Accreditation signifies a health department's commitment to accountability, transparency, continuous quality improvement (QI), and strong collaborations with multiple partners to advance a culture of health for all members of the community. As national health care reform approaches implementation, health departments are using the standards and measures of accreditation as a guide to reshape their roles and activities. Those who have perceived health departments as simply administrative sites for a collection of miscellaneous services are beginning to recognize that accredited health departments are mission-driven organizations of excellence that are implementing strategic plans to improve and protect the health of their communities. Accreditation is rapidly proving itself to be a powerful lever for the transformation of public health practice.
We believe it is useful to reflect on the recent history of partnership efforts between the Robert Wood Johnson Foundation (RWJF), the Centers for Disease Control and Prevention (CDC), and a number of other key stakeholders from the public health practice and academic communities over the past decade that contributed to the relatively rapid adoption of accreditation and QI by the public health community. In this commentary, we review this recent history and highlight the role of RWJF.
The 2003 Institute of Medicine's second committee report on The Future of the Public's Health in the 21st Century found that “public health was in disarray,” just as it had in 1988.1 A popular maxim of the time was, “If you've seen one health department, you've seen one health department,” which oddly was often said as a badge of honor rather than as evidence of a dysfunctional system. One of the report's recommendations was that a national steering committee be formed to examine the potential benefits of accreditation of public health agencies. The public health practice community, however, voiced significant concerns about the value of accreditation and how such a system would be implemented.
Acting as a neutral convener, RWJF convened a meeting of stakeholders including practitioners, public health membership organizations, CDC, and other federal agency representatives in December of 2004 to reach a consensus on whether or not an agency accreditation system should be developed.2 Prior to the meeting, RWJF synthesized findings from the Foundation-supported work of the Turning Point Performance Management Collaborative and the “Operational Definition of a Functional Local Health Department” project of the National Association of County & City Health Officials (NACCHO). In addition, RWJF commissioned 2 research papers3,4 to aid meeting participants in developing guiding principles for an accreditation system and deciding to form a steering committee to study the feasibility and desirability of a national accreditation program.
The Foundation then collaborated with CDC to support the Exploring Accreditation (EA) Project in 2005, again serving as a neutral convener. The executive directors of NACCHO, the Association of State and Territorial Health Officials (ASTHO), the American Public Health Association, and the National Association of Local Boards of Health formed the EA planning committee and named an EA Steering Committee, which used an open, consensus-building framework. Contemporaneously, RWJF supported 5 selected states with experience in public health agency assessment and accreditation to enhance their processes and share results with other states in the first phase of the Multistate Learning Collaborative (MLC-1) managed by the National Network of Public Health Institutes (NNPHI). This project provided valuable empirical, real-world information about what worked and what did not to the EA steering committee. This evidence contributed to the committee's decision in the winter of 2006 to recommend that a national voluntary public health accreditation program be developed and implemented, and the draft recommendation was circulated for vetting by public health departments across the nation.5
By this point, it was clear to RWJF that the success of accreditation hinged upon it being a process developed by practitioners for practitioners, rather than a top-down or strict grant compliance system. The EA steering committee's principles of keeping the system voluntary, of establishing the accrediting body as an independent nonprofit, and of setting standards to be achieved without prescribing the specific processes to be used to achieve them, have all turned out to be key in the success of the program. Particularly important to the future of public health practice, the committee laid out a vision of accreditation as a platform for continuous QI to increase agency efficiency and effectiveness and achieve better health equity and improved health outcomes in the communities they serve.
On the basis of the EA recommendations to implement accreditation, the Foundation's portfolio of programs expanded to enhance the readiness of local and state health departments to pursue accreditation, and to tackle the need for public health practitioners to develop the skills necessary to systematically adopt QI. On the basis of the success of MLC-1, the program was increased to include 10 states during MLC-2 (2006-2008) and 16 states during MLC-3 (2008-2011) with continued management by NNPHI. The MLC states exchanged their approaches to increasing readiness as well as catalyzing the application of QI through training, mentoring, and funding to support QI implementation. The MLC grantees continued to inform the development of the accrediting body, served on Public Health Accreditation Board (PHAB) workgroups, and communicated PHAB's progress and promoted vetting of draft measures in their home states. Over the period from 2005 to 2011, the Foundation invested $15 million in MLC,6 including an extensive external evaluation.7,8 The MLC program knit together a community of practice across the nation that had a major impact on accelerating the emphasis on QI in public health and the momentum for public health accreditation.
