national public health accrediting body. Financial backing has been provided solely by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.9 To begin the development of an accreditation system, the PHAB appointed work groups and committees from the public health practice and academic communities to develop the standards and measures, the accreditation process, the accreditation review process, and the preliminary testing of the entire accreditation system. As with the Exploring Accreditation Project, the major professional public health organizations contributed to this important work.12 The development of the national public health accreditation program also involved public health leaders and practitioners from the national, state, and local levels. By 2009, a pilot system of accreditation had been developed, and in 2009 to 2010, 30 diverse local, state, and tribal health departments beta tested the standards and accreditation process to inform the launch of the accreditation system in the fall of 2011.9

A central philosophy that has guided and informed the work of the PHAB and the accreditation process is to integrate the achievement of standards with continuous quality improvement (CQI). CQI involves identifying a distinct process and using a specific set of tools and techniques to achieve measurable performance improvement.19 Accreditation and CQI are separate but powerful mechanisms to ensure superior performance of public health departments, and when combined they empower health departments to continuously improve their services and performance.20 With a focus on CQI in the standards of the accreditation process, the PHAB hopes to contribute to a culture of quality and continuous improvement in the public health field.

Accreditation is based on standards that allow health departments to demonstrate that they are providing, either alone or in partnership, the public health services necessary to keep their communities healthy and safe. The Standards Development Workgroup, composed of national, state, and local public health professionals; public health researchers; and other technical experts, developed the PHAB standards and measures. After an initial alpha test in the fall of 2008, the work group conducted a 3-month national public vetting period in spring 2009. The work group reviewed more than 4000 comments and adopted documents in July 2009 for use in the beta test.9 The work group developed 6 goals for the standards and measures:

  1. advance the collective practice,

  2. be simple and reduce redundancy,

  3. minimize burden on participating health departments,

  4. reinforce local and state health departments’ roles and demonstrate shared accountability,

  5. apply to all sizes and all forms of governance structure, and

  6. accord with American National Standards Institute principles.14

The final version of the PHAB accreditation categories will incorporate 3 areas: domains, standards, and measures. A domain is a broad area of common characteristics for which criteria and standards are specified for assessing performance. A standard is an expected level of performance, and a measure is an observable metric that can be documented. The first 10 domains and their associated standards and measures focus on the 3 core public health functions16 and the 10 essential health services of public health, building on seminal work in the field over the past decades.17 Two additional domains focus on administration–management and governance. Each measure is designated as either a capacity (something that is in place), a process (something that must be done), or an outcome measure (a change or lack of change resulting from an action or intervention). Two outcomes are described: process outcome, in which the results of a process are tracked, and health outcome, which incorporates health status information.14

The beta test used 2 sets of standards and measures: 1 for local health departments and 1 for state health agencies. A set of tribal-specific standards and measures, derived from the same framework, was developed and vetted in the public domain. The final iteration of the PHAB domains, standards, and measures (including the tribal-specific language) was made available as version 1.0 in the summer of 2011. Box 1 describes the 12 domains of the PHAB accreditation process.

Public Health Accreditation Board Accreditation Domains

Conduct assessment activities focused on population health status and health issues facing the community.
Investigate health problems and environmental public health hazards to protect the community.
Inform and educate about public health issues and functions.
Engage with the community to identify and address health problems.
Develop public health policies and plans.
Enforce public health laws and regulations.
Promote strategies to improve access to health care services.
Maintain a competent public health workforce.
Evaluate and continuously improve processes, programs, and interventions.
Contribute to and apply the evidence base of public health.
Maintain administrative and management capacity.
Build a strong and effective relationship with governing entity.

