As public health leaders, we seldom encounter momentous opportunities for true and sustainable public health systems change. Ten years ago we were faced with such an opportunity following the avalanche of public health preparedness funding that occurred after the September 11, 2001, terrorist attacks. Once again, public health leaders face a true “moment of opportunity.” The current health care reform legislative discussion provides an unprecedented opportunity to visualize and shape the direction of the future of public health over the next decade.
With the recent enactment of the Patient Protection and Affordable Care Act (PL 111–148),1 public health officials are addressing the implementation of many new public health infrastructure and workforce provisions. These provisions have the long-term potential to significantly alter the shape and scope of public health capacity to improve the quality of life of Americans. In addition to dramatic changes to individual health care reimbursement mechanisms, the law creates the Prevention and Public Health Fund that has the potential to provide resources for prevention, wellness, and public health activities that could include workforce training initiatives, community transformation grant programs, and core infrastructure assistance for state, local, and tribal health departments.
As we in public health deal with the intense activity to implement these new programs, it is also imperative that we focus our leadership attention farther out on the event horizon and ask, “Where do we want to be in 10 years, and how do we use this moment of opportunity to help us get there?”
Now is the time for public health to look toward a vision of accreditation of all our US local, tribal, and state health departments by 2020. We should use this opportunity to establish practical strategies for allocating the necessary resources to ensure that all local, tribal, and state public health agencies that receive federal funding (directly or indirectly) will be fully accredited by 2020.
Accreditation of All Health Departments by 2020: The Challenge
A long overdue US public health goal has been gaining momentum for more than a decade: implementation of a universal and standardized public health agency accreditation program.2,3 Activities led by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention are moving toward the objective of having 60 percent of our US population being served by accredited health departments by the year 2015. The Public Health Accreditation Board, created in 2007, is currently beta testing the proposed accreditation standards, measures, and assessment process in 30 public health departments.4
Efforts to develop consensus and coordinate implementation around accreditation will require time and resources. Realistically, it may take until the end of this decade to achieve the ultimate goal of having all public health jurisdictions achieve accredited status. However, public health leaders and practitioners need to take seriously the vision of having all US health agencies accredited by 2020 and also carefully address the challenges remaining to achieve that success.
One major challenge in standing up a national accreditation program is that the economic downturn has severely constricted the availability of government and foundation funding available to support this multi-year initiative. For example, the cutting-edge accreditation efforts that were under way in North Carolina were put on hold in 2009 when the state's General Assembly cut FY 2009–2010 funding for this multi-partner initiative because of the state budget deficit.
Tight government funding cycles put extreme pressures on discretionary budget items. Experienced public health leaders are well aware that resources during lean years are concentrated on maintaining more politically visible categorical public health programs (eg, immunizations, AIDS, diabetes) and tend to drift away from less visible (but equally important) initiatives designed to maintain our eroding public health infrastructure (eg, training, leadership development, capacity building).
It is comforting that the 2010 health care reform legislation contains provisions that could help in sustaining and rebuilding our weakened public health infrastructure. On the other hand, history has shown that public health infrastructure funding streams, like those established after the terrorist attacks of 2001, are among the first to be redirected to politically sensitive and highly visible threats, such as during the National Smallpox Immunization Program of 2002–2004 or the pandemic flu responses of 2007–2010.
It is somewhat paradoxical that one of the greatest beneficiaries of universal health agency accreditation will be those same categorical programs that can easily outcompete public health infrastructure programs in the tough political infighting over tight budgets.
During this once-in-a-generation moment of national policy flexibility for redirecting public health resources, it is vital that we seize this opportunity to put into place realistic, long-term, politically sound mechanisms that preserve public health infrastructure resources, such as accreditation.
Accreditation Implementation Strategy: The “Stick” and the “Carrot” Only Go So Far
One of the complex accreditation issues being debated among public health leaders, academics, funders, and professional organizations involves financing mechanisms and incentives to support implementation. Discussions about various “carrot and stick” approaches to participation have been very sensitive, particularly because of the obvious need to build a broad consensus among public health leaders regarding participation in an accreditation program.5 In 2004, for example, Mays et al. reported that “the costs of accreditation programs need to be distributed and financed equitably to ensure they do not preclude participation by organizations that could benefit the most.”6
With respect to the “stick approach” to accreditation, there is the immediate analogy to the significant incentive for hospitals to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a route to eligibility for Medicare participation.6,7 An obvious accreditation parallel to this JCAHO approach would be a requirement that funders of public health programs would, at some point to be determined in the future, require health agencies to be accredited as a condition of eligibility for funding.
