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Increasing Efforts to Encourage Governmental Health Departments to Seek Accreditation

Policy Date: 11/1/2011
Policy Number: 201119

There is an important opportunity to demonstrate the value that various sectors play in ensuring the optimal health of populations across the United States. The often-overlooked conduit for this critical function across cities, towns, and counties has been through health departments working in concert with state-level and federal entities. According to the National Association of County and City Health Officials (NACCHO), there are more than 2700 local health departments in the United States.[1] These agencies provide the essential services of public health on a day-to-day basis. Similar to the experience of state-level health departments, most of these entities gained more visibility during the national response to the declared global pandemic of H1N1 influenza in 2009. One of the more significant challenges for the existing infrastructure of local health departments has been the diversity of governance structures for governmental public health across the United States and the lack of standardization of performance of these local health departments.

Problem Statement
Public Health agencies comprise one component of the US health system that has yet to develop an accreditation system particular to its specific needs.[2,3] Local and state health departments face systemic and organizational obstacles that compromise their effectiveness and capacity to respond to public need, yet leaders of those agencies find themselves increasingly pressed for accountability and demonstrated return on policy and financial investments. Formal accreditation of local and state public health agencies would provide evidence that the agencies have met accepted professional standards of performance based on well-established, predetermined criteria.[4] Meeting the benchmark of professional acceptance represented by accreditation would provide the public with assurance that the governmentally organized and funded entities designed to protect their health and to prevent the spread of disease are performing at acceptable levels.

The first mention of accreditation as a potential system to strengthening public health infrastructure dates back to an article by Bernard Turnock and Arden Handler in 1996.[5] The authors questioned whether the uniqueness of health departments in the United States was leading to the “disarray” and weakening of the public health infrastructure as described in the 1988 Institute of Medicine (IOM) report, The Future of Public Health[6]. Turnock and Handler called for a core function–based approach to accrediting health departments.[5] Their article was followed in 1998 by a call by Halverson et al. for performance measurement and accreditation.[7] As in the previous article, the authors stated that accreditation could contribute to stronger health systems in the United States. The Future of the Public’s Health in the 21st Century, a report published by the IOM in 2002, recommended that a national steering committee be established to explore the benefits of accreditation and noted that “accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards.”[8(p157)]

The NACCHO Board passed Resolution 04-06[9] in July 2004, supporting the establishment of a voluntary accreditation program with the potential of moving to a national program of accreditation.[9] An October 2004 technical report to The Robert Wood Johnson Foundation (RWJF) recommended that there no longer be an emphasis on the uniqueness of local health departments.[10]

In December 2004, RWJF convened the Exploring Accreditation Committee (EAC). The final report of the committee, “Final Recommendations for a Voluntary National Accreditation Program for State and Local Health Departments,”[11] laid out the framework for a voluntary health department accreditation. In August 2005, the planning committee of the EAC established a steering committee that included representatives from federal, state, and local jurisdictions. The steering committee’s decisions were informed by 4 work groups comprising public health practitioners from all levels of government and academia: Governance and Implementation, Finance and Incentives, Research and Evaluation, and Standards and Development. Parallel to the work of the Exploring Accreditation Steering Committee was another RWJF project that funded 16 selected states with experience in public health assessment, accreditation, and quality improvement. The goal of this project was to continue these core activities and share their experiences with other states through 3 phases of the Multistate Learning Collaborative (MLC) during the period July 2005 through April 2011. MLC Phase 1 (MLC-1) states provided empirical and practical information about what worked and what did not to the Exploring Accreditation Steering Committee, thus contributing to its decision to recommend that a national voluntary public health accreditation program for state and local health departments be implemented.[12] The work accomplished by the MLC-1 and MLC-2 states accelerated the emphasis on quality improvement in public health and the move toward public health accreditation. MLC-3 states focused not only on quality improvement but conducted self-assessments on accreditation readiness through the use of tools developed by national organizations. The work of the MLC states also informed the work of the Public Health Accreditation Board (PHAB), established in 2007 by RWJF and the Centers for Disease Control and Prevention (CDC) to manage and promote the national voluntary public health accreditation program. Experience by the MLC states working with the standards developed by CDC’s National Public Health Performance Standards Program and local certification standards led to the development of the draft PHAB standards and measures. The draft PHAB standards were vetted at national meetings attended by the 16 MLC state representatives, who suggested revisions of the measures before publication. In addition to the vetting by the MLC participants, the PHAB standards were made available for public comment over a period of 3 months, during which intensive feedback was submitted from various sources. This feedback, along with expert reviews, helped shape the PHAB standards.

