Over the past decade, the public health system and our nation's public health departments have encountered numerous challenges and opportunities for improvement. Events such as the 2009 H1N1 influenza pandemic and the 2010 passage of the Affordable Care Act highlight the need for a strong public health infrastructure. Initiatives such as national voluntary public health accreditation, and greater investments in public health emergency preparedness (PHP) can foster efforts to strengthen that infrastructure.
Public Health Department Accreditation
In the 1990s and early 2000s, several initiatives1–3 began to build the foundations for national voluntary health department accreditation. In 2005-2006, the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation cofunded the Exploring Accreditation project, which provided the basis for the subsequent work in establishing a national accreditation program.4,5 The Public Health Accreditation Board (PHAB) was incorporated in 2007 and the national voluntary health department accreditation program was formally launched in September 2011.5 The first health departments were accredited by PHAB in early 2013.
The Public Health Accreditation Board accredits health departments on the basis of their conformity with an established set of standards. The PHAB Accreditation Standards5 are constructed on a framework of 12 domains, the first 10 of which are based upon the Essential Public Health Services. The domains and their associated standards and measures are intended to address the categorical work of a public health department but are not intended to be program-specific.
Public Health Emergency Preparedness
Due to the 2001 anthrax attacks6 and subsequent events, public health preparedness is now recognized as being central to the public health mission, and Congress has appropriated more than $9 billion to state and local public health agencies since 2002 to develop and implement all-hazards public health preparedness.7 In March 2011, the Centers for Disease Control and Prevention created Public Health Preparedness Capabilities: National Standards for State and Local Planning in response to concerns from stakeholders for more focused content regarding public health's role in emergency preparedness and to support greater program accountability.8 These PHP capabilities provide a guide that state and local jurisdictions can use to better organize their work, plan their priorities, and help ensure that federal preparedness funds are directed to priority areas within individual jurisdictions.
The PHP Capabilities are developed from content found in the 10 Essential Public Health Services,9 the National Health Security System,10 the Pandemic and All-Hazards Preparedness Act,11 and other reference documents from the emergency management community12 and the medical community.13
The Link Between Public Health Accreditation and Preparedness
The links between PHAB and PHP content were reinforced through a concerted attempt in the programs' respective development processes. The Centers for Disease Control and Prevention staff and field practitioners involved in both PHAB and PHP initiatives sought opportunities to build synergy, while also recognizing the unique intent of the programs. The PHP Capabilities frequently cite PHAB standards, and PHAB documents reflect terminology recommended by the CDC's Office of Public Health Preparedness and Response.
Both preparedness and accreditation initiatives are cross-cutting efforts and require functional, integrated, and coordinated health department operations and a solid public health infrastructure. Each addresses 3 key needs in public health: increasing the visibility and legitimacy of their services with stakeholders, closing the gap in strategies to improve the overall quality and efficiency of services, and enhancing service coordination and interoperability within and across agencies. This consistency of goals provides preliminary support for an alignment between public health accreditation and preparedness. This article examines the current alignment of PHAB Standards and PHP Capabilities in order to identify bidirectional accountability opportunities to achieve efficiencies and improve quality of services during a time of challenging economic and political pressures.
A crosswalk is a means of examining relationships by displaying 2 sets of standards in a matrix format and then examining the intersection of each, providing insight into how the 2 sets of standards are related. During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP Capabilities and the PHAB Domains. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities)8 and the Public Health Accreditation Board Standards and Measures, Version 1.0 (PHAB Standards)5 as its source documents. Table 1 identifies the components of the 15 PHP Capabilities and the 12 PHAB Domains.
The PHAB/PHP crosswalk was completed via an iterative process, whereby initial linkages were identified by research team consensus. To increase the utility of the crosswalk, 3 levels of linkages were identified to best define alignment between PHP Resource Elements and the text of PHAB measures, significance statements, or documentation guidance. If a commonality between 2 items suggested that the items were representative of the same concept, a linkage was identified and coded at the appropriate linkage level. Levels of relationship between 2 items were defined as direct links (DL), indirect links (IL), and/or potential links (PL) (Table 2). In some cases, no linkages were found, and in others 2 types of linkages were found in a single comparison (eg, both a direct link and an indirect link). The strongest association is reported.
