Mays, Glen PhD, MPH; Beitsch, Leslie M. MD, JD; Corso, Liza MPA; Chang, Carol MPH; Brewer, Russell DrPH, MPH
Strategies for establishing a national voluntary public health agency accreditation program have been gathering momentum in recent months. Spurred to action by the Institute of Medicine's 2003 report, The Future of the Public's Health in the 21st Century,1 exploratory activities, funded by the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention, have been under way. Intense review involving broad representation of the public health community has generated wider interest in the concepts of accreditation and assessment, as well as quality improvement and performance management.2 Upon concluding its initial work to determine the feasibility and desirability of a national voluntary public health agency accreditation program, the Exploring Accreditation Project (EAP),2 jointly staffed by the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, with the American Public Health Association and the National Association of Local Boards of Health as key partners, issued a call for moving forward.
To inform the movement toward national voluntary accreditation, a parallel effort was launched in the fall of 2005 designed to generate information and insight from states already engaged in related activities. This effort, the Multi-State Learning Collaborative on Performance and Capacity Assessment or Accreditation of Public Health Departments (MLC), endeavored to confirm and cultivate what several prior studies had suggested—that sizeable numbers of states have relevant experience with performance measurement, standard-setting, benchmarking, credentialing, and/or accreditation activities in public health that could serve as learning opportunities for a national initiative.3–5 Through a competitive application process, five states (Illinois, Michigan, Missouri, North Carolina, and Washington) were selected to participate in the MLC. The project was designed with several objectives in mind: (1) to advance existing public health performance assessment or accreditation programs in five states through grant support; (2) to convene representatives of the selected states to share experiences and learn from one another; (3) to synthesize and disseminate information to local and state public health agencies and other key parties involved in developing systematic public health agency performance assessment or accreditation programs; and, of equal importance; (4) to inform the contemporaneous EAP based upon the experiences of real-time state public health laboratories.6
The characteristics and features of the assessment and accreditation activities under way in the five MLC states have been analyzed previously.6 However, because accreditation and assessment are increasingly being recognized as a national phenomenon, this article examines key elements of the programs in 16 of the 18 states originally seeking RWJF grant support through the MLC.
Letters of invitation to participate in the MLC were sent to all state public health agencies and other relevant associations and organizations. Twenty-three states responded with letters of intent, while 18 ultimately submitted full proposals. Sixteen states, including the five grantees, consented to the use of their proposals in this analysis. Common data elements were abstracted from each of the full proposals to paint a composite portrait of the applicant states. In addition, we have incorporated our insights regarding cross-cutting issues that influenced program development in the MLC applicant states. These latter concepts are presented in the “Discussion” section.
Rather than describe each state's accreditation or assessment program separately herein, we have constructed a table containing key attributes, which we break out by individual state. This will enable the reader to compare and contrast states of interest by referring directly to Table 1. The key elements highlighted include program name, founding date, program goals and objectives, related activities that influenced the program development, partner organizations, and performance domains assessed by the program. Below we report common features of our findings from the review of the 16 state application submissions.
* Chief among the reasons accreditation and assessment programs were initiated was the perceived lack of consistency or uniformity of public health services within a state. For several states there was also a strong emphasis on quality improvement and a willingness to accept greater accountability for the receipt of public funds.
* States choosing to go forward are building their initiatives with solid foundations based upon earlier, accepted work as opposed to creating new models de novo.
* Current accreditation and assessment efforts primarily are focused on the local public health agency. To date, fewer states have taken formal steps to introduce state health department assessment (Washington, New Hampshire, Ohio, and Vermont) or accreditation (North Carolina).
* In addition to the pivotal nature of the relationship between local and state health departments, MLC applicants have cultivated a wide variety of effective partnerships—both traditional and nontraditional—which have helped propel accreditation-like activities forward.
* Although the proposed national model for accreditation emphasizes a voluntary approach, the existing programs are more likely to be mandatory (data not depicted in Table 1).
* Assessment and accreditation programs may have a basis in statute (Minnesota, New York), rule/administrative code (Illinois, Michigan, New Jersey), or both (North Carolina, Wisconsin).
* Accreditation programs, through collections of best practices, may assist in building the science base for public health practice.
From our perspective, the sheer magnitude of interest in the MLC, coupled with the quantity and depth of the programs showcased, suggests that a national accreditation movement is already well under way. For purposes of analysis, we highlight several themes that are crosscutting among the states implementing public health agency accreditation and assessment. Moreover, we suggest that health departments contemplating new initiatives give consideration to these themes at the point of embarkation.
