Matthews, Gene W. JD; Markiewicz, Milissa MPH, MIA; Beitsch, Leslie M. MD, JD
After extensive study through the Exploring Accreditation Project,1 a national voluntary accreditation program has been endorsed by leading public health organizations, including the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the National Association of Local Boards of Health.2 The accreditation of public health agencies is expected to play a significant role in strengthening the performance, effectiveness, and accountability of governmental public health.3 The Centers for Disease Control and Prevention has stated that accreditation has the potential to “bring consistency, accountability, and quality improvements to public health.”3(p333)
In 2007, the Public Health Accreditation Board (PHAB) was incorporated. With support from the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention, PHAB is “working with leading public health experts from the field to develop a voluntary national accreditation program that will help public health departments assess their current capacity and guide them to become even better providers of quality service, thus promoting a healthier public.”4 The voluntary national accreditation program is set to launch in fall 2011; PHAB aims to have 60% of the US population covered by accredited public health agencies by 2015. To meet this goal, a strong legal and policy foundation will be essential to support participation in the national voluntary accreditation program.
Law plays a fundamental role in the prevention of disease and the promotion of health.5 There is strong evidence to support the efficacy of laws that directly impact health outcomes, such as mandatory seat belt laws, food-labeling laws, and laws that establish drinking water's quality standards. Laws, regulations, and policies also impact health outcomes indirectly, for example, through the establishment of authorities for state and local public health systems. However, there appears to be little research that examines how these “enabling” laws, regulations, and policies are developed and adopted.6 Even less attention has been devoted to exploring their impact on the capacity of the systems that they create or endorse to achieve their mandates.
Laws, regulations, and policies (“legal frameworks”) that establish public health agency accreditation programs likewise had limited study. In 2007, Beitsch et al7 examined the legal frameworks that support state accreditation or performance assessment programs in 5 states participating in the first phase of the Multistate Learning Collaborative (MLC), a project funded by RWJF, to explore accreditation and quality improvement processes.8 A natural experiment was found unfolding in these states. Although each state had developed a unique legal foundation to support its accreditation or performance assessment program, 3 distinct types of legal structures emerged: policy implementation; formal rulemaking (regulation); and specific accreditation statute.
The existence of different types of accreditation legal frameworks, embedded in complex and varying state legal infrastructures and political environments, raises important legal implications for the national voluntary accreditation program.4 Additional research and analysis, beyond a simple descriptive study into the 3 legal alternatives, are necessary to inform policymakers, public health practitioners, and other stakeholders, as they attempt to craft a state's approach to accreditation. In an effort to increase the understanding of accreditation-enabling laws nationwide, the present mapping and case studies were undertaken, supported by the Public Health Law Research program at Temple University with RWJF as grantor.
In 2010 to 2011, the North Carolina Institute for Public Health conducted a study of state legal frameworks supporting public health department accreditation or related programs, such as certification/assessment, performance management, and quality improvement. First, a mapping study of 23 states was conducted to identify current programs and their legal frameworks. Ten states were then selected for in-depth study (Figure). Even as all 10 states are planning to participate in the national program, they approach accreditation from a variety of starting points. Some have accreditation (or related programs) mandated by statute, while others operate voluntary programs that are authorized by statute or regulation or based on state health department policy.
FIGURE . Legal Accre...Image Tools
LaFond et al9 concluded that “for research of newer, more innovative state policies, a multistage data collection method—using surveys and secondary research in conjunction with historical legal research—may be necessary to provide sufficiently accurate information. In either case, historical legal research is a requisite component of the research process.”9 Therefore, data were collected in 2 phases. During the first 6 months of the project, the research team used policy analysis methods to map the legal terrain surrounding public health agency accreditation. Initially, 16 states were selected for the mapping study based on their participation in the MLC. An additional 7 states were selected for the mapping study based on their identification by the Association of State and Territorial Health Officials and/or the National Association of County and City Health Officials as states involved in accreditation and/or quality improvement. In the first phase, the research team conducted semistructured interviews with 1 to 2 public health practitioners directly involved in administering accreditation, certification/assessment, performance management, or quality improvement programs in these 23 states to identify the type of program currently in place and the legal framework supporting it. In addition, legal and policy documents were collected from interviewees and online sources to complete the historical record.
In the second phase of data collection, 10 states were selected from among the original 23 to participate in case studies. Selection as a case study state was limited to those states actively preparing to participate in the national voluntary accreditation program. Secondary selection criteria aimed at obtaining diversity among case study states with regard to (1) the type of legal framework (policy, regulation, and statute) currently supporting accreditation or a related program, (2) whether the current legal framework is based on broad or specific legislative authority, (3) whether accreditation or related efforts rely on recently updated or long-standing legislative provisions, and (4) geographic location within the United States. These 10 states are Illinois, Iowa, Kansas, Michigan, Missouri, Montana, New Hampshire, North Carolina, Oklahoma, and Wisconsin.