The Exploring Accreditation Steering Committee met in April 2006 to discuss the recommendations from all work groups and to develop a proposed model for voluntary health department accreditation. In August 2006, a final model was proposed for implementing accreditation across local health departments. The PHAB was formed in 2007 to carry out the daunting task of implementing accreditation. The PHAB founding organizations included RWJF, CDC, NACCHO, the Association of State and Territorial Health Officials (ASTHO), the National Association of Local Boards of Health (NALBOH), and the American Public Health Association (APHA). On March 24, 2011, CDC issued a press release supporting and encouraging health departments to seek accreditation.[13] APHA has a long history of encouraging the professionalization of public health workers and their associations. APHA Policy Statement 5610, “Professional Qualifications of Public Health Personnel,”[14] published in 1956, and Policy Statement 6007, “Strengthening Professional Public Health Associations,”[15] published in 1960, call for strengthening the public health workforce and systems through benchmarks and measures. Support for accreditation of local and state public health departments echoes those long-held positions with a continued call for improving the delivery of public health programs and services.

Factors Influencing Accreditation
Development of the accreditation standards required many work group and board discussions on whether one set of standards could fit the large variety of organizations that comprise the public health system. The PHAB Board has taken a strong position that there be one set of standards for all local health departments and one set of standards for all state health departments. These standards, as outlined by the PHAB Board in Part A of the “Proposed Local Standards and Measures,” and in the state, tribal, and territorial health department standards, address the variety in the governance structures of health departments by assessing the public health infrastructure and financial management systems and by defining the public health authority; they also provide an orientation for governing entities regarding their responsibilities and those of the public health agency.[16] The measures that determine compliance with the standard will provide adequate flexibility for the variability in types of state and local governance and organizations.
A beta test of the accreditation process was conducted in 2010 using the proposed standards and measures. Thirty health departments (8 state, 19 local, and 3 tribal) representing the variability in the public health system were selected to participate in an effort to understand how the measures and the processes under consideration might apply in a real-world setting. This process led to the development of Version 1.0 of the PHAB Standards and Measures, which was released in July 2011; minor updates were published December 22, 2011.[17] In the end, the most important question was whether beta test participants, including both beta test sites and site visitors, felt that the accreditation process worked. Indeed, the majority of respondents to a post-beta test site and site visitor survey indicated that only minor changes to the piloted accreditation processes were needed prior to implementation.[18]

