National public health accreditation has been the focus of increasing attention over the past several years. The 2003 Institute of Medicine report, The Future of the Public's Health,1 called for the establishment of a national Steering Committee to examine the benefits of accrediting governmental public health departments. Within its Futures Initiative,2 the Centers for Disease Control and Prevention identified accreditation as a key strategy for strengthening the public health infrastructure. The Robert Wood Johnson Foundation3 convened public health stakeholders in 2004 to determine whether a voluntary national accreditation program for state and local health departments should be explored. The Exploring Accreditation4 Project commenced at that point, and 10 months of assessing other accreditation processes, seeking public health workforce and stakeholder input, and deliberating details in four structured workgroups (governance, standards development, financing and incentives, and evaluation) began. The consensus building aspects of the project are described in detail elsewhere in this issue. At the conclusion of the inquiry, the Exploring Accreditation Steering Committee (SC) determined that a voluntary national public health accreditation program is both desirable and feasible and provided recommendations for how such a program might be initiated.
For this project, the purpose of a voluntary accreditation program was identified as improving the quality and performance of public health departments without regard to their organizational structure or jurisdiction. In order for this purpose to be fulfilled, the SC recommended that a new, not-for-profit entity be created to govern the program. Four organizations comprising the original Planning Committee (Table 1) should initially oversee the board appointments and the incorporation process that establishes the legitimacy and credibility of the accrediting organization. Since the Planning Committee has been the oversight body of this project from the beginning, the members are familiar with the intent of the recommendations, and therefore can best ensure their implementation. Under its governing board, the organization would direct the establishment of accreditation standards; develop and manage the accreditation process; and determine whether applicant health departments meet accreditation standards. The organization would maintain the needed administrative and fiscal capacity and would evaluate the effectiveness of the program and its impact on health departments' performance. The governing board and the organization would advocate for available training and technical assistance for public health departments seeking to meet the standards and to develop a culture of continuous quality improvement. The report provides guidance on the type of individuals who should be considered for appointment to the governing board, specifically noting the need for comprehensive public health experience to be represented.
Eligible Applicants and Existing Initiatives
While the SC recommendations regarding implementation were purposely not detailed in scope, there were two areas related to governance that warranted specific guidance: the definition of eligible applicants and the relationship with existing public health performance improvement initiatives. For the former, the definitions of eligible applicants are intended to be as inclusive as possible. Any governmental entity with primary legal responsibility for public health in a state, territory, tribe, or at the local level would be eligible for accreditation. Eligibility to apply for accreditation would be determined in a flexible manner, given the variety of jurisdictions and governmental organizations responsible for public health. For example, some state public health activities are dispersed in “umbrella” organizations. The SC recommended, in those cases, that the applicant health department should demonstrate collaboration with other agencies with respect to those functions, or, in some instances, may request exemptions.
Second, the SC recognized and valued that existing state-based accreditation and performance improvement programs provide a natural laboratory for national program and national standards testing. The participants of the Robert Wood Johnson Foundation's Multi-State Learning Collaborative (MLC) contributed substantially to the exploration of this topic.5 It is important that state and national programs continue to learn from, and maintain good relationships with, each other. A national program should complement state-based efforts to establish performance standards for health departments. This may be accomplished by a recognition/approval process by which state accreditation programs demonstrate conformity with national accreditation standards and processes. Such a process should not preclude states' having additional requirements over and above those in the national program. If a state accreditation program is not so recognized, it may seek to act as an agent to provide training, preparatory services, site visits, and other services. If agents are used in this manner, the governing board would still make the final accreditation determination.
The SC recognized that quite a bit of work has been done through the past decade on the development of standards to guide the improvement of performance of public health agencies and systems. A deliberate decision of the SC at the outset of its work was not to recommend particular standards. Therefore, these recommendations describe principles upon which standards for a voluntary national public health accreditation program would be developed. Recognizing that a voluntary national accreditation program is a tool to advance the pursuit of excellence, continuous quality improvement, and accountability for the public's health, the SC recommended that standards be developed in a way that promotes these attributes. The American National Standards Institute6 principles referenced in the final recommendations clearly speak to the inclusive developmental process that the SC recommended as a national program is implemented. It was agreed that a combination of process, capacity, and outcomes standards is desirable as the basis for an accreditation program because it is likely to be the most effective way of addressing improvement in governmental public health agencies.
The SC created 11 domains for which state, territorial, tribal, and local health departments should be held accountable (Table 2), and recommended that standards be established for each domain. Measures of compliance may differ, but standards should be complementary and mutually reinforcing to promote the shared accountability of public health departments at all levels of government. It was determined that program-specific standards and criteria exist separately and are outside the scope of the national voluntary accreditation process, since programming varies from state to state and locality to locality.