Determining the best approaches to spreading and deepening the use of QI in public health was a significant challenge. Although health care QI approaches could be transferred to the more clinical activities of health departments, they were not relevant to many of the population-level or administrative aspects of health departments. Assessments of health department staff in 2005 found that most of the activities survey respondents were labeling QI were actually quality assurance, quality control, or evaluation activities. It was clear that examples from public health needed to be available for health departments to learn from.
It also became clear that it was not enough to teach QI in an in-person or virtual classroom. Learning QI required doing, participating in a project, with additional just-in-time learning available as the project progressed. Two early RWJF-supported demonstration projects helped prove the usefulness of process mapping as a fundamental QI technique in public health; one a RAND collaborative of health departments focused on improving aspects of emergency preparedness9 and the other the Common Ground project, managed by the Public Health Informatics Institute, that also used collaboratives of health departments to map out the business processes involved in preparedness and chronic disease management.10,11
To make the connection between accreditation and QI, RWJF expanded a NACCHO program initially funded by CDC from 10 in the pilot to 56 additional local health departments (LHDs). The LHDs performed a self-assessment using the Operational Definition of an LHD tool and then conducted a QI project on an issue highlighted by the self-assessment. Informed by this experience, when PHAB was ready to conduct a beta test of the accreditation standards and measures, the Foundation advocated for and funded the 30 beta sites to do a QI project they selected after their self-assessments and review visits, again reinforcing the relationship between pursuing accreditation and QI.
In addition, RWJF partnered with ASTHO to support state health departments to carry out QI projects with the assistance of a dedicated QI coach in 3 different programmatic areas—maternal and child health, environmental health, and chronic disease. One goal of this project was to demonstrate the relevance of accreditation and QI for these programs to state and federal staff as well as to member organizations in these areas. This project led to another opportunity for RWJF to act as a neutral convener, this time for representatives of federal agencies including CDC, Health Resources and Services Administration, US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, and the Department of Agriculture to share their individual agency experiences with applying QI and explore collaborations with each other and with state and local agencies on system-level QI.
As PHAB moved closer to launching, RWJF felt that it was critical to continue to build QI capacity and further the momentum toward accreditation. As the MLC ended, funding was provided to NNPHI to continue the twice-yearly open forum meetings as part of NNPHI's Community of Practice in Public Health Improvement program. This program has continued to expand the community of practice, enlarging the meetings, adding pre—meeting training workshops, and hosting participants from all 50 states, the territories, and tribes.
Robert Wood Johnson Foundation staff recognized that although participants at MLC and other meetings could hear about QI projects conducted by their peers, there was no single place to search for QI projects on specific topics or to learn how various QI tools had been applied. With the support of NNPHI, an advisory committee of public health QI leaders considered development of a Web site dedicated to collecting and organizing QI experience in public health. The Public Health Quality Improvement Exchange, PHQIX.org, was launched in November of 2012 by the Research Triangle Institute, with an initial 50 projects presented in a standardized format, and with sophisticated search capabilities. User response has exceeded expectations, additional submissions are rapidly flowing in, and PHQIX staff have succeeded in fostering an online community for public health QI. Practitioners are now able to learn from the experiences of their peers in applying QI to topics relevant to their work and share their QI plans and other practices, and academic faculty are beginning to use PHQIX as a resource for teaching students.