Common genesis of programs
Accreditation and assessment programs were often initiated because of perceived lack of consistency or uniformity of public health services within a state.9 This indicates that, despite the need to ensure that health department services are uniquely targeted to their population needs, there is an increasing recognition that the “commonalities” among health departments are far more significant and important than the differences. Related drivers included providing a level of public health services that every citizen deserves or has a right to expect. Sometimes momentum was created by an identified need significant enough to prompt dramatic change concurrently at both the state and local levels. For example, early in the history of Michigan and Wisconsin accreditation, there was urgency to demonstrate compliance with multiple state contracts covering numerous programs, yet without the constant interruption of frequent site visits.
Accreditation/assessment programs of the MLC applicants have employed a wide range of methodological approaches to achieve desired endpoints, measuring agency capacity, performing programmatic reviews, or analyzing the larger public health system. The forces that build momentum within a given state could potentially have an impact on uptake of national level accreditation. For example, if accreditation is interpreted as a possible solution to a particular local/state problem, national accreditation may not be perceived as responsive to their specific needs. However, a differing viewpoint might consider such areas ripe for national models, because the conditions are auspicious for meaningful system change. Framers of a national system must be cognizant of these dimensions, and demonstrate the ability to be responsive to locally identified needs or risk being perceived as irrelevant.
Built upon a solid foundation of previous work
There is both irony and comfort in the fact that the “innovators” of accreditation have relied so heavily upon preexisting contributions. Transformational projects such as defining the Essential Public Health Services,7 Healthy People 2010,8 the National Public Health Performance Standards (NPHPS),9 Mobilizing for Action through Planning and Partnerships (MAPP),10 the Turning Point Performance Management National Excellence Collaborative (Turning Point),11 and the National Association of County and City Health Officials Operational Definition of a Functional Local Health Department12 have served as inspiration for several states. Another example of heavy reliance on previous work is that North Carolina greatly diminished the length of the development cycle for their accreditation system by relying extensively at the outset on the standards established in Missouri. In addition, work currently being conducted by the Association of State and Territorial Health Officials through its Understanding State Public Health project may likewise guide future deliberations. This pattern of common antecedents may auger well for the adoption of a voluntary national system, also likely to be premised upon similar previous efforts.
State/local relationships and the importance of shared leadership and mutual accountability
Although the predominant focus thus far has been upon local health department accreditation, there is widespread recognition regarding the mutuality of an accreditation/assessment process. This shared responsibility comes in many forms. At one end of the continuum you have states in which the founding organizations and governance structure “institutionalize” the joint nature of the enterprise. Most of the MLC applicant states fall into this category, in which there is some measure of shared decision making. North Carolina, Washington, and to a lesser extent Illinois and Ohio represent the quid pro quo model, which embraces the concept that accreditation or assessment is appropriate for both state and local levels. In Washington, this commitment of mutual accountability is embedded deeply in their process: local and state health departments must both comply with the same set of standards, but with different measures reflecting their respective functional roles.
Less obvious from the data depicted in Table 1 is the shared commitment to success. For example, in North Carolina, technical assistance for each local health department undergoing accreditation is provided by an assigned team from the state health department. Failure to gain full accreditation is considered joint failure by the state health officer. This is one of many illustrations that the state/local dyad is sacrosanct; one cannot succeed without the other.
The power of partnerships as a critical success factor
In addition to the pivotal nature of the relationship between local and state health departments, MLC applicants have cultivated a wide variety of effective partnerships which helped propel accreditation-like activities forward. Most typically, but not exclusively, these relationships focused on traditional public health stakeholders. For example, state public health associations were directly involved as founders and in governance (as board members) in several states (Indiana, Missouri, Montana, and New Jersey). State associations of local health officials, as vehicles to convene local health departments, played crucial instigating roles in altering the status quo (Kansas, Michigan, and North Carolina). Partnerships with boards of health (local and state) were instrumental as well (Illinois, Indiana, Washington, and Wisconsin).
Beyond their partnership roles, universities and schools of public health offered expertise and technical assistance, even financial support (Missouri). Institutes of public health have been actively engaged with the MLC grantees, serving as lead agency in four of five. Often these institutes are housed at academic centers. Their ability to act as neutral third parties can positively influence the mating ritual between other key partners. They also frequently play integral roles in managing or coordinating the accreditation process.
Support from government or elected officials at the state and local levels may ultimately dictate the success or failure of accreditation and assessment processes. North Carolina (county commissioners) and Minnesota (state legislators) have cultivated these relationships through their governance structures. States with large American Indian populations and potentially overlapping jurisdictions (Arizona, Montana, and Wisconsin) have included tribal government in their partnerships. Representatives from the Indian Health Service and National Indian Health Board have likewise participated in the EAP.
Inventive partnerships, sometimes fostered through previous Turning Point collaborations, have been effective in several states. Among the most unique is the participation of health plans in Minnesota. There is even greater involvement of the medical community in Indiana through its Medicine and Public Health Initiative,13 which serves as the project lead. New Hampshire, with relatively few local health departments, is heavily dependent on its public health system partners.