A beta test is a formative evaluation for obtaining feedback from intended users of a new product. The PHAB undertook the beta test to test accreditation standards, measures, assessment processes, and written support documents. The work group selected a sample of 30 health departments for the beta test, conducted from November 2009 to September 2010. Figure 1 shows the 19 local, 8 state, and 3 tribal health departments that participated in the beta test. To ensure that the test sites represented a diverse cross section of the population, the work group carefully selected health departments that varied in size, structure, population served, governance, geographic region, and degree of preparedness for accreditation.9 The beta test allowed the PHAB to further refine the accreditation tools and processes. Because the sample was selected specifically to represent a broad array of health departments in varying degrees of readiness for accreditation, results from the beta test can only be used for its intended purpose of refining the accreditation documents and tools. It was not meant to examine health department performance on accreditation standards in general and is not generalizable to other public health departments.

The PHAB contracted with the National Opinions Research Center at the University of Chicago to conduct a multimethod evaluation of the beta test to determine what worked well and to identify areas in which the accreditation process could be improved.21 The evaluation examined the accreditation process overall as well as the specific steps in the process: the application, self-assessment, and site visit. Both quantitative and qualitative data were included, and the information was collected through surveys, interviews, site visits, tools to track levels of effort, and other relevant data from the beta-test sites and site visitors. The evaluators also solicited feedback from PHAB staff and partner organizations. More than 600 comments regarding the standards and measures were submitted for review.

Overall, the beta-test evaluation confirmed that the standards, measures, and accreditation process were well developed.21 Table 1 shows the results of the beta-test evaluation from site surveys. The overall accreditation process was ready to implement with minor changes according to 74% of respondents, with significant changes according to 22%, and with no change according to 4%. In the opinion of 21% of respondents, the site assessment process could proceed with no change; 79% recommended only minor changes. Regarding the site visit, 72% of respondents would implement it with minor changes and 24% would implement it with significant changes. Only 4% believed the site visit process should not be implemented. At the time of this writing, the PHAB is considering changes that will improve the accreditation process in response to these results and the helpful feedback of beta-test site participants.

Feedback From Participants at Beta-Test Sites for Public Health Department Accreditation: United States, 2009–2010

Implementation Recommendations%
Overall application process
 Implement with no changes4
 Implement with minor changes74
 Implement with significant changes22
Self-assessment process
 Implement with no changes21
 Implement with minor changes79
Site visit process
 Implement with minor changes72
 Implement with significant changes24
 Do not implement4

The PHAB used the beta-test results to validate the domains, standards, and measures and to assess the usability of the accreditation protocols and formats. After consideration of this important feedback, public health accreditation was rolled out on a national level in Fall 2011. The PHAB and its national partners are working together to identify and provide technical assistance and education to potential accreditation applicants. Health departments across the country are preparing for accreditation by working on the 3 major prerequisites: a community or state health assessment, a community or state health improvement plan, and an agency strategic plan. During the accreditation process, health departments will provide documentation to be reviewed by a team of peers who will also make a site visit. Consistent with most accreditation systems, accreditation status for a health department will remain valid for 5 years, after which a follow-up application will be required.

More than 500 tribal health departments operate in the United States, serving an estimated 3.3 million people in 35 states.22 Under the leadership of the National Indian Health Board, an accreditation study group reviewed the accreditation system from the perspective of tribes' unique circumstances.23 The Tribal Public Health Accreditation Advisory Board conducted a formal study to assist in the development of the draft national public health accreditation standards,24 and 3 tribal sites participated in the beta test. After the beta test, the PHAB appointed a Tribal Standards Work Group to provide recommendations on the application of the standards and measures in the tribal setting. Those recommendations were incorporated into version 1.0 of the standards, to be used for the launch of the program.

From past research on incentives for accreditation, the PHAB learned that the federal government and other public health funding organizations have a growing interest in this topic.14,25 A health department that has met national standards, as determined by peer review, has a stronger infrastructure to support public health programs funded by a myriad of sources. In turn, accreditation will make public health departments more attractive to potential funders, which could give those departments greater opportunities to innovate. To create incentives for participation, the PHAB Board of Directors will work with national partners to

  • Institute regular internal checkpoints to ensure that the accreditation program is credible, reliable, reasonable, and linked to current practice.