The findings of the PHAB/PHP crosswalk were presented at a June 2012 PHAB-convened “think tank” of thought leaders from state and local public health departments, academic institutions, national partner organizations, multiple units from across CDC, and PHAB. Think tank attendees provided feedback to the PHAB board regarding the crosswalk's connections between accreditation and preparedness, discussed the feasibility and utility of this type of crosswalk to health departments preparing for the voluntary accreditation process, and identified potential future opportunities for aligning both sets of standards.
The review of PHAB Standards and PHP Capabilities identified 32 PHAB Standards and 62 PHP Functions, which defined the matrix of linkages that demonstrated the depth and breadth of intersection between the 2 programs. Based on the crosswalk methodology developed for this analysis, direct, indirect, and potential linkages were identified between 11 of 12 PHAB Domains and 13 of 15 Capabilities. Public Health Accreditation Board Domain 12 (Governance) is the only domain not linked to any PHP Capabilities. Public Health Accreditation Board Domains 6 (Enforcement of Public Health Laws), 7 (Access to Care), 8 (Workforce Development), and 11 (Health Department Administration) contained potential linkages, which may present future opportunities for alignment. Public health emergency preparedness Capabilities 5 (Fatality Management) and 14 (Responder Safety and Health) were not found to have links to any PHAB Domains.
In total, 101 linkages were found among the 94 Standards and Functions. Linkages ranged from 0 to 28 (μ = 2) per standard/function, including 26 direct linkages, 25 indirect linkages, and 50 potential linkages. Public Health Accreditation Board Standards 5.4 (Emergency Preparedness) and 8.2 (Workforce Development) were found to have the greatest number of linkages, followed by PHAB Standards 3.2 (Community Outreach and Education) and 2.1 (Surveillance and Response). Direct links were most frequently identified (n = 5) between the PHP Capabilities and PHAB Standard 2.1, followed by PHAB Standards and PHP Capability 1 (Community Preparedness) and Function 2 (n = 4). In cases in which PHP tasks or resource elements were linked to PHAB Measures (and vice versa), as subcomponents, these linkages were attributed to the count of their corresponding PHP Function and PHAB Standard, respectively.
To help illustrate the results of the crosswalk, alignment between the 2 programs was depicted through a network graph to transform the results into a visual depiction of the linkages between PHP Capabilities and PHAB Standards (Figure 1). In Figure 1, the points represent individual items that are connected by lines, indicating linkages and alignment, which are arranged on the basis of a standard network graph-drawing algorithm.14 This network figure was created using the sna package within the computing environment of R v.188.8.131.52,16 The Figure illustrates the crosswalk, depicting the various types of linkages and the overall alignment between the PHP Capabilities/Functions and PHAB Domains/Standards. To differentiate the programs, PHP Capabilities are represented by circles (•) and labeled by the associated Capability and Function, using the notation Cx.Fy (Capability X: Function Y). Public Health Accreditation Board Domains and Standards are represented by triangles (▸) and labeled by similar notation format, Da.Sb (Domain A: Standard B). In the figure, the linkages between the items are depicted by the different lines representing the type of linkage (ie, direct, indirect, potential), and the size of the point varies according to the total number of linkages to that item (ie, larger size, greater number of linkages).
With the intent of exploring where alignment exists, the PHAB/PHP crosswalk provided an opportunity to leverage linkages between PHP activities and requirements for national voluntary public health accreditation. The PHAB/PHP crosswalk also provided an opportunity to examine the extent to which these 2 programs support the Institute of Medicine's call that an accreditation program can be a performance monitoring and accountability system for agency preparedness.17
The noted synergies may also facilitate health departments' ability to identify activities and documentation that can serve both preparedness and accreditation accountability requirements. Examples of activities that could meet both sets of requirements include emergency preparedness training (multiple PHP Capabilities require specific emergency preparedness training such as ICS 100 and NIMS 700, whereas PHAB Domain 8 requires an agency workforce development plan that may include ICS 100 and NIMS 700) and maintaining the physical equipment infrastructure of the health department to support emergency response activities (PHP Capability 3 and PHAB Domains 2 and 11).