Public health laws form a strong basis
States with a strong legal foundation appear to be able to institutionalize accreditation/assessment activities for the foreseeable future. Voluntary programs potentially may face a more tenuous existence. However, with multiple differing legal frameworks, it raises the question whether these diverse approaches pose a substantial implementation challenge for the introduction of a new voluntary national system. Moreover, designing a new model that is consistent with all existing laws may not be realistic, but perhaps adopting an existing framework, like the Model Public Health Act,14 may be. As another possibility, states could consider amending statutes and rules to accommodate a national program. A related question might be whether state legislatures and governors would be willing to delegate their authority to an external, as yet unproven, national organization.
Peggy Lee paradox: Is that all there is?
Some MLC grantees with mature accreditation and assessment programs have found themselves in the same position as famed raspy singer, the late Peggy Lee, asking, “Is that all there is…?” Programs were initiated for the reasons mentioned earlier, and in addition, to improve the performance of public health agencies and the quality of their services. However, without specific quality improvement and performance management content designed into such programs, improvements in performance and outcomes may remain disappointingly elusive. In fact, similar findings have been noted with accreditation in other industries.15 The proposed use of RWJF grant funds by MLC states frequently centered on enhancing their previously limited focus on quality and performance. Nonetheless, this potential disconnect between accreditation and achievement of desired performance and outcomes goals may represent current design flaws, and should be specifically addressed in any emerging national model.
Public health infrastructure
Ironically public health infrastructure has been both a key driving force and a major obstacle to accreditation. Some states have recognized accreditation as a potential vehicle to build the case for strengthening long-neglected public health capacity to ensure consistency of public health services. It remains an open secret that public health is tasked too much while resourced too little.16 If health departments fail to meet the expected “bar” because of insufficient infrastructure, they can make a strong case with boards and commissions for increased support. Utilizing self-assessment tools to reveal infrastructure weakness before site reviews can lead to financial transfusions while sparing more public embarrassment associated with the inability to attain accreditation. Yet one of the chief reasons some health departments are reluctant to seek accreditation is fear that their existing infrastructure is inadequate to meet required standards. This paradox is well recognized in Missouri, one of the few fully voluntary models, and will have to be accounted for by the national program if it is to achieve widespread uptake.
Efforts to build a stronger evidence base
A painful truth separating public health from other scientific endeavors is the relative dearth of evidence supporting what actually works in the field. One of the four major goals of the NPHPS Program is to build a stronger evidence base for public health practice.9 Accreditation and assessment activities may likewise hold similar potential. Accreditation programs, through their efforts in identifying best practices, establishing universally accepted criteria, and collecting data, are well positioned to advance the science base of public health. In fact, several MLC applicants and grantees have proposed to do precisely that, with efforts in Michigan and Missouri already well under way. However, these activities do not mitigate the need for a strong ongoing public health systems research commitment to continue to expand the public health practice science base.
Preparedness as a metaphor
Loud choruses indicating the rising levels of concern about accountability are emanating from governmental bodies and funders across the nation. Nowhere is this demand greater than in the realm of preparedness. In the wake of 9/11, and more recently Katrina, policy makers and the general public want to know what it has purchased with the multibillion dollar investment. It is precisely this attention and demand that have helped fuel the growth of preparedness certification for local health departments through Project Public Health Ready.17
Although the glare of scrutiny is more sharply focused on preparedness, it is certainly not on that alone. State and local governmental efficiency and accountability initiatives are increasingly widespread. MLC applicants have responded to these growing accountability demands through their assessment and accreditation programs. To the extent that a national accreditation model can prove responsive to such accountability concerns, it is more likely to resonate with key decision-makers outside the circle of the immediate public health community.
Another concern, one voiced by local health officials, is that accreditation is a stalking horse to drive smaller health departments to consolidate. This intent is far from evident among the MLC applicants. Rather, there is greater evidence of flexibility (Missouri and North Carolina), allowing health departments to configure themselves in manners of their own selection, but still requiring conformance with standards. However, one novel approach came from Kansas, which like most of the United States, had arrayed itself in regions for preparedness. In a partnership led by the Kansas Association of Local Health Departments, they proposed to develop the concept of functional regional accreditation. Rather than consolidation, the Kansas vision called for defining shared accountability across a region composed of smaller local health departments.
Unlike the language of hieroglyphics, there is no single Rosetta stone deciphering the pathway to accreditation or assessment. States have individually taken many different routes only to arrive at the same destination. The MLC applicants described here offer an insightful glimpse into an emerging national movement, just as a national model is itself gathering momentum. States contemplating such programs in the future, as well as the implementers of the proposed national accreditation program, would be wise to reflect on the lessons of these real-time laboratories.
© 2007 Lippincott Williams & Wilkins, Inc.