Koo, Denise MD, MPH; Miner, Kathleen R. PhD, MPH, MCHES; Tilson, Hugh H. MD, DrPH; Halverson, Paul K. DrPH, FACHE
Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Koo); Rollins School of Public Health, Emory University, Atlanta, Georgia (Dr Miner); UNC Gillings School of Global Public Health, Chapel Hill, North Carolina (Dr Tilson); and Indiana University Richard M. Fairbanks School of Public Health, Indianapolis (Dr Halverson).
Correspondence: Denise Koo, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, Mailstop E-92, Atlanta, GA 30333 (firstname.lastname@example.org).
Drs Tilson and Halverson are on the board of directors for the Public Health Accreditation Board.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 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.
A capable workforce is foundational to the success of any enterprise, and public health is no exception. The Public Health Accreditation Board (PHAB) acknowledged this by including standards related to workforce development as part of the requirements for public health department accreditation. In defining such standards, PHAB faced the difficult challenge of finding the right balance between foundational and aspirational expectations. We commend PHAB for its effort in developing standards and measures that underscore the crucial role of workforce in at least 2 domains, 8 (Maintain a competent workforce) and 11 (Maintain administrative and management capacity); the latter includes measures related to human resources processes and procedures.1 Although PHAB's workforce-related domains acknowledge that a commitment to its workforce is necessary for a public health department to function, the standards and measures in version 1.0 do not yet fully address the complex activities of public health departments; there are opportunities to enhance these topics with upcoming revisions of the PHAB standards and measures. Such revisions could include placing workforce development within the context of the public health department's strategic plan or priorities, including how future needs will be addressed, how workforce development efforts will be evaluated, and how those efforts support the department's priorities. More explicit cross-references, not only between Domains 8 and 11 but also among the other domains, can weave the workforce elements into the accreditation standards, thus strengthening them and health department function overall.
In constructing a coherent approach to the accreditation standards and measures, PHAB aligned the first 10 domains with the well-recognized framework of the 10 Essential Public Health Services.2 In addition, PHAB developed metrics for 2 other domains, one each for rigorous management and accountable governance. Each of the 10 essential services requires trained, competent, integrated professional and support staff in adequate numbers; thus, one of the services is workforce, which translates to PHAB's Domain 8. In its supporting descriptive materials, PHAB describes this domain as focusing on the need for a trained and competent workforce. Two standards are included in the domain, Standard 8.1, related to developing sufficient numbers of qualified workers, and Standard 8.2, which deals with assessing staff competencies and addressing gaps through training and development.1
For each standard, PHAB developed a series of measures to use as evidence of attainment of said standard. PHAB considered the need for validity (and opportunities for further validation) of the measure, as well as whether the requirements were reasonable (ie, can a health department reasonably be required to reach such a level of activity and can objective documentation be made available?). These considerations governed the choice of measures. Standard 8.1 outlines an expectation that health departments work with schools or programs to develop the future public health workforce. For Standard 8.2, agencies must document that they “maintain, implement and assess the health department workforce development plan that addresses the training needs of the staff and the development of core competencies” (8.2.1) and “provide leadership and management development activities” (8.2.2).1 Furthermore, states are required to provide consultation or to assist their colleagues in tribal and local health departments in workforce development, training, and continuing education (8.2.3S).1 To meet these standards, agencies must provide evidence of the partnerships, curricula, development plans, participation by staff in courses, and, for states, provision of the envisioned technical assistance.1
Complementary to and supportive of Domain 8, management of departments is addressed in Domain 11. Standard 11.1 specifies the need for an operational infrastructure. Within this, Measure 11.1.4 requires that the health department itself “maintain a human resources system,” and Measure 11.1.5 specifies the need to implement and adhere to the policies and procedures of such a system.1 Required documentation of such a system includes policies and procedures, labor agreements, and staff access to human resources policies and procedures as well as records documenting the recruitment of qualified persons reflective of the population served, retention activities, position descriptions, processes to verify staff qualifications, and evidence that qualifications have been checked.
With 141 health departments now engaged in PHAB registration and review and 14 health departments accredited as of May 30, 2013, the standards and measures have received positive reviews. PHAB has heard from training officers, human resources officials, accreditation coordinators, and site reviewers that the standards clarify expectations and help health departments improve and document their performance (H.H.T., Public Health Accreditation Board, written communication, May 2013). As data become available through accreditation visits, PHAB expects to learn more about the power of these measures to differentiate highly active or high-performing departments from those requiring more effort to meet PHAB standards and whether further measures are needed.