Health outcomes standards were viewed as the most desirable with respect to demonstrating the impact of public health interventions—particularly to governing boards, elected officials, and the general public. Although a robust evidence base to support such standards does not exist, the SC did not want the field to shy away completely from health outcomes standards. It is not unusual for the public health field to limit the use of health outcomes standards since there are many factors beyond the influence of governmental public health departments that impact health status, thus making it difficult to link public health interventions to improved health status. The conclusion was that health outcomes standards should be added as the evidence base expands to support them, and in the interim, other indicators of outcomes (as described in the final recommendations) could be effectively incorporated.
Process measures can serve as a good internal management tool, particularly when they are shown to be linked to outcomes. Process measures are also more responsive to change. In addition, the inclusion of a standard related to the process undertaken by eligible applicants to assess health problems and achieve health-related goals would attend to the desire to address health outcomes as part of the accreditation process.
Finally, capacity measures are useful for administrators to help define infrastructure needs, defend procurement decisions, and make budget decisions. They also present an opportunity to tie capacity to outcomes, and are also more responsive to change than outcomes measures. By using a combination of standards that measure outcomes, process, and capacity, the strengths found in one set of measures could help offset deficiencies in others. Furthermore, this comprehensive approach would cover many bases with respect to what an accreditation system may seek to accomplish and the target audiences for accreditation results. This approach will also help demonstrate the connections between outcomes, process, and capacity—all of which must be considered to improve agency performance, and ultimately public health.
The SC viewed existing standards as the cornerstone of developing standards for a national program. Several sources in particular were identified that should receive special consideration in order to avoid “re-inventing the wheel.” As previously discussed in the context of recognizing existing state-based accreditation and related programs for governance purposes, various states have also utilized standards for performance and quality improvement. In addition, National Association of County and City Health Officials' Operational Definition7 was recognized as a framework for local health department standards, as it was developed through an extensive vetting process, and reflects perspectives from public health professionals at all three levels of government.
The National Public Health Performance Standards Program8 model standards and measures were also recognized as a source for health department standards. It is important to recognize that these model standards have been developed to assess public health systems, not individual public health departments, so any standards used would need to be adapted to accommodate this difference. Moreover, assessment of the public health system using the National Public Health Performance Standards Program instruments could be a recommended “self-study” in preparing for or maintaining accreditation. Such attention to the public health system, in a manner that complements health department-specific standards, could serve to emphasize the important role of external relationships and document the role that health departments play in creating such a system.
In terms of “scoring,” a moderate level of performance should be sought, with the understanding that continuous quality improvement aspects would be built in. However, great caution needs to be exercised in selecting terms used to describe this level. In lieu of stating “moderate” (which was viewed as having the potential to suggest a substandard level of performance), the language chosen reflects the philosophy in the Operational Definition, that is, one should reasonably expect that one's health department is performing in a manner that ensures public health protection while improving the public's health. This mid-level does not describe a “criterion standard,” but rather strikes an important balance between being realistic about what can be achieved and leaving room for health departments to improve. Furthermore, as the number of accredited health departments grows, and as the norm of expected performance rises, standards and measures will need to be updated and revised accordingly.
Another important theme emerged both in the SC deliberations and the public comment period around the need to make sure that the standards are relevant and applicable to health departments of all sizes. The national system should be attractive to more robust health departments in order to be credible, yet it should not be out of reach of health departments with fewer resources or those constrained by state statutes. However, the desire to include health departments with fewer resources should not compromise the level of standards. This issue was addressed by agreeing that while all health departments should be held to the same standards, different measurements may be used to recognize the variety of ways in which the standards are met by health departments with different capacities, governance structures, etc. For example, every community should be served by epidemiological expertise. Larger health departments may have an epidemiologist on staff, while smaller health departments may demonstrate that they have ready access to an epidemiologist if needed, for example, through an epidemiologist who is employed on a regional basis, through a mutual aid agreement with another local health department, or from the state health department.
Finally, standards should be developed in a manner that avoids duplication of effort to the extent possible. A potential barrier to accreditation is the perception that the conformity process will entail additional paperwork, and the governing board should consider ways to promote accredited status as a proxy for other accountability measures; for example, accreditation status could be used in lieu of reporting requirements for grantors or contractors. The SC identified this concept as being consistent with the potential incentive of streamlining reporting requirements for grant funds.
Financing the development and operation of the accrediting program can be considered in three phases. In the initial development phase, a consortium of funders interested in promoting public health improvement should be sought to fund the start-up organization itself.
Financing initial development and operations
The principal start-up activities were identified as securing leadership, negotiating contracts with vendors and consultants, developing standards, creating the assessment process, developing information systems, and conducting beta tests or pilot programs. Other start-up activities, such as marketing to applicants and potential funding sources, managing an application process, recruiting and training site visitors, and managing the assessment process through an initial round can be tailored to the number of applicants expected. The SC recommended that incorporators finance the initial legal work to establish the nonprofit corporation, provide in-kind services to refine the business plan, and work with a consortium of grant makers, government agencies, and organizations of state and local health departments to finance the start-up of the voluntary national accreditation program.