The PHAB/PHP crosswalk process identified specificity differences in the 2 programs. The PHAB Standards and documentation requirements were found to be more specific on the topic of health surveillance and environmental health, emergency communications with health department and staff, and partnerships related to health coalitions and nonemergency partner activities. Public health emergency preparedness Functions were found to be more specific regarding the content of emergency operations plans, continuity of operations and risk communications plans, workforce development training, and the roles/responsibilities of health departments and partners in an emergency. There were also subtle differences found in the language used by the PHP Capabilities and PHAB Standards for related concepts. For example, PHP uses the term “functional needs of at-risk individuals” whereas PHAB uses terms such as “populations who experience barriers to care” and “target populations.” Finally, the 2 documents varied in their approach to preparedness activities; the PHP Capabilities refer to preparedness, response, demobilization, and recovery while the PHAB Standards refer to preparedness and response.
The link between preparedness and accreditation offers opportunities to explore performance among accredited and nonaccredited health departments. The University of North Carolina at Chapel Hill North Carolina Preparedness and Emergency Response Research Center has been examining the extent to which health departments accredited through the North Carolina Local Health Department Accreditation program perform on preparedness measures compared with nonaccredited health departments. One of these early studies compared performance on preparedness measures among accredited and nonaccredited health departments following the H1N1 epidemic and revealed that accredited agencies on average performed more response activities and initiated these activities faster than nonaccredited agencies.18
It is important to recognize the limitations of the crosswalk process and its interpretation. First, the analysis conducted during the crosswalk process erred on the side of being very detailed but cannot absolutely represent all existing and potential relationships. Second, the PHAB/PHP crosswalk has not been validated or vetted outside of the PHAB think tank. Third, if the crosswalk were to be used as a standalone reference document, it would require implementation and application in a manner that is unique to each health department. Fourth, as noted previously, differences were noted in the level of specificity required in each of the documents, as well as differences in language that may have prohibited linkage in some cases or reduced the strength of the linkage. The resultant crosswalk is intended as a working document with the potential to be used as a tool indicating where the 2 instruments reference the same construct or concept.
PHP Capabilities and PHAB Standards both represent cross-cutting expectations of health departments; this study demonstrated a methodology for connecting common concepts. Crosswalk efforts such as this one, as well as current PHAB-supported think tanks, help to seek out new opportunities for more direct linkages between PHAB Standards and categorical public health programs. The crosswalk findings demonstrate that a one-to-one relationship is not needed for an association that can be leveraged to support improved public health accountability and public health value.
1. Centers for Disease Control and Prevention. National public health performance standards program. http://www.cdc.gov/nphpsp
. Published 2007. Updated 2012. Accessed February 8, 2013.
3. Beitsch LM, Mays G, Corso L, Chang C, Brewer R. States gathering momentum: promising strategies for accreditation and assessment activities in multistate learning collaborative applicant States. J Public Health Manag Pract. 2007;13(4):364–373.
4. Final Recommendations for a Voluntary National Accreditation Program for State and Local Public Health Departments. Exploring Accreditation Project Report. Washington, DC: Exploring Accreditation; 2006.
6. Centers for Disease Control and Prevention. Investigation of bioterrorism-related anthrax. MMWR Morb Mortal Wkly Rep. 2001;50(45):1008–1010.
7. Centers for Disease Control and Prevention. Funding and guidance for state and local health departments. Office of Public Health Preparedness and Response. http://www.cdc.gov/phpr/coopagreement.htm
. Updated 2012. Accessed February 8, 2013.
8. Centers for Disease Control and Prevention. Public health emergency preparedness capabilities. Office of Public Health Preparedness and Response. http://www.cdc.gov/phpr/capabilities/index.htm
. Published 2011. Accessed February 8, 2013.
9. Public Health Functions Steering Committee. Public Health in America Statement. Washington, DC: Department of Health and Human Services; 1994.
14. Fruchterman TMJ, Reingold EM. Graph drawing by force-directed placement. Softw Pract Exp. 1991;21(11):1129–1164.
15. Butts CT. Social network analysis with sna. J Stat Softw. 2008;24(6):1–51.
16. R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing. ISBN 3-900051-07-0. http://www.R-project.org/
. Accessed 2011.
17. Institute of Medicine. Research Priorities in Emergency Preparedness and Response for Public Health Systems: A Letter Report. Washington, DC: The National Academies Press; 2008.
18. Mays G, Davis MV, Wood BW, Marti C, Wayne J, Bellamy J. Variation in local public health response to the 2009 H1N1 outbreak: comparative analyses from North Carolina. Paper presented at: American Public Health Association 2009 Annual Meeting; November 7-11, 2009; Philadelphia, PA.