Of course, training partnerships, the health department's workforce development plan, and basic administrative measures only skim the surface of challenges regarding public health practice and ensuring the right workforce for the right jobs. Certain elements are absent from the standards, in large part because of a lack of evidence sufficient to support the measures. For example, the standards lack measures for what attributes of a partnership (eg, with a training institution) render it effective. Other omitted measures include the definition of adequate staffing (eg, the right numbers and mix of professional and support staff to accomplish the health department's mission) and the needed staff credentials, qualifications, or competencies. Although clearly essential to fulfilling the requirement for an adequately staffed health department, these dimensions lack the evidence base required for a PHAB measure. Information learned through early accreditation efforts, together with data from the burgeoning field of public health services research, will in turn contribute to stronger, evidence-based PHAB standards and measures, thus leading to strengthening of public health practice in the future.
In Standard 8.1, PHAB demonstrates leadership in a key area—that of linkages between academia and public health practice—and mirrors the expectation of CEPH (Council on Education for Public Health; www.ceph.org), which accredits nearly 201 schools and programs in public health.3,4 Accredited academic institutions are required to involve their students in population-based practical experiences. CEPH accreditation criteria also require the academy to attend to the professional development needs of the public health workforce. Through their students' experiences and the requirement to provide the public health workforce with courses that are responsive to workforce assessments, faculty gain insights into the needs of public health practice. However, the tenure and promotion policies within most universities do not reward such expertise, emphasizing extramural research funding over workforce activities. Thus, the needs of the public health workplace may not be adequately represented in the local academy. For example, public health informatics, systems integration, public health law, translational science, knowledge management, and interprofessional education are just a few examples of professional content areas that are frequently underrepresented in the public health academies. However, together PHAB's and CEPH's accreditation standards can reinforce the interaction and mutual education of practice and academia, to their anticipated mutual benefit.
PHAB rightly ensured that workforce is included as part of public health department accreditation standards version 1.0, notably in Domains 8 and 11.1 As outlined in the US Government Accountability Office (formerly US General Accounting Office) human capital report,5 an effective governmental agency has a system for developing its workforce, regardless of whether an accrediting system per se exists. Thus, PHAB-accredited public health departments will be expected to be workforce development models. Ideally, such a department's workforce strategy will include (1) clearly identified needs (along with the type of worker and competencies that meet each need); (2) workforce development goals, including recruitment, training or retraining, retention, and succession planning; (3) plans for addressing any identified workforce development gaps; (4) monitoring of the composition of the department's workforce and evaluation of how well employees are performing; (5) an assessment of progress toward achieving the department's stated workforce development goals; and (6) demonstration of how the workers' output contributes to its mission and priorities. Both the health department's strategic plan and its accompanying workforce strategy should identify future practice needs, the department's direction within its current environment, and how its workforce strategies will address those needs.
We understand that the next version of the PHAB workforce standards will likely have a stronger context for a health department's workforce development activities. That is, to what end are all such activities directed? What is the vision or mission of the department and how is it changing? (For example, given the need for closer alignment with the health care system or the imperative to integrate electronic records and data from multiple sources, how will public health practice change?) What are the main priorities for the department's future functioning? What are the workforce implications of these priorities? How did the health department define what disciplines and competencies are needed? How did they select the leadership development targets? What is the impact (ie, do all their efforts make a difference in department performance and function)? The Government Accountability Office report specifies the vital role of workforce development in support of an individual department's needs and priorities.5 Such an emphasis, not only on conducting workforce development in the right way but also on selecting the right workforce development activities and targets and evaluating their impact, will strengthen these workforce standards.
Effective workforce strategies emphasizing development, retention, and continuous improvement of the workforce are essential to the current and future success of public health both within a department and in the overall public health system; this is rarely disputed. By including standards related to workforce in its initial effort, PHAB set an important precedent and laid a foundation for accreditation. Through its standards revision process, PHAB has an opportunity to strengthen the expectation that workforce activities explicitly support health department strategies and mission. Future updates to the PHAB standards and measures also should reflect the essential role of a competent, learning workforce by providing deliberate linkages between the workforce standards and all the other PHAB standards, for example, by asking—in the guidance for other standards—whether workforce needs have been considered in plans or activities related to such areas. Moving forward, PHAB's expectation of academic-practice linkages provides an important vehicle and impetus for continuing to build the bridge between the academic and practice communities and encourage up-to-date practice and practical, relevant education. The gaps in the evidence base for certain workforce-related areas also reveal a future research agenda. Such a research agenda, plus the rapid adoption of alternative, technology-driven methods for delivering competency-based public health education and training, provides natural opportunities for enhanced partnership between academia and practice. Public health departments must make an explicit commitment to workforce development through specific partnerships and purposeful investment in preparing their workforces for both today's and the future's challenges. Clearly, a deliberate, strategic approach to workforce policy is both needed and vital for meeting imminent challenges. PHAB's continued engagement and ongoing strengthening of standards in this arena will make a valued contribution.
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