Semistructured interviews were conducted with public health practitioners and other stakeholders involved with accreditation or related programs in each case study state (2-6 interviews per state) by utilizing an interview protocol as guidance. Names of potential interviewees in each case study state were elicited from the individuals who participated in the mapping study. The research team sought to include as interviewees individuals who were familiar with the history and development of each state's accreditation or related program, its current implementation, and its legal framework. Interviewees included current and former state and local public health officials (including state public health attorneys), as well as representatives of state public health institutes, associations of counties, associations of local health departments, associations of public health officials, and private legal consultants.
The team used process tracing, as employed by Meier et al,10 to “examine the chain of events and decision-making processes by which underlying policy conditions” led to the development and adoption of a legal framework.10 Team members focused on identifying the key environmental and system-level determinants that impacted decision making (eg, relationship between the state public health agency and local partners). The case studies examined the following questions: (1) What were the decision-making processes and chain of events by which states developed a specific legal framework? (2) What considerations led to the specific content of the legal framework (eg, mandatory vs voluntary participation)? (3) What factors facilitated or hindered the adoption of the legal framework, or particular elements thereof? (For example, Meier et al10 identified “legal experts within the state health department” as an important factor in initiating health reform.) (4) What lessons have been learned in implementing the legal frameworks?
Relevant legal and policy documents were collected from each state, as well as educational materials and formal and informal program-related documents, such as program descriptions, guides, and fact sheets, for content analysis. For each state, a case record was created, which included transcribed interviews and related documents. Case records were analyzed to identify unique and cross-cutting themes related to legal issues and lessons learned regarding the development of state-based accreditation and related programs (eg, important definitions, date of enactment/implementation, whether accreditation is mandatory or voluntary, governance structure, accreditation standards, accreditation requirements and process, review process, reaccreditation process, funding arrangements, and fees). In addition, case records were analyzed to identify legal issues related to participation in the voluntary national accreditation program.
The findings from the mapping study are displayed in Table 1. For each state, the accreditation, certification/assessment, performance management, or quality improvement program currently in place is identified, as is the type of legal framework supporting it. The citations for statutes and regulations are also included. The research team categorized each state's “type of program” based on the state's self-definition due to the fact that no universally accepted definitions for the various types of state-based programs (accreditation, certification/assessment, performance management, and quality improvement) existed among the case study states. Five of the original 23 states (not in the table) indicated that they lacked formal programs for accreditation, certification/assessment, performance management, or quality improvement. From preliminary phase 1 exploratory work, the remaining 18 states have some of the most developed accreditation and related programs and accompanying legal infrastructures.
Among the 18 states in the sample, 4 had accreditation programs, 6 had certification/assessment programs, and 8 had performance management/quality improvement programs. Accreditation programs were most likely to have a statutory basis, while performance management and quality improvement programs were most often supported via health department policy. The voluntary Missouri accreditation program, sponsored by a public health institute, operates independently of statute, regulation, or policy. A combination of statute and regulations was the foundation for 4 of the 6 certification/assessment programs, while 2 were founded in statute alone.
The 10 states forming the case study group are shown on the US map (Figure). Four are the states with accreditation activities underway, while 2 have certification/assessment programs, and 4 operate either performance management or quality improvement programs. Greater detail is provided about each state in Table 2, reflecting public health structures, programs, legal frameworks, approaches to PHAB accreditation, and legal strategies for achieving accreditation.
Iowa, Michigan, Missouri, and North Carolina have state accreditation programs, 2 of which are mandatory for local health departments (LHDs). All these programs, with the exception of Missouri, are based in statute. A statutory approach was considered fundamental, because it indicated the serious intent of the stakeholder groups promoting accreditation.
Illinois has a voluntary certification program authorized by statute and based in regulation; however, certification is an eligibility requirement for state-funded local health grants. Wisconsin has a regulatory “review process,” which operates similar to certification and is mandatory for LHDs. It is premised in statute. The 4 remaining case study states are engaged in performance management and/or quality improvement processes. Public health agency attorneys and private attorneys (consultants) were involved in creating the legal frameworks for these programs in 6 of the 10 case study states.
All 10 case study states are planning to participate in the national voluntary accreditation program, although to varying degrees. Because the national program is voluntary, no states anticipate significant barriers in their laws, regulations, or policies that will prohibit or hinder participation. Minor statutory-conforming amendments or technical regulatory changes may be needed in some states. In particular, Illinois and Wisconsin are considering recognizing accreditation by PHAB as fulfilling current state review requirements. States with performance management or quality improvement programs derived from policy will not require changes to legal authority but may wish to seek additional legal structures to support and encourage accreditation applications.