  • Develop a grant application procedure change that acknowledges accredited health departments by accepting the certificate of accreditation in lieu of selected infrastructure components of federal grant applications.

  • Encourage other funding organizations to acknowledge the accreditation process and provide the same incentives as those being requested of the federal government.

  • Establish an information system to provide data about characteristics and attributes of high-performing health departments.

  • Educate program managers in federal agencies about the potential for public health accreditation to reduce duplication in program review efforts.

  • Identify and provide support for the special needs of extremely small and extremely large health departments.

  • Seek out and use funds from federal and other grantors to build capacity for or undertake the process of accreditation.25

Accreditation of public health departments is associated with several important organizational and operational benefits, such as (1) promotion of high performance and CQI, (2) recognition of high performers that meet nationally accepted standards of quality, (3) clarification of the public's expectations of state and local health departments, and (4) increased visibility and public awareness of governmental public health, leading to greater public trust and stronger constituent support.26

Despite these considerable benefits, the PHAB is aware of the cost, time, and effort for a public health department to successfully complete an accreditation review. A series of surveys in 2006 discerned 2 major areas of costs of accreditation to a health department: the fee associated with the accreditation application and the personnel time and resources required to prepare for an accreditation review.27 The exact cost of an accreditation review will vary by health department size and complexity. In the beta test, a wide range of staff time and associated costs were reported, varying by each department's capacity for locating and uploading appropriate documentation.21 Consistent with other accreditation organizations' business plans, the PHAB appointed a Fee Development Committee of the Board of Directors to develop a fee structure for public health accreditation. This fee structure was completed before the launch of the accreditation process in 2011, and fees will be published a year in advance of each accreditation application cycle to assist health departments in preparing their budgets.9

Concern has also been expressed that public health accreditation will generate a teach-to-the-test mentality among health departments rather than improving performance and outcomes. For this reason, CQI is an essential component of the accreditation system. However, the use of CQI in public health departments raises another concern regarding the time required to become proficient in quality improvement methods and techniques. Although quality improvement takes time, not taking time to improve processes and outcomes in health departments indicates certain assumptions regarding current public health department performance, such as

  • Existing processes are performing adequately.

  • Existing processes are deliberately planned when initially developed and implemented.

  • Public health processes do not deteriorate over time.

  • Public health process performance is stable and capable.

  • Public health processes are standardized, with all staff following the same steps every time.

It is unlikely that either state or local health departments have service processes in place that consistently realize these 5 assumptions. Most processes develop as a result of accretions and modifications over time rather than from rational planning and deliberate design.28 Even when a process is designed deliberately through methodical steps, it is the nature of all processes, including those in public health, to gradually deteriorate, and they will not perform at expected levels without substantial process documentation, auditing, and capability assessment. Accreditation will empower public health departments to continuously improve services in the face of these challenges, which will ultimately raise the visibility of public health practice and its critical role in protecting the health of our nation.

Several aspects of public health accreditation require substantial research. For example, it is assumed that a public health department that meets accreditation standards will perform better than will a health department that does not, that a quality improvement method can be used to continuously improve health department performance, and that a community that has an accredited health department undergoing CQI will be better served and protected than will a community that does not. A rigorous research agenda must be developed and executed to evaluate these assumptions and provide the evidence base necessary to validate the accreditation process.

No evidence yet exists on the extent to which health departments across the nation can achieve PHAB accreditation standards, and possibly some public health departments will be unable to sufficiently address all of the measures of the process. However, it is the foundational conviction of the PHAB that wherever strides are made toward achieving the standards of public health accreditation, health department performance and the health of the population will benefit. If this conviction is correct, focused attention to public health accreditation will transform public health department performance throughout the country.

The authors would like to acknowledge Carmen Parrotta MPH and Jonathan Godsall, BA for their assistance.

No protocol approval was required because no human participants were involved.

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