Importance of Accreditation
Public health is recognized for its role in preventing the spread of disease and injury, promoting healthier lifestyles, and protecting the community at large. The past decade has seen emerging diseases and public health emergencies at an unprecedented rate in the form of terrorist attacks, natural disasters, manmade disasters, and pandemics. Public health is valued as a critical component of a broader coordinated system of response to threats ranging from anthrax attacks to H1N1 influenza. The landmark legislation of the Patient Protection and Affordable Care Act led to the establishment of a Prevention and Public Health Fund. For Fiscal Year 2011, funding opportunity announcements through the fund’s Improvement Initiative funding stream included one to support activities that are preparatory to accreditation.[19] The goal of the national public health accreditation program is to improve and protect the health of the public by advancing the quality and performance of all health departments in the country—state, local, territorial, and tribal.[17] Experts predict that an accreditation system will help public health departments to continuously improve the quality of the services they deliver to the community.[20]
Nonprofit hospitals are required to complete community health assessments every 3 years and show improvements in order to meet Internal Revenue Service criteria to maintain nonprofit status. Each hospital must identify and prioritize community benefit initiatives through a community health assessment process based on population data, particularly from the public health sector.[21] While the majority of hospitals in the United States seek and maintain accreditation through The Joint Commission, there is no similar system for public health systems to demonstrate their level of performance. Hospitals accredited by The Joint Commission enjoy a “deemed status” whereby they are automatically eligible for Medicare funding,[22] but there is no similar provision for public health departments in terms of seeking and becoming eligible for federal funding. Similarly, the US Department of Education has incentives whereby postsecondary institutions receiving accreditation through the Council for Higher Education Accreditation become eligible to receive many federal educational grants and student loans.[23] The proposed PHAB accreditation model has the potential to become a comparable accreditation system for governmental health departments and raise their profile to be on par with other public service systems.
With the significant increases in minority and foreign-born populations across the United States over the last couple of decades, one of the goals of the Healthy People blueprint has been the elimination of health disparities. This reality prompted the US Department of Health and Human Services (HHS), along with the Office of Minority Health, to design and implement the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) in 2001. The aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans.[24] They are also intended to be used by accreditation and credentialing agencies to assess and compare providers who say they offer culturally competent services and to ensure quality for diverse populations. PHAB Standard 11.1 aims to “Develop and maintain an operational infrastructure to support the performance of public health functions.” Measure 11.1.3 A reflects the board’s commitment to ensuring provision of effective services by assessing agencies on their ability to “maintain socially, culturally, and linguistically appropriate approaches in health department processes, programs, and interventions, relevant to the population served in its jurisdiction.” [17(p227)] The PHAB accreditation can assist with reinforcing the CLAS standards, thereby addressing some of the gaps that exist in the training of health professionals for providing culturally competent care.
Health departments now face harsh economic challenges and increasing burdens. Why should health departments consider accreditation during this time of stress? For many public health departments, accreditation will help define survival, using nationally recognized standards to declare a required essential framework of services for their communities; it also means an improvement in quality and accountability. Recognizing that “place matters” for the various factors that influence one’s overall health status, public health accreditation ensures that people across the country can expect the same quality of public health programs and services no matter where they live—a bustling metropolitan city, a farming town, or anything in between. The public health accreditation logic model put forward by the Exploring Accreditation Steering Committee asserts that accreditation leads to strengthened health departments and services, thereby leading to better health outcomes in the community.[11] Accreditation has been proposed as a process supporting quality improvement and performance management initiatives.[20] Accreditation has been linked to strengthened public health outcomes. Joly et al. propose a logic model in which undergoing accreditation has the potential to strengthen public health systems and lead to improved health outcomes. They state that accreditation, with its inherent focus on quality improvement, has the potential to lead to better health outcomes in the long term.[25]
PHAB’s beta test, conducted in 2010, was intended to mimic the accreditation process as closely as possible in order to improve the final process, not to create changes in health departments. Nevertheless, some of the 30 state, tribal, and local departments participating in the PHAB beta test experienced increased employee morale, communication, accountability, and credibility as a result of their participation in the process.[26] Accreditation has also been proposed as a mechanism to promote cooperation between state and local health departments, thus leading to better alignment of services and strengthened systems.[11] The latest version of the National Public Health Performance Standards Program (NPHPSP) is designed to sustain accreditation. It adds credibility to the process and enables coordination between NPHPSP and accreditation standards.[27] The principles of quality improvement are embedded in the accreditation program and supported by CDC.[28] The mission of PHAB is to advance the continuous quality improvement of governmental health departments, and the PHAB board of directors has set the accreditation model on a cornerstone of continuous quality improvement.[20] Quality improvement approaches have the potential to strengthen governmental health systems and lead to improved performance.
The process of undergoing accreditation appears to be an intervention in and of itself. Short-term benefits for the participating health departments include increased accountability and increased knowledge of their strengths and weaknesses, whereas projected long-term outcomes include strengthened public health systems, increased investment in public health, and increased public recognition of public health’s role and value. Some of the participating agencies are already experiencing some of the short-term benefits.[29]
Considering the improvement and accountability structure offered by accreditation, APHA proposes to do the following.
a. Encourage governmental health departments to participate in the accreditation process by completing prerequisite work to collect and demonstrate necessary evidence to meet PHAB standards and measures and to ultimately support successful application for national accreditation.
HHS, including CDC, should encourage health departments to undergo accreditation, but the process at this point should remain voluntary. Health departments should be made aware of the benefits of accreditation, which in turn will encourage them to seek accreditation voluntarily. This will allow health departments to recognize the value of accreditation while incorporating standards into day-to-day operations.