Potential private sector funders include grant-making organizations promoting healthcare quality improvement, public health performance improvement, and general government improvement. Within the government sphere, the US Department of Health and Human Services agencies (Agency for Healthcare Research and Quality, Food and Drug Administration, and Centers for Medicare and Medicaid Services as well as Centers for Disease Control and Prevention and Health Resources and Services Administration) are the most important, but the Environmental Protection Agency (environmental health and toxicology), the Department of Agriculture (food safety and women, infants, and children), and the Department of Homeland Security (bioterrorism response and emergency management response) should be interested in promoting continuous quality improvement through accreditation. The financing plan should recognize that sponsoring organizations and health departments could be willing to provide in-kind contributions and volunteer services. Examples include providing space and equipment, volunteers serving on committees, assisting in the recruitment of funders, and/or assisting in training and in peer review.
In the initial operating phase, funding should be a mix of direct support from funders for operations and revenue from services. Over time, more of the funding should come from the applicants, ensuring a customer focus in the accrediting program. In full operation, the goal is for the accrediting program to be self-sustaining, with reasonable fee revenues from the application fees and accredited departments. Support for applicant fees could still come from other sources. The accrediting program should advocate for and promote incentives and capacity building in health departments. Financing the start-up through a consortium of funders was identified as a key strategy. The SC recognized that a consortium of funders would improve the stability of the new program financially and signal the breadth of interest in accreditation in the field. The support of legislators and chief executives was identified as being very important for the development of state public health accreditation and improvement programs. Similarly, demonstrating in-kind and volunteer support by public health organizations and leadership was also viewed as crucial in signaling interest in the program and in controlling costs.
Transparency in financing the start-up was also valued. The potential for a voluntary accreditation program to succeed will be influenced by the “company it keeps” in the very beginning. Other accrediting organizations depend heavily on applicant fees to support the program, but that is not how most started. Most programs examined had been financed by trade organizations in their start-up periods. Commentary in the public comment periods and discussion within the SC reflected concerns about capture of an accreditation program by single interests, however benign their intentions may have been.
Cost containment in the start-up phase was viewed as an important signal for the field. However, an open, highly participatory process of developing the standards, the measures, and the conformity determination process was also deemed to be critical. The business case developed for SC consideration placed significant emphasis on the need to support extra cost in time and resources invested in full participation in developing these elements of the accreditation program.
Financing ongoing operations
Ongoing operational costs were determined to be those related to maintaining the standards, training and supervising site visits teams, administering and evaluating the program, maintaining its supporting information systems, and promoting research (to contribute to the evolving evidence base). After examining a number of national accreditation programs' finance structures, the SC recommended that ongoing operations be funded primarily by the applicants and accredited agencies through fees, with other funding sources to decrease the burden. By introducing other funding sources into the ongoing operations, the application fees needed to sustain operations could be kept low enough to attract a wider range of health departments to seek accreditation. The final recommendation of the SC called upon the accrediting entity to work with federal agencies to consider application fees and health department accreditation costs as allowable costs under grants and cooperative agreements. The accrediting entity should also work with state and local public health departments to support budget requests for funding accreditation applications by providing data on the cost-effectiveness and value of accreditation. Other funding sources may include organizations at the national, state, and local levels that seek to promote performance improvement and continuous quality improvement in public health services, and organizations that use information about performance quality in decision making.
Controlling the cost of accreditation
Affordability of fees is critical to success, particularly when the value of a voluntary national accreditation program is being established. Affordability should be measured by the actual fees charged, by the cost of the process to the applicant, and by the perceived cost-effectiveness of the operation. The fees and the costs of becoming accredited should be commensurate with the value of accreditation to the applicants. The costs of the accreditation program's operation should be commensurate with the value of accreditation to the public's health and to the sponsoring agencies.
The SC recommended that an accrediting entity should design a streamlined accreditation process making maximum use of electronic data exchange. Standardized formats could also meet the needs of funding agencies and other oversight bodies. Goal-directed self-assessment and site visit assessment procedures and orientation to the accreditation process for applicants are also essential to controlling costs. Benchmarks and best practices for completing the application and conducting the self-assessment should be made available in preapplication orientation, providing guidance on cost-effective ways to complete the processes. Providing sample policies from high-performing agencies, setting guidelines on the maximum length of documentation, and providing for the use of existing data formats to submit information are other techniques to control applicant costs.