At least 5 of the 6 states with accreditation or certification/assessment programs (Illinois, Iowa, Michigan, North Carolina, and Wisconsin) plan to maintain their state program after the national voluntary accreditation program is launched. Iowa and North Carolina may seek to have their state program recognized by PHAB as equivalent to the voluntary national accreditation program, mitigating any need to modify state laws, regulations, or policy. Michigan plans to maintain their mandatory accreditation program alongside the national voluntary program. The LHDs in this state would be required to participate in the state program and could, if desired, also seek accreditation by PHAB.
Shared service delivery among 2 or more LHDs is a strategy under consideration in several states to facilitate successful accreditation for LHDs that cannot meet all standards on their own. There is a wide spectrum of options for shared service delivery, ranging from informal agreements to consolidation of health departments into a multijurisdictional district health department. Interlocal agreements or formation of district/regional LHDs are legal options along the continuum of shared services. These conversations are taking place most prominently in Kansas and Iowa. Other states, like Illinois, do not view these developments positively, fearing consolidation and loss of local autonomy.
Early adopter states have pursued a variety of legal frameworks to develop their accreditation, certification/assessment, performance management, and quality improvement programs. With the voluntary national accreditation program scheduled to go live in late 2011, these 10 states have also carefully considered options for aligning their activities with PHAB accreditation. Lessons derived from this examination can inform public health care practitioners, advocates, and elected officials about how to best structure legal preparations to support accreditation and related activities.
States with long-standing accreditation and certification/assessment programs were more likely to have underlying statutory or regulatory authority—some utilized both. This tendency may also be understood from the standpoint of the processes required to bring parties into accommodation on the path forward. According to key informants, laws and regulations were important in several states to emphasize the gravity of the deliberations. Complexity of accreditation and certification/assessment also argues pointedly for greater formality than what policy may typically provide.
For states with limited accreditation, certification/assessment, performance management, or quality improvement activities currently underway, if the intent is to align with the PHAB accreditation program, less legal structure may be necessary than the examples presented here. Generally, a permissive legal environment is a necessary threshold, which will minimize the need for statutory and regulatory modifications and entanglements. Incentives could be provided through legal or policy mechanisms, depending on state intent. Nonetheless, as several states in the case studies noted, shared service delivery among 2 or more LHDs can catalyze successful accreditation for LHDs that cannot meet all standards on their own. There are a variety of legal structures that can support shared service delivery, ranging from statutes enabling regional/district health departments to legal technical assistance with preparing interlocal governmental agreements.
Three legal structures for accreditation
The legal frameworks first identified by Beitsch et al7 in the 5 original MLC states can be described as policy implementation, formal rulemaking (regulation), and statute. The findings of this study confirm this earlier work and extend the lessons learned. The data may indicate that a “pure policy” approach has the advantage of being the easiest for a state to initiate. It may also allow the health department to retain maximum flexibility for adapting to economic and political changes. On the contrary, a policy approach may not have the broader legal foundation of a formal regulation or statutory enactment that can better support its long-term implementation.
The existence of properly promulgated regulations may add authority, enforceability, and credibility to accreditation programs; yet, such regulations can take more time and resources to introduce than a “pure policy” approach. Moreover, successful state accreditation legislation may be harder to accomplish than a regulatory “or pure policy” approach to accreditation. Yet, there may be a long-term benefit: once executive and legislative consensus is expressed in the form of enacted accreditation legislation, it may be more straightforward for public health care practitioners implementing the program. The initial hurdle was more likely to have been achieving political consensus around the choice of legal framework. Practical information of this nature may also be useful to states that have accreditation or certification/assessment programs in place but are considering migration to an alternate legal framework.
The mapping and case studies presented have limitations. They are informed by data collected at 1 point in time, during a rapidly changing public health landscape. Furthermore, information provided by key informants may be subject to bias due to lack of objectivity or poor recall of events. Finally, all pertinent laws and supporting documentation affecting findings may not have been shared with our team, found in research, or otherwise reviewed.
The key findings and legal lessons learned from the 10 case studies are intended to be of practical use to other states, either as they examine their existing state public health statutes, regulations, and policies in preparation for participation in the voluntary national accreditation program or as they contemplate establishing their own state accreditation program. Interviewees stressed the value of the accreditation process itself-–from developing critical assessment and planning skills among public health practitioners to improving the efficiency, accountability, and sustainability of public health systems, to gaining recognition from elected officials which can translate into additional resources. Notably, these values align closely with accreditation benefits endorsed by PHAB.4