b. Support PHAB in its efforts to encourage health departments to seek accreditation.
Given the national coalition that has pledged its support for the efforts by the Public Health Accreditation Board, PHAB’s efforts should continue to be endorsed by national associations, including APHA, ASTHO, NACCHO, NALBOH, and the National Indian Health Board (NIHB), and supported by RWJF and CDC. Health departments lacking the resources needed to seek accreditation should be provided technical support.

c. Request authorization of federal funds to support implementing accreditation on a national level.
Health departments need to be supported financially in their efforts to seek accreditation. Accreditation can lead to better alignment of state, tribal, local, and territorial health services, thereby leading to a strengthened national public health system. The federal government should support such efforts to improve the health of the nation on a systemwide level.

d. Advocate for support for research to explore the linkages between accreditation and various components of performance management and quality improvement.
Funding agencies should support researchers exploring the role and impact of accreditation on performance management in public health systems. New research findings will add to the body of knowledge about the benefits and outcomes of accreditation and will help health departments in the future to make informed decisions about accreditation.

e. Urge funding sources to support governmental health departments that seek, achieve, and maintain accreditation status by providing incentives.
HHS, including CDC, should provide incentives to governmental health departments to seek, achieve, and maintain accreditation. Local governing bodies should be encouraged to support health departments that seek, achieve, and maintain accreditation. In addition, the federal government and local governing bodies should encourage and support health departments that are not accredited to seek accreditation in the future.
Public health is recognized for its role in preventing the spread of disease and injury, promoting healthier lifestyles, and protecting the community at large. Assessing the return on investment for programs and services enhances the ability of public health agencies to deliver the greatest benefit to the community. Emerging quality and performance assessment practices offer promise for further improvement in public health practice. The voluntary public health accreditation process represents a significant vehicle to structure public health quality and accountability efforts.[30]
1. National Association of County & City Health Officials. 2010 National Profile of Local Health Departments. August 2011. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/upload/2010_Profile_main_report-web.pdf. Accessed January 4, 2012.
2. Mays GP. Can accreditation work in public health? Lessons from other service industries. Working paper prepared for the Robert Wood Johnson Foundation. November 2004. Available at: http://www.phaboard.org/wp-content/uploads/CanAccreditationWorkinPublicHealth.pdf. Accessed January 5, 2012.
3. Turnock BJ, Handler AS. From measuring to improving public health. Ann Rev Public Health. 1997;18:261–282.
4. The Free Dictionary. Available at: http://medical-dictionary.thefreedictionary.com/accreditation. Accessed February 11, 2011.
5. Turnock BJ, Handler A. Is public health ready for reform? The case for accrediting local health departments. J Public Health Manag Pract. 1996;2(3):41–45.
6. Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine. The Future of PublicHealth. Washington, DC: National Academy Press; 1988.
7. Halverson P, Nicola R, Baker E. Performance measurement and accreditation of public health organizations: a call to action. J Public Health Manag Pract. 1998;4(4):5–7.
8. Committee on Assuring the Health of the Public in the 21st Century, Board of Health Promotion and Disease Prevention, Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002.
9. National Association of County and City Health Officials. Statement of Policy 04-06: Voluntary Accreditation of Local Health Departments. Available at: http://www.naccho.org/advocacy/positions/upload/04-06-Accreditation-rev.pdf. Accessed February 1, 2011.