From the beginning, the accrediting entity should establish its architecture to control costs. Volunteer committees should be used to develop and maintain the standards, with significant participation by accredited states and local public health departments and academics. The standards and benchmarks used in accreditation should be simple, not complex. The accreditation cycle should be reasonably long, using interim data submissions and targeted follow-up on improvement plans to ensure ongoing attention to transforming state and local health departments into high-performing, continuously improving organizations.
In the start-up period and initial operational phases, in-kind contributions, volunteer services, and contractual services should be highly valued by the accrediting entity, but there should also be sufficient investment in training and supporting site review teams to ensure standardized assessments and efficient administration. As the program develops and the number of accredited public health departments grows, the accrediting entity should reassess the balance of volunteer, in-kind, and contractual services to ensure continuing cost-effectiveness. The accrediting entity should provide services to encourage cost controls in accreditation processes at the applicant level. It should also work with state and local public health departments, designing its assessment processes to streamline the applicant's work while maximizing the value of the self-assessment, data collection, site visit, and feedback activities. Moreover, the accrediting entity should collect and aggregate data on the costs of the accreditation process, including costs to applicants. These data should be available to applicants for benchmarking their costs and identifying potential cost controls. Finally, making use of a recognition/approval process by which existing state-based programs could demonstrate conformity with national standards is another way to keep costs down.
Surveyed public health leaders have identified recognition, consistency, and quality and performance improvement as the most important benefits of accreditation. In the developmental phases of the voluntary national accreditation program, incentives should be uniformly positive.
High performance and quality improvement
Among state and local public health departments, a high value is placed on performance improvement and continuous quality improvement. A successful accreditation program should provide a transforming process that supports these goals.
Recognition and validation of the public health department's work
A successful accreditation program should be credible among governing bodies and recognized by the general public, providing accountability to the public, funders, and governing bodies (legislatures and governors at the state/territorial level; tribal governments; and boards of health, county commissions, city councils, and officials at the local level). The accrediting entity should establish an information program that promotes the value of accreditation for the public and key stakeholders. Accredited public health departments should receive rights to use credentials in promoting their work to their constituencies and in seeking access to grants, contracts, and reimbursement preferences. The accrediting entity should provide documentation, promotional materials for customized use, and specialized support to accredited public health departments. In addition, the accrediting entity should maintain an active program promoting the value of quality and performance improvement in public health and the role of accreditation in encouraging and documenting continuous improvement in public health departments.
Access to resources and services to undergo the accreditation process
To encourage state and local public health departments to seek accreditation, the accrediting entity should provide assistance for the application process. The accrediting entity should also work with potential funders to develop scholarship programs and encourage peer-consulting services for departments needing assistance in specific domains. There should be no penalty (other than expended costs and fees) for terminating the application process during the prequalification process or before an accreditation decision is reached.
Improved access to resources
The accrediting entity should partner with public health organizations, foundations, and governmental agencies to promote incentives for accredited public health departments. These can include access to funding support for quality and performance improvement; access to funding to address gaps in infrastructure identified in the accreditation process; opportunities to pilot new programs and processes based on proven performance levels; a streamlined application process for grants and programs; and acceptance of accreditation in lieu of additional accountability processes.
Access to support for continuous quality improvement
The accrediting entity should maintain active support for continuous quality improvement among accredited public health departments. The components of this transformational practice support program may include in-person and Web-based services, best practices exchange, peer-group data exchange and analysis, and similar resources. Leadership awards may be developed as the accreditation program matures.
The SC recommended that the accrediting entity should develop evaluation and research strategies early in its development. A logic model was suggested to serve as the framework for evaluation of a voluntary national accreditation program. This approach, intended to link accreditation activities and outputs to both short-term outcomes (eg, changes in health department capacity and practices) and long-term outcomes (eg, changes in health status indicators), is described in detail elsewhere. However, the importance of not suggesting an automatic link between the short-term and long-term outcomes was noted by the SC. Improving the capacity, programs, and/or operations of a public health agency has not been proven to lead to improvements in health indicators (such as infant mortality or water quality). Conversely, these outcomes can improve for reasons that have only limited relationship with health department performance. Many other contextual variables (independent of the work of health departments) affect these long-term outcomes. Currently, the evidence base to support the linkage between specific standards for public health and improved public health outcomes is very limited. The SC recommended a robust set of domains for program evaluation and noted that some evaluation questions should have higher priority in the early phases of the accreditation program. A sequencing approach to program evaluation was recommended.
Clearly, the SC developed a recommended model to serve as a framework upon which a voluntary national accreditation public health program could be built. While the SC acknowledged that accreditation of public health agencies in this country will not solve all of the problems that they face, the desire to form a stronger commitment to performance and quality improvement is evident. While it will logically take a few years for an accreditation program to become established, operational, and mature, a good start has been made. Maintaining the commitment through a multiyear process will allow adjustment of the accreditation program to make it more successful in promoting public health performance and improved community health outcomes, and to increase the cost-effectiveness of the operation.