Discussions regarding such “stick approaches” remain sensitive during this delicate period in the development of a national accreditation agenda, and incentives need to be carefully thought out and discussed. For example, any accreditation eligibility requirement would need to be telegraphed transparently well in advance of any deadline in order for public health and political leaders in each jurisdiction to have the time to prepare for and meet such required accreditation criteria. Similarly, we can anticipate a ramping-up process prior to any eligibility deadline that will recognize the incremental steps leading to agency accreditation. It is possible that funders may establish interim criteria along the way, such as requiring recipients at some point to be actively enrolled in a recognized accreditation program designed to achieve certification before the final deadline.
“Carrot approaches” for providing incentives are also being carefully examined.7 For example, accredited state agencies would no longer have to document a long list of eligibility requirements each time they applied for a separate grant, contract, or cooperative agreement. Evidence of accreditation would dispense with duplicative paperwork and repeated loss of staff time in applying for multiple grants.
Regardless of the complex selection of various “carrot and stick” incentive arrangements that could ultimately be worked out, accreditation cannot become a reality without a small but dedicated source of funding over an extended period of time in order for individual health agencies to meet the challenges of becoming an accredited organization.
In the current economic recession, state and local agency officials are overwhelmed by increases in the demand for services while simultaneously laying off staff because of budget cuts. Initiating an accreditation process in this economic environment without a dependable and identifiable source of new funding is simply out of the question in many locations. It is unrealistic to expect the majority of political jurisdictions to consistently dedicate scarce hard-money appropriations to pay for health agency accreditation efforts, whose benefits are somewhere in the future.
Accreditation Opportunity: Set-Asides for Accreditation Within Categorical Public Health Funding Streams, Medicaid Reimbursement, and New Health Care Infrastructure Programs
A practical system needs to be developed now to pay for the otherwise “unfunded mandate” placed upon jurisdictions by an accreditation requirement for funding eligibility.
A reasonable and direct approach to this dilemma is for funders (both governmental and foundations) to earmark a small percentage of their categorical public health funding streams over the next decade to pay for a recipient agency's participation in an accreditation program. In addition to federal categorical grant programs, such “set-aside” arrangements should include a mechanism built within Medicaid reimbursement allowances for administrative costs relating to the accreditation activities of state, tribal, and local health agencies.
There are two obvious reasons why a small tap on existing and new public health funding streams makes sense.
First, national accreditation is in the enlightened self-interest of the funder of every categorical public health program. To have a credible and accredited health agency in place improves the efficiency of both the funding process and the effectiveness of the implementation of the program.
Second, it is a matter of simple equity that each donor and categorical program pay its fair share, through a small set-aside, for the benefit it ultimately receives by having a pool of qualified recipients that is produced by the successful implementation of the national accreditation process.
Beyond this “set-aside” approach to funding the real costs of accreditation and the quality improvement efforts that accreditation will require, we advocate that a portion of the new Prevention and Public Health Fund be dedicated to core capacity building in state and local public health agencies. Ideally, a new core capacity grant program could be designed to fund organizational capacity building with accreditation and quality improvement as centerpiece. Other core capacity needs include core workforce development, building legal capacity, information systems development, and public health systems and services research funding. Such a grant program was authorized a decade ago as part of the Frist-Kennedy Public Health Threats and Emergencies Act of 2000.8 Unfortunately, the provision of the Act to establish a core capacity grant program was never realized.
This Is the Time for Action
To achieve universal health agency accreditation in this decade, we need to use this historic moment in our national public health history and take immediate action to lay out the necessary steps.
National accreditation is a long overdue goal that both is within our grasp and makes good political sense. Given the cyclical nature of public health funding in a political environment, it is clear that a small but dependable source of funding for national accreditation is essential.
Public health leaders, funders, academics, and professional organizations are urged to seize the current moment and mutually demonstrate the vision and discipline to insist on small set-asides within all existing and new public health funding streams to pay for public health agency accreditation.
If the potential to achieve a system of public health agency accountability is to be realized in our working lifetime, a sustainable approach to financing the real work associated with accreditation is of vital importance. If financing is not made available, a decade of increasing momentum toward a national system to accredit all public health agencies will be lost.