10. Thielen L. Exploring public health experience with standards and accreditation: is it time to stop talking about how every health department is unique? Working paper prepared for the Robert Wood Johnson Foundation. October 2004. Available at: http://www.rwjf.org/files/publications/other/publichealthaccreditation.pdf. Accessed January 5, 2012.
11. Exploring accreditation: final recommendations for a voluntary national accreditation program for state and local public health departments. Winter 2006–2007. Available at: http://www.rwjf.org/files/research/explore_accreditation.pdf. Accessed January 5, 2012.
12. Mays G, Beitsch LM, Corso L, Chang C, Brewer R. States gathering momentum: promising strategies for accreditation and assessment activities in multistate learning collaborative applicant States. J Public Health Manag Pract. 2007;13(4):364–373.
13. Centers for Disease Control and Prevention. New accreditation opportunity for state, local, tribal health departments [press release]. March 24, 2011. Available at: http://www.cdc.gov/media/releases/2011/p0324_publichealthdeptaccreditation.html. Accessed January 6, 2012.
14. American Public Health Association. Policy Statement 5610. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=381. Accessed January 3, 2012.
15. American Public Health Association. Policy Statement 6007. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=446. Accessed January 3, 2012.
16. Proposed Local Standards and Measures. Adopted by the PHAB Board of Directors, July 16, 2009. For PHAB Beta Test. Available at: http://www.in.gov/isdh/files/PHABLocalJuly2009-finaleditforbeta.pdf. Accessed January 6, 2012.
17. Public Health Accreditation Board. Standards & Measures Version 1.0. Approved May 2011. Available at: http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf. Accessed January 4, 2012.
18. NORC at the University of Chicago. Evaluation of the Public Health Accreditation Board beta test [Brief report; July 2011]. Available at: http://www.phaboard.org/wp-content/uploads/EvaluationofthePHABBetaTestBriefReportAugust2011.pdf. Accessed January 6, 2012.
19. Trust for America’s Health. Chart of FY 2011 Prevention Fund FOAs [funding opportunity announcements]. June 28, 2011. Available at: http://www.healthyamericans.org/assets/files/Chart of FY2011 Prevention Fund FOAs.pdf. Accessed January 6, 2012.
20. Bender K, Halverson P. Quality improvement and accreditation: what might it look like? J Public Health Manag Pract. 2010;16(1):79–82.
21. Internal Revenue Service. Available at: www.irs.gov. Accessed May 10, 2011.
22. The Joint Commission. Available at: http://www.jointcommission.org. Accessed February 14, 2011.
23. Council for Higher Education Accreditation. Available at: http://www.chea.org. Accessed February 14, 2011.
24. National Standards for Culturally and Linguistically Appropriate Services in Healthcare—Executive Summary. Washington, DC: US Dept of Health and Human Services, OPHS, Office of Minority Health; March 2001.
25. Joly BM, Polyak G, Davis MV, et al. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract. 2007;13(4):349–356.
26. Public Health Accreditation Board. Accreditation: why it’s important now. Available at: http://www. improveph.org/accreditation/important.asp. Accessed January 6, 2012.
27. Centers for Disease Control and Prevention. The National Public Health Performance Standards Program (NPHPSP) version 2. Available at: http://www.cdc.gov/nphpsp/TheInstruments.html. Accessed February 3, 2011.
28. Lenaway D, Corso L, Buchanan S, Thomas C, Astles R. Quality improvement and performance: CDC’s strategies to strengthen public health. J Public Health Manag Pract. 2010;16(1):11–13.
29. Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support. November 2010. National voluntary accreditation for public health departments. Available at: http://www.cdc.gov/ostlts/accreditation/benefits.html. Accessed January 6, 2012.
30. American Public Health Association. APHA Policy Statement 201015: Securing the Long-Term Sustainability of State and Local Health Departments. 2010. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1404. Accessed January 4, 2012.