Through the North Carolina Local Health Department Accreditation program, North Carolina has carried out one of the nation's exemplary local health department accreditation programs over the last 5 years.1* Fifty of North Carolina's 85 health departments have been accredited, a process involving a self-assessment; a site visit from a multidisciplinary team of peers representing administration, nursing, environmental health, and governance; state public health nursing consultants who provide technical assistance to departments undertaking their self-assessments and readying for site visits; on-line training and conference calls; and adjudication by an independent board. We believe this program has been a means to improve public health practice in our state by ensuring that all citizens are served by a local health department with the capacity to fulfill the core functions and essential services of public health.
As of this writing, funding for the North Carolina Local Health Department Accreditation program is very much up in the air. Although the program is supported widely, the budget deficit is so dire that legislators are looking closely at every line item. Evaluation efforts have and will continue to analyze the measurable public health benefits of the program. However, it may be worthwhile, now more than ever, to acknowledge some of the work that has been done, some of the less quantifiable value gained, and lessons learned by this program. To this end, we asked several of our stakeholders, public health nurses and site visitors, legislators, local health directors, and others involved with the program, to give us a snapshot of what they see as the “benefits gained and lessons learned—both expected and unexpected” from the program so far. Presented here are some of their thoughts.
The Value of Standardization and Sharing
Every state and local health department has its unique challenges, but the common challenges are legion. Standardizing how we address those challenges that know no territorial boundaries goes a long way toward ensuring parity in public health practice quality throughout the state. Furthermore, it is clearly difficult to improve or even understand a process if that process has not been documented in a way that is understandable to a broad audience. Recruiting and hiring staff, maintaining personnel files, keeping track of continuing education requirements, developing policy, ensuring patient privacy—these are areas where “unique” is not necessarily better. Great advancement has been made in the standardization of policies, procedures, and benchmarks to ensure a basic level of capacity in all counties in North Carolina. The sharing of information, policies, procedures, and best practices has been done willingly and swiftly, between and among agencies, to the benefit of all.
Accreditation has promoted and expedited the sharing of best practices throughout the state via at least four avenues: (1) direct communication between local health departments; (2) state nursing consultants sharing their experience, wisdom, and expertise with agencies preparing for accreditation (after having helped other departments through the process successfully); (3) site visitors taking good ideas back to their own home counties; and (4) sharing model programs with broader audiences. At every turn, we have found “experts” among the seasoned health directors and other staff throughout our state, ready and willing to share the methods and systems that work for them. For example, in one county, the site visit team learned about a very well-developed and successful program for succession planning for all levels of leadership within the agency. Later that same year, we asked this health director to present the succession planning program at the annual meeting of the North Carolina Public Health Association. The session was filled to capacity with other local health directors, all of whom were grappling with the same issue in their respective settings.
Understanding + Respect = Morale
North Carolina's accreditation program is mandatory. It might be expected that more mandates would not necessarily raise morale among the already overworked public health workforce. However, we have had organizations line up—voluntarily—to take part in the process. How has a program such as this gained such support?
One way is by building a program from the ground up and infusing it with strong support from the state's Division of Public Health, from the North Carolina Institute for Public Health, the NC Association of Local Health Directors, and from state legislators eager to build accountability into our programs to improve the health of NC citizens. In turn, the health departments rose to the occasion, accepting accreditation as an essential part of their daily work and responsibility to the taxpayers.
Interestingly, just preparing for accreditation review has seemed to affect morale positively. Staff of local health departments preparing for the process mention that a major benefit they have realized, individually and collectively, was new knowledge of and appreciation for all the programs and services provided by their health department. Even in very small agencies, with long-term seasoned staff, we heard feedback such as “Before accreditation, I really didn't know what other programs did, aside from my own.” and “I feel like I know more about public health now.” Learning about what others did increased everyone's pride in what the entire organization and profession can accomplish. Within organizations, individuals found that they truly had not understood what their colleagues did day to day.
