Ingram, Richard C. DrPH; Bender, Kaye PhD, FAAN, RN; Wilcox, Robin MPA; Kronstadt, Jessica MPP
One of the great challenges encountered by the Public Health Accreditation Board (PHAB) is assuring that the standards and measures used to accredit state, local, Tribal, and territorial public health departments are relevant to public health practice in each of those settings. Enormous variance exists between public health departments with respect to characteristics such as size of population served, governance structure, relationship between state and local public health departments, and services offered. PHAB's goal is to protect and promote the health of the public by advancing the quality and performance of governmental public health departments.1
Developing and maintaining a voluntary national accreditation program with standards, measures, and processes specific enough to assure the capacity of health departments to fulfill their role in assuring the 10 Essential Public Health Services within the wide context of public health practice is PHAB's order of business.2 To assure that PHAB's accreditation program remains consensus-based, PHAB has convened (and continues to convene) a series of discussion meetings, or think tanks, designed to seek input from subject-matter experts in the public health practice and research community. To date, more than 400 experts have provided feedback as part of the development and revision of the standards and measures.3–5 The think tanks complement multiple other activities to engage the public health community in its work.
A think tank is defined as an institute, conference, or session aimed at exploring new ideas and strategies around a particular subject.6 The origin traces back to the turn of the 19th century when dialogue between academics and government concerning United States foreign policy was most needed. In more recent times, the phrase think tank is most commonly used to describe specific organizations devoted to this type of exchange, primarily to affect public policy.7 McGann8 described various approaches to conducting think tanks to achieve a specific outcome.
The think tank methodology developed by PHAB is fairly straightforward and provides thought leaders in the public health community the ability to shape and mold PHAB's accreditation tandards and measures to ensure that they are both timely and relevant. For each think tank, PHAB convenes a carefully chosen panel of public health professionals, as well as PHAB staff and a representative of PHAB's board of directors, to participate in brainstorming sessions intended to uncover and deliberate on a particular topic. Working with its partner organizations, PHAB identifies public health practitioners with experience working on the specific issue and researchers who have studied the topic and invites them to participate. The meetings are typically 2-day events, with approximately 20 individuals participating. Additional meetings are scheduled as may be needed to adequately cover the topic.3–5
The think tanks are facilitated by PHAB staff, a representative of PHAB's board of directors, or a knowledgeable facilitator. Each think tank meeting uses the same methodological approach: identification of and consensus on meeting outcomes and process by think tank participants; a specific period of knowledge sharing on evidence and promising or best practices; and the development of a work plan to achieve the outcomes. The stated outcomes are basically the same in each think tank: sharing information on best and promising practices in public health in a given topic area; sharing information on PHAB's proposed or intended standards and measures concepts; identification of areas where the two can best align; development of a glossary of terminology; and identification of future implications for the topic as it relates to accreditation.
After an initial think tank meeting, PHAB and think tank participants decide whether more meetings on the topic are necessary. If more meetings are deemed necessary, they are held either in person or by various electronic communication means.4 When a think tank is concluded, a report is compiled, which is submitted to PHAB's board for review. Information from the report then is used to inform ongoing policy discussions regarding the accreditation standards and measures or, in some cases, the accreditation process. Typically, the recommendations from the think tanks result in changes in the standards and measures specifically in the purpose and significance statements for the measures, or in the documentation guidance for health departments to use in selecting their best evidence of conformity with a measure. In the case of the Tribal think tank, for example, recommendations resulted in language changes to ensure that the measures were applicable in those public health settings.9
Think Tank Topics
The Table contains a list of the various PHAB think tanks completed or in progress as of the writing of this article. It should be noted that a think tank listed as completed may be reopened for further discussion if the need is identified. There are 3 types of think tank topics: programmatic, contextual, and emerging issues.
The programmatic think tanks are largely focused on the traditional core program areas of public health—environmental public health services, public health laboratory services, emergency preparedness, maternal and child health, chronic disease—and have 2 broad objectives.3,4 The first objective is making sure that accreditation standards and measures encompass these areas of public health practice. While these are specific programmatic areas that are in some ways unique, they do share commonalities with public health practice in general; the think tanks are intended to assure that the standards and measures recognize this commonality. The second objective is making sure the standards and measures do not conflict with preexisting accreditation/certification programs–-many areas of public health practice have preexisting certification/accreditation programs, and the think tanks are intended to assure there is little, if any, conflict or duplication of effort between PHAB accreditation and these preexisting programs.
