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Journal of Public Health Management & Practice:
doi: 10.1097/PHH.0b013e31829a2cdd
Accreditation Research: Commentary

Embedding Quality Improvement Into Accreditation: Evolving From Theory to Practice

Beitsch, Leslie M. MD, JD; Riley, William PhD; Bender, Kaye PhD, RN, FAAN

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The Florida State University College of Medicine, Tallahassee (Dr Beitsch); School for the Science of Health Care Delivery, Arizona State University College of Health Solutions, Phoenix (Dr Riley); and Public Health Accreditation Board, Alexandria, Virginia (Dr Bender).

Correspondence: Leslie M. Beitsch, MD, JD, The Florida State University College of Medicine, Tallahassee, 1115 W Call St, Tallahassee, FL 32306 ( les.beitsch@med.fsu.edu).

All authors are on the Board of Directors for the Public Health Accreditation Board.

The information contained in this article reflects the opinions of the authors and does not represent official PHAB board policy.

The authors declare no conflicts of interest.

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Accreditation and Quality Improvement Linkage

Quality improvement (QI) is one of the cornerstones of the Public Health Accreditation Board (PHAB) program. From inception, PHAB is predicated upon a foundation of QI to drive performance improvement. The primary goal of accreditation is to strengthen the level of health department performance in order to facilitate the pathway toward improved community health outcomes, the Holy Grail of public health.1,2 Several articles in this dedicated accreditation issue focus on QI in accreditation. The purpose of this commentary is to describe the central strategies PHAB has used to integrate QI into the accreditation program and to portray the evolutionary process of transitioning from theory into everyday public health practice. In addition, the leadership of PHAB has recognized that it is incumbent upon PHAB itself to model QI as an organizational commitment, reflecting the intent of Domain 9 (Evaluate and Continuously Improve Health Department Processes, Programs, and Interventions) standards.3 That effort is also highlighted.

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Quality Improvement With PHAB Standards as Benchmarks

Before PHAB could become operational, a consensus set of health department standards had to be developed.3 A workgroup with broad public health sector representation crafted draft standards heavily influenced by previous efforts, including the National Public Health Performance Standards, existing state accreditation programs, and the Operational Definition of a Functioning Local Health Department.4–7 The resulting PHAB standards are nonprogrammatic, based upon the Ten Essential Public Health Services framework,8 and encompass capacity and performance across the entire health department. Feedback solicited through public comment and vetting, as well as alpha and beta tests, resulted in further refinement prior to the release of the first version of state, local, and tribal health department standards in July 2011. Prior to this point, no standards had been uniformly accepted as reflecting the content of public health practice nationally. With their release, the consensus standards became the method upon which to benchmark, a comparison indicator, for assessment of health department performance nationally.

Benchmarking is a tested and proven QI tool used by industry that allows for immediate comparison among similar entities. The gap between the industry leader (or the established standard) and the measuring organization reflects the QI opportunity for improvement. The similar public health application was introduced later, but by referencing PHAB standards and measures (with guidance specifying their meaning for each public health setting),9 every health department can be informed about what is needed to conform with national standards. This provides the health department a roadmap for its QI journey whether or not it plans to seek PHAB accreditation. For PHAB accreditation program applicants, a comprehensive self-assessment is included in the accreditation process.

Following their site visits, candidates for PHAB accreditation will receive a report from the Accreditation Committee summarizing the impressions of the evidence received, measure by measure, with comment on each. This feedback underscores the QI opportunities for the health department going forward, allowing it to focus prioritized attention where it can be most impactful. The final site visit report prepared by a team of public health care practitioners also highlights the health department's key areas for improvement.

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Domain 9

Although QI opportunities present themselves within each standard and measure, evaluation and QI standards are the key foci of Domain 9. Standard 9.1 details the incorporation of a performance management system to enable the health department to monitor and improve its performance enterprise-wide, whereas Standard 9.2 relates to the deployment of QI processes and tools to improve individual programs and practices. Considered together, these 2 standards establish a high bar for expected QI and evaluation activity within every accredited health department, constituting a continuous QI system. This is a radical departure from the predominantly informal status of QI implementation frequently reported in the literature as the public health norm.10–14 Furthermore, it sets the stage for development of a quality culture within the health department, an emphasis set forth in the Roadmap to Quality.15–17

PHAB leadership understands that as currently designed, Domain 9 standards represent stretch goals for many health departments. The evolution that accreditation exemplifies intends precisely that dramatic transformation—catalyzing the conversion of QI from theory into fundamental bedrock of everyday public health practice. Framed less provocatively, the standards and measures of Domain 9 provide a descriptive pathway for health departments striving to become high-performance organizations. Moreover, for the past several years, resources provided by national public health organizations, government, and philanthropy have been dedicated to accomplishing this desired outcome.18–20

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Maintaining Accreditation: Annual QI Reporting

Successfully accredited health departments will report annually on the progress of their QI activities: triangulating and reinforcing the efforts behind ongoing benchmarking measured against PHAB standards; addressing feedback from the Accreditation Committee; and meeting the stretch guidelines undergirding Domain 9. The PHAB Evaluation and QI Committee will collaborate with the Accreditation Committee to define the content and parameters of the annual report. Accredited health departments will also participate as members of a learning community of their peers, dedicated to QI and strengthening health department performance through the mutual exchange of ideas, experience, and expertise.

