Cabarrus Health Alliance (see Table) started the journey toward accreditation in 2004 when it first volunteered to be 1 of 6 pilot counties in North Carolina to pursue state accreditation. Since receiving NC (North Carolina) accreditation in 2004, it has been an ongoing journey that included being reaccredited by NC in 2008, participating in the beta test for the Public Health Accreditation Board (PHAB) in 2010, and culminating in being fully accredited by PHAB in February 2013.
The focus of this case report is to describe the history of the accreditation efforts of the Cabarrus Health Alliance in pursuing both State and National accreditation for public health departments.
To ensure that all the local health departments were performing at a prescribed, basic level of quality in the 3 core functions of assessment, assurance, and policy development and the 10 essential services as detailed in the National Public Health Performance Standards Program, the North Carolina Division of Public Health and the North Carolina Association of Local Health Directors developed a mandatory, standards-based system for accrediting local public health departments in 2002. Once the standards had been developed, there was a request for counties to test the standards and the accreditation process. The Cabarrus Health Alliance volunteered to be 1 of the 6 counties in the pilot test in January 2004. The Cabarrus Health Alliance was awarded NC accreditation in 2004 and successfully completed the NC accreditation process again in 2008.
Accreditation for health departments expanded to the national level when PHAB was established in 2007 and developed their own standards and processes. When PHAB was ready to pilot the standards, tools, and process in 2010, they (in conjunction with NACCHO [National Association of County and City Health Officials] and ASTHO [Association of State and Territorial Health Officials]) recruited health departments to participate in the beta test. Cabarrus Health Alliance was striving to become a model health department and felt that national accreditation would be a logical step in that direction. Cabarrus Health Alliance was 1 of 19 local health departments along with 8 State and 3 Tribal health departments chosen to participate. Funding from NACCHO helped pay for some of the staff time spent on accreditation efforts as well as provided valuable training in quality improvement. Participation in the beta test provided an excellent opportunity for the Cabarrus Health Alliance to assess its ability to meet the national standards and to provide feedback regarding the standards and the entire accreditation process. The successful completion of the beta test provided the impetus for the Cabarrus Health Alliance to pursue national accreditation.
Cabarrus Health Alliance's application for accreditation was accepted by PHAB in September 2011 in the first cohort of applicants. Our documentation submission was completed on April 4, 2012, when the big red “Submit” button was pushed. Our site visit was conducted on October 17-18, 2012, and we received our site visit report January 2, 2013. All of the hard work and waiting paid off when we received our notification on February 28, 2013, that the Cabarrus Health Alliance had been accredited by PHAB!
The Cabarrus Health Alliance has gained invaluable experience and has made significant changes as a result of its participation in the NC Accreditation Program for Local Health Departments, the beta test for PHAB, and then the actual accreditation process for PHAB. In each case, the Cabarrus Health Alliance was required to step back and examine its goals, objectives, programs, and processes with a different perspective. While each of the 3 processes had somewhat different standards and measures, the overall goal was the same—to ensure that the 3 core functions and the 10 essential services were being met. The process of preparing for accreditation allowed the Cabarrus Health Alliance staff members to look at our organization as a whole rather than focusing on their specific area. It did allow, in fact required, more interaction between departments within Cabarrus Health Alliance, thereby diminishing the “silo” effect. As we searched for the best evidence to document various measures, it was enlightening to discover the diverse aspects of our agency and gain more appreciation for the different types of services and functions of our health department. In meeting with our community partners as part of the site visit, it was very rewarding to hear how they value the Cabarrus Health Alliance and the work that it does.
The preparation for accreditation involved a paradigm shift in how we thought about the entire process. Previously, we had considered each accreditation process an endpoint. With the encouragement from PHAB to think of it as a quality improvement process, we began to regard accreditation as a starting point to apply continuous quality improvement strategies to areas in need of improvement. The site visit report provided opportunities for improvement, even for those measures that had been fully demonstrated, thus illustrating the fact that there is always room for improvement.
Achieving accreditation from PHAB was very rewarding to our staff. It was a great morale booster to know that all of their efforts to improve the health of our community had been recognized by an accrediting agency, especially one on a national level.
Finding time to work on the accreditation process was one of the most challenging aspects of the endeavor. It was difficult for staff to add another major activity to their already busy schedules. While we were preparing for accreditation, Cabarrus Health Alliance was also in the midst of preparing to move into a new building so there were many competing priorities. Going through each standard and measure was time-consuming and tedious but necessary to determine what would best demonstrate conformity. Meeting with different groups of staff members and providing worksheets with assigned responsibilities and required documents helped to minimize this problem. The fact that we had an experienced accreditation coordinator whose main responsibility was accreditation also provided relief in this area.
Another obstacle alluded to earlier was the fact that many of the areas in our agency work in “silos.” Because Cabarrus Health Alliance is a fairly large organization (∼217 employees) with many different types of activities and programs, it is easy for staff working in a specific program to work within the confines of their own program without a lot of interaction with the rest of the agency. The accreditation process did help break this down a bit because we were looking at all aspects of our agency and brought representatives of those programs together to share in the determination of the best evidence for a specific measure.
Advice for Other Health Departments
The following is a list of “lessons learned” or things we did that facilitated our process and may help others:
- Start early
- Read the standards and measures very carefully! Ask your Accreditation Specialist from PHAB if you do not understand something
- Participate in the Accreditation Coordinators Learning Community sponsored by NACCHO or the ASTHO equivalent
- Borrow from and share with other health departments
- Involve as many staff as possible
- Have a mock site review
- Upload your documents into e-PHAB as you complete them (Don't wait until the last minute to upload everything—it takes longer than you think!)
- Meet regularly to keep staff updated and maintain deadlines
- Make sure your accreditation coordinator has Adobe Professional (or the equivalent software) to edit pdf files
- Use the narrative boxes on e-PHAB to explain to the site visit reviewers how the documents presented relate to each other and how they demonstrate conformity with that specific measure
- Build a robust quality improvement (QI) program that addresses all programs; dedicate resources to QI including at least part of a staff position; and train all staff in QI methodologies
- Build accountability for accreditation into job descriptions and evaluations as appropriate
- Celebrate the completion of each major milestone—final submission of documents (an excellent time to schedule a vacation for the accreditation coordinator), site visit, and finally accreditation!
Note: Learn more about the NC Accreditation Program for Local Health Departments at the following Web site: http://nciph.sph.unc.edu/accred/.