PHAB is currently conferring with some of these programs on common areas of interest, with the long-term goal of developing a process that mutually supports the endeavors of PHAB and the other organizations. These programmatic think tanks have also provided opportunities for PHAB to engage a broad range of public health practitioners and raise awareness about the national accreditation program.
The contextual think tanks, in contrast, grapple largely with the environment in which public health departments operate.4 These think tanks focus on ensuring that PHAB standards and measures are appropriate to encompass the enormously different contexts under which various public health departments operate. The governance, centralized states, large city/metropolitan, multijurisdictional/shared services, and workforce think tanks focus largely on the organizational attributes of public health departments, which may impact accreditation. For example, in centralized states, the state health department may have responsibilities and authorities that would be the responsibility of local departments in a decentralized model and the centralized state think tank addressed the organizational structure where local health departments are administrative units of the state health department.
The Tribal, Texas, and California think tanks are focused on how accreditation relates to particular populations. For example, Tribal public health departments serve sovereign nations within the United States, and many Tribal departments have vastly different responsibilities, dictated by Tribal legislation, than many state or local health departments. The Tribal think tank is focused on developing and refining standards and measures that recognize the unique status and responsibilities of Tribal public health agencies. Texas and California represent states that have extremely diverse populations, a variety of health department organizational structures, and as a result are, to some degree, microcosms of the country as a whole.
The third category of think tanks addresses emerging public health issues. For the current period, this category of think tanks includes topics such as public health informatics, public health ethics, health equity, and communication science. Public health informatics addresses such areas as emerging health information exchanges, electronic health records, and general data sharing between health departments and health care providers. Public health ethics includes the overarching principles around which health departments make their decisions in serving the communities in their jurisdiction. The health equity think tank explores how health departments consider engaging all of the people in their jurisdiction in planning, policy development, and decision making. The communications science think tank addresses issues concerning state-of-the-art communication processes and the effective use of digital communications. PHAB expects the link between public health and primary care to be added to its list of think tanks in the near future. PHAB will consider other emerging topics as they are identified within the broader public health community.
PHAB follows the same overall methodological approach for all 3 types of think tanks; however, the nature of the conversation may change depending on the type and the specific content area of the discussion. As one example, while the think tank focused on governance dealt with a number of issues related to the topic, participants expressed concern that the definition of a governing body, as defined by PHAB at the time, was inadequate. Thus, a significant portion of the think tank focused specifically on creating a definition of a governing body that suitably described the varying models of governance in public health practice in the United States.
Relationship to PHAB's Accreditation Improvement Process
The think tank process is part of a series of steps that are being used in the revision to Version 1.0 of the PHAB Standards and Measures, which will become effective on July 1, 2014. The PHAB board of directors has adopted an iterative process of seeking input, developing revisions, and seeking review and additional input as it revises the standards and measures. This process includes 3 separate drafts of revisions of the standards and measures before submission to PHAB for their adoption.
Step 1: Gather and review information to inform changes
PHAB staff will draw on several sources of information for the development of proposed revisions to the Standards and Measures, Version 1.0. Sources will include the following.
Recommendations from the public health community
PHAB announced its plans to revise Version 1.0 of the Standards and Measures in the July 2012 issue of the PHAB online newsletter. PHAB invited its readers to submit recommendations for changes or additions to the standards and measures. PHAB will accept and consider recommendations from the field throughout the process. PHAB will also incorporate what it learned from the participants of the think tanks by revising the text of the measures and their guidance, expanding the glossary, and considering adding new measures. Future areas for exploration may also be identified and kept by PHAB to assist with defining more long-term accreditation related work.
Results of measure assessments
PHAB staff will review completed site visit reports. In particular, PHAB will look for measures that were consistently “fully demonstrated” and consistently “not demonstrated.” Some of the consistently “fully demonstrated” measures may be a basic requirement of a health department and should remain unchanged. Others may be so basic that they can be deleted. Still others should be strengthened to promote continuous quality and performance improvement. The measures that were consistently assessed to be “not demonstrated” will be reviewed for adjustment and/or clarification. PHAB will also consider measures that were met but for which “Opportunities for Improvement” were identified. This information may provide guidance for strengthening the measure or increasing specificity around the Required Documentation.