Two things happen when this type of information is shared: First, the one who is doing the work suddenly gets the message that what he or she does matters. Second, others who now understand all the work that is getting done have a greater respect not only for their colleagues but also for the organization as a whole. When this knowledge is shared between organizations, the respect for the whole profession grows and chances for greater collaboration between organizations. It is impossible to come out of a close analysis of the work going on in public health without gaining a sense of the tremendous amount of time, effort, resources, and caring given by each local public health department to protect the public's health.
Building a Network
Although there are common challenges across all health departments, North Carolina is still a state (and the United States is still a nation) of distinct places and individuals, histories, and outlooks. The North Carolina Local Health Department Accreditation program has gone a long way toward helping build bridges between these entities without losing sight of the importance of individuality. The program has strengthened the relationships among and between all components of the public health “system” in North Carolina: local and state agencies, boards of health, and academia.
At a most basic level, participating site visitors get the opportunity to spend time in some of the towns, cities, and counties of the state that they may in the past have only briefly passed through en route to “somewhere else.” Several of the site visitors claim to have gained a greater appreciation for the distinct qualities of each individual county with its communities and its sense of “place.” There is a saying in North Carolina that “if you've seen one health department, you've seen one health department!” Even with a mandatory accreditation program in place, and even if/when all local health departments are accredited and basic capacity for the provision of services is ensured in every county, that old saying will be true in its most positive sense: Each county agency will still be autonomous and uniquely suited for the community it serves.
Sometimes, in quality improvement programs, there is a real or perceived sense of “top-down” information sharing. State-level people, working with folks in academia, tell local practitioners how to do their jobs. Conversely, the NC program had its genesis from the grassroots through the NC Association of Local Health Directors. One of the effects of this genesis has been to instill in all participants an appreciation for what is being done at the local level, where the real work of public health takes place, and where “the rubber hits the road.” Also, emphatically, we have found that bigger is not always better. North Carolina is growing rapidly, but it is still largely a rural state. We have found that some of the smallest agencies in some of our state's most rural counties (and with very modest budgets) provide a high quality of service to their patient populations. In numerous cases, site visitors have seen examples of innovative programming, which could well serve as “best practices,” in small county health departments with the most limited financial resources. Such agencies have something to teach staff from other departments about offering personalized attention, understanding, and care to their clientele.
Up Close and Personal
The on-site visit is an integral part of the North Carolina Local Health Department Accreditation program. This is true not only because the site visitors gather important information but also because it makes the program a true collaboration of equals working together toward the clear goal of improving public health practice. Site visitors spend 3 days of intensive, demanding teamwork with each department they visit. They get a chance to make real connections with the staff of the department, clarifying and verifying the information in the self-assessments and related evidence.
When health departments prepare their documentation, it is with an insider's view—and information may not always be as clear or explanatory to the outside reader. The ability to have two-way communication is critical to making this program a quality improvement process and not merely an assessment process: The goal is not to punish a department that provides incomplete information but to understand in what this department is doing well, what it needs help with, and move this department forward toward full capacity to provide the essential services of public health.
We do not pretend here to present an evaluation of the North Carolina Local Health Department Accreditation program. Such evaluations can be found elsewhere.2,3 The observations presented here do not begin to measure the performance or process of this or any other accreditation or assessment program. Also, there are other aspects of North Carolina's efforts on behalf of the public health system that may contribute to its success. For example, the East Carolina University Department of Public Health has a contract with the NC Division of Public Health to orient boards of health to public health practice, including the accreditation process. Boards of health in North Carolina are made up of community members who may or may not be educated or experienced in public health, yet they play a key role holding the health department accountable to the community. Useful evaluations of the accreditation program will have to take into account the effects of other contributions such as this. What we present here are unscientific reflections by dedicated individuals involved deeply with this program (B. Alexander, G. Bond, B. Chavious, D. Williams, J. Nicholson, D. Plyler, W. Sandele, unpublished data). These individuals, and many more, have put forth enormous effort in this endeavor.