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A Self-Assessment Process for Accreditation Preparedness: A Practical Example for Local Health Departments

Erwin, Paul Campbell MD, DrPHfor the Knox County (Tennessee) Work Group on Accreditation

Journal of Public Health Management and Practice: November-December 2009 - Volume 15 - Issue 6 - p 503–508
doi: 10.1097/PHH.0b013e3181aa282a

Introduction Accreditation of local health departments (LHDs) is already a reality in many states, and with the establishment of the Public Health Accreditation Board, a national voluntary accreditation program will be forthcoming. To help prepare LHDs for accreditation, the National Association of County and City Health Officials has developed a self-assessment instrument on the basis of the Operational Definition of a Functioning Local Health Department.

Methods The article is a case study, describing the inputs, processes, and outputs of using the self-assessment in an LHD in a manner that can be applicable to other settings.

Results A seven-member work group conducted the self-assessment over an 11-week period, providing a total of 184 person-hours, with an equivalent cost of $8 565. The self-assessment was scored on the basis of indicators of performance of Essential Services and Standards. There were significant correlations between the scores on Essential Services and Standards with the scores on the documentary evidence that the indicators were being met (r = 0.7545, P = .0117; r = .7264, P < .0001, respectively).

Conclusion Overall, the workgroup found the self-assessment tool to be useful, particularly for emphasizing the importance of documentation, and the process of conducting the self-assessment valuable for accreditation preparedness and for improving current internal communications and work practices.

This study describes the inputs, processes, and outputs of using a self-assessment tool in a local health department in that can be applicable to other settings.

Paul Campbell Erwin, MD, DrPH, is Professor and Director, University of Tennessee Center for Public Health.

Corresponding Author: Paul Campbell Erwin, MD, DrPH, Center for Public Health, University of Tennessee, 302 Bailey Education Complex, Knoxville, TN 379996 (

The author thanks Mark Jones, Director of the Knox County (TN) Health Department, for his support; Austin Stephenson, Diane Krause, and Debra Butenko for data compilation and management; and Micky Roberts for review and comments on an earlier draft of this manuscript.

*This article was prepared on behalf of the Knox County (Tennessee) Work Group on Accreditation by Gary Acuff, BS; Kathleen C. Brown, PhD, MPH, RN, CHES; Scott Bryan, BS, CEHS; Martha Buchanan, MD; Cheryl Griggs, MS, RN; Mark Miller, MS; and Stephanie Welch, MS, MPH.

© 2009 Lippincott Williams & Wilkins, Inc.