Over the last 5 years, RWJF has collaborated with CDC to provide complementary programming to NACCHO and ASTHO to provide technical assistance and develop tools and resources for health departments to pursue accreditation and QI. These included forming communities of practice for accreditation coordinators and QI leads at state and local health departments, developing guidance and providing consultants on strategic planning and QI, and developing tools for organizing accreditation documentation. Robert Wood Johnson Foundation also supported NACCHO to provide technical assistance and funding to 12 LHDs to conduct community health assessment and improvement plans that would meet PHAB's requirements. PHAB standards place a very high premium on broad community engagement, community prioritization, and multiple partnerships with other sectors in the community.
One of RWJF's roles in supporting the establishment of PHAB as the accrediting entity in 2007, in addition to co-funding the startup together with CDC, was to bring its considerable expertise in creating new nonprofit organizations and fostering sound management and financial practices. This relationship was key to RWJF's later willingness to provide an award to PHAB to set up a reserve fund, thus avoiding the need to set higher fees for applicants to build a reserve fund. RWJF viewed more affordable fees as critical to the success of the accreditation program, and PHAB demonstrated its ability to invest the reserve funds wisely and articulate the conditions under which they would be used. An additional role RWJF played was in communicating the value of accreditation and QI, particularly to policy makers. Early messages came from the mayor of Bethlehem, Pennsylvania, who stated, “Our police department is accredited, our fire department is accredited, of course our public health department should be accredited,” and from a state health official who wished that national accreditation was already in place when her Governor asked the cabinet which departments would be at risk of losing accreditation to make decisions about funding cuts. The Foundation convened the leaders of PHAB and representatives from several states to hone the message and visit their congressional representatives and senators on Capitol Hill. These policy makers responded with surprise that public health departments were not accredited, strong favor for greater accountability, efficiency and effectiveness, and a request for information on what it would cost.
A notable aspect of public health accreditation and QI is that it has included tribal health departments. As PHAB was being established, RWJF supported the National Indian Health Board to convene a tribal advisory committee to explore the desirability and feasibility of accreditation in Indian country. The committee found value in pursuing accreditation and worked with PHAB to adapt the standards and measures for a tribal version. More recently, RWJF has supported National Indian Health Board to continue the annual Tribal Public Health Summit with additional training workshops on accreditation and QI, and a reconvening of the tribal advisory committee on accreditation. In addition, RWJF has supported a tribal coalition led by Red Star Innovations to demonstrate community health assessment and improvement planning in tribal country and increase accreditation and QI capacity through a train-the-trainers program. It is also notable that CDC's National Public Health Improvement Initiative provides ongoing grants to 6 tribes to support work on QI and accreditation. Tribal leaders have affirmed the value of the accreditation community's commitment to tribal inclusion.
Taking stock after 10 years of investment, the early successes of accreditation are profound, particularly in the face of the progressive cuts to public health budgets and staffing over the last 5 years. When the RWJF began its investment in public health agency accreditation and QI 10 years ago, we set an admittedly very ambitious goal that by the end of 2015, 60% of the US population would be served by an accredited health department. And, remarkable to even the strongest adherents of accreditation, in September of 2013, only 2 years after PHAB opened the door to application, the agencies engaged in the application process and those already accredited serve 53% of the US population, well on the way to meeting that goal. The ability of national, voluntary public health accreditation to bring about change in practice across the country has been shown by the vast increase and improvements in health department performance of community and state health assessments and improvement plans in collaboration with multiple partners including community-based organizations, other government sectors, elected officials, academic organizations, health care organizations, and the private sector. Performance management systems, QI infrastructure, comprehensive workforce development, and administrative efficiency are being catalyzed by the pursuit of accreditation. Robert Wood Johnson Foundation envisions future versions of the standards that will include measures for multisector collaboration to achieve health in all policies, health and health care collaboration, promotion of health equity by addressing upstream determinants and discrimination, and improved financial management.
RWJF is committed to continuing support of national, voluntary public health accreditation and QI to improve the impact of health departments, and together with other partners, to foster a culture of health in their communities. Our hope is that the next Future of Public Health committee will find that public health is no longer in disarray. Instead, what will have emerged is that people and policy makers understand the value and role their health department plays in conducting high-quality practices that improve, protect, and promote the health of all community members.