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PHAB Organizational QI

With the guidance of the CEO, board of directors, and the Evaluation and QI Committee, PHAB has embarked on an ambitious organizational QI process. PHAB's current strategic map (Figure) is heavily QI driven, with one key goal area dedicated to “advancing QI in public health” and another built upon a track of work: “continuously improve standards and process.” Furthermore, continuous QI and evaluation are foundational. The PHAB operational plan implementing the strategic map is one cogent example, with specific QI activities and timelines. In addition, both internal and external evaluations, also under the auspices of the Evaluation and QI Committee, are underway in accordance with PHAB's operational logic model.21

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Transforming Public Health Practice

The multilayered reinforcing linkages between QI and accreditation are a synergistic design that integrates QI into accreditation at every level. If the blueprint is followed faithfully, QI becomes more than the intended foundation of accreditation and the default option for all our public health programs and processes. When we achieve that endpoint, with the purposeful collaboration of our public health systems partners, improved community health outcomes are sure to follow.

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REFERENCES

1. Public Health Accreditation Board. http://www.phaboard.org/. Accessed April 18, 2009.

2. Bender K, Halverson PK. Quality improvement and accreditation: what might it look like?. J Public Health Manag Pract. 2010; 16:79–82.

3. Public Health Accreditation Board. Public Health Accreditation Board Standards and Measures, Version 1. Alexandria, VA: Public Health Accreditation Board; 2011; .

4. Centers for Disease Control and Prevention. National Public Health Performance Standards Program. http://www.cdc.gov/od/ocphp/nphpsp/. Accessed April 16, 2010.

5. 2011 Public Health Exemplary Practice. Olympia, WA: Washington State Department of Health; 2010; . Contract No. DOH Pub 822-019 10/11.

6. National Association of County & City Health Officials. Operational definition. http://www.naccho.org/topics/infrastructure/accreditation/OpDef.cfm. Published 2005; . Accessed August 10, 2009.

7. North Carolina Local Health Department Accreditation. Materials for Health Departments. http://nciph.sph.unc.edu/accred/health_depts/materials/index.htm. Published September 2012; . Accessed April 29, 2012.

8. Public Health Functions Steering Committee. Public Health in America. Washington, DC: US Department of Health and Human Services; 1994;. http://www.health.gov/phfunctions. Accessed February 12, 2013.

9. Public Health Accreditation Board. Guide to National Public Health Department Accreditation. Alexandria, VA: Public Health Accreditation Board; 2011; .

10. Beitsch L, Leep C, Shah G, Brooks R, Pestronk R. Quality improvement in local health departments: results of the 2008 NACCHO Survey. J Public Health Manag Pract. 2010; 16:49–54.

11. Leep C, Beitsch L, Gorenflo G, Solomon J, Brooks R. Quality improvement in local health departments: progress, pitfalls, and potential. J Public Health Manag Pract. 2009; 15:494–502.

12. Madamala K, Sellers K, Beitsch LM, Pearsol J, Jarris P. Quality improvement and accreditation readiness in state public health agencies. J Public Health Manag Pract. 2012; 18:9–18.

13. Joly BM, Booth M, Shaler G, Mittal P. Assessing quality improvement in local health departments: results from the multi-state learning collaborative. J Public Health Manag Pract. 2012; 18:79–86.

14. Joly BM, Booth M, Mittal P, Zhang Y. Using the QI maturity tool to classify agencies along a continuum. Front Public Health Serv Syst Res. 2013; 2:(3): Article 2.

15. National Association of County & City Health Officials. Roadmap to a culture of quality improvement. http://www.naccho.org/topics/infrastructure/accreditation/upload/QI-Roadmap-11-16-11.pdf. Published 2011; . Accessed February 20, 2013.

16. Randolph G, Stanley C, Rowe B, Massie S, Cornett A, Harrison L, et al. Lessons learned from building a culture and infrastructure for continuous quality improvement at Cabarrus Health Alliance. J Public Health Manag Pract. 2012; 18:55–62.

17. Morrow C, Nguyen Q, Shultz R, Murphy J, Mignano M. A local health department's journey to the summit: a case study of a decade of quality improvement. J Public Health Manag Pract. 2012; 18:63–69.

18. Beitsch LM, Thielen L, Mays G, et al. The multistate learning collaborative, states as laboratories: informing the national public health accreditation dialogue. J Public Health Manag Pract. 2006; 12:217–231.

19. Mays G, Beitsch LM, 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; 13:364–373.

20. Joly B, Booth M, Shaler G, Conway A. Quality improvement learning collaboratives in public health: findings from a multisite case study. J Public Health Manag Pract. 2012; 18:87–94.

21. Riley W, Lownik E, Scutchfield D, Mays G, Corso L, Beitsch L. Public Health Department Accreditation: setting the research agenda. Am J Prev Med. 2012; 42:263–271.

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