Likewise, identified “Areas of Excellence” may provide examples that can be included in the Guidance for each Required Documentation.
Questions received by PHAB concerning version 1.0 and answers
PHAB regularly receives questions from health departments and site visitors about the intent or interpretation of specific standards and measures. All of the questions and their answers are logged and organized by measure number. These questions and answers provide a wealth of information concerning what in the Standards and Measures, Version 1.0, should be clarified or made more specific.
Evidence from the literature and emerging research
One of the challenges PHAB encountered when developing Version 1.0 of the Standards and Measures was the relative scarcity of research related to optimal administrative practice.10 Public health is a dynamic field, and PHAB's standards and measures are intended to allow it to distinguish high-performing health departments. Some view the relative scarcity of evidence as an advantage and suggest that it may encourage the development of a robust evidence base pertaining to accreditation.10
Given that many significant public health practice innovations are published in peer-reviewed literature, PHAB staff continuously monitor the literature to keep abreast of the evolving evidence base in public health. In addition, think tank participants often bring to PHAB's attention emerging research. Research will drive the continued refinement of the standards and measures. When new research pertaining to the Essential Public Health Services and the administration and governance of governmental public health departments emerges, PHAB will review it and determine when it is appropriate to convene experts to discuss potential revisions to the standards to ensure that they reflect state-of-the-art public health science and to support accreditation's goal of advancing the quality and performance of public health departments.
Fortunately, a number of recent events suggest that there will be more research available to inform the refinement of the standards and measures. A revised research agenda for Public Health Services and Systems Research has been recently published, and it contains a number of research questions specifically regarding accreditation, as well as questions that look at the broader issues of optimal administrative practice.11 In addition, a research agenda specific to public health accreditation has also been recently published, and it should help stimulate research on accreditation.10
The focus on identifying optimal administrative practice seems to already be bearing fruit. A recently published article by Brownson et al12 contains one of the first attempts to identify administrative practices that are supported by an adequate evidence base to recommend them as leading to/being associated with high-performing public health departments. The results of this research, as well as similar research conducted in the future, could lead to the refinement of the current standards and measures, as well as the development of new ones, that encompass the changing evidence base of public health.
Step 2: Develop revision (draft 1)
PHAB staff will develop proposed amendments to the Standards and Measures, Version 1.0, based on the information gained from the sources listed in step 1.
Step 3: Vet revision (draft 1) for 30 days of public review and comment
Draft 1 of the revisions will be vetted with the public health community for a 30-day comment period. Thirty days will be sufficient, as an entire set of new standards and measures is not being proposed, but only revisions to the standards and measures with which people have been working with for over a year.
Step 4: Develop and consider a second revision (draft 2)
The second draft will be produced that will reflect suggestions, explanations, and considerations obtained from vetting comments as well as other ongoing processes of think tanks and public comment. These proposed changes will be presented to a PHAB-appointed accreditation improvement advisory committee for their review and recommendations for revisions.
Step 5: Develop revision (draft 3)
Draft 3 will be developed to incorporate the recommendations of the Accreditation Improvement Advisory Committee. This version of the standards and measures will be submitted to the PHAB board by the Chair of the accreditation improvement advisory committee for the board's consideration and adoption.
Step 6: Board adopts standards and measures revision
Revised standards and measures will be released in early 2014 for implementation in July 2014. The new version will be available to the field no less than 6 months prior to implementation.
In order for PHAB accreditation to improve public health practice in the United States, the standards and measures must meaningfully reflect processes that encourage excellence in public health. The standards must meet 2 conditions: they must be relevant, and they must apply to the context in which public health is practiced daily. Given that public health practice is a dynamic endeavor, and that the standards and measures are intended to promote continuous quality improvement, it is vital that PHAB continuously try to improve the quality of the accreditation experience. The think tank processes developed by PHAB and the other methods described in this article are mechanisms designed to ensure that these 2 conditions are met and, as a result, that accreditation offers public health agencies a useful framework to improve the quality of services that they offer. By engaging thought leaders and public health practitioners in think tanks and soliciting feedback as part of the vetting, this consensus process also serves as a communication vehicle for PHAB to educate the field about the national accreditation program.
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