For several years before the Public Health Accreditation Board (PHAB) launched the national voluntary public health accreditation process in 2011, tribes and American Indian/Alaska Native partner organizations took an active role in discussions about public health improvement. PHAB's ongoing collaboration with the Robert Wood Johnson Foundation, the Centers for Disease Control and Prevention (CDC), the National Indian Health Board (NIHB), and Red Star International (formerly Red Star Innovations) has been critical in supporting tribal public health accreditation. The work of these organizations, and the partnerships forged between them, laid the groundwork for a network of support for tribal health departments (THDs) interested in learning about the benefits of public health accreditation and the process of attaining accreditation.
PHAB chose 3 THDs among the 30 health departments that served as beta-test sites in 2009-2010. The beta-site review results provided feedback for honing the standards and measures developed for accreditation of tribal, state, and local health departments. To facilitate implementation of voluntary public health accreditation in Indian country, NIHB established the Tribal Public Health Accreditation Advisory Board, with membership drawn from THDs, area Indian health boards, Tribal Epidemiology Centers, and other key partner organizations to provide continuing feedback on the applicability of the standards and measures used at THD sites.
CDC recognized early on the potential positive impact of public health accreditation. CDC's Office for State, Tribal, Local, and Territorial Support (OSTLTS) was established to strengthen the nation's health departments. Between 2010 and 2014, OSTLTS implemented and supported the National Public Health Improvement Initiative (NPHII), a program to promote accreditation readiness, increase efficiency and effectiveness through quality improvement initiatives, and expand performance management capacity. NPHII worked with 73 public health agencies that included 4 tribes, as well as 4 tribal organizations that together supported an additional 250 tribes. CDC's NPHII also invested in the Accreditation Support Initiative (ASI). The Tribal ASI, administered by the NIHB, has worked closely with more than a dozen tribes since 2015. Both NPHII and ASI have provided direct funding to tribes through subawards, technical assistance, and training, allowing them to explore the feasibility of accreditation, complete prerequisites, and prepare for the application process. Red Star led the way in accreditation-related training and capacity-building for tribes and consulted directly with tribal health programs during their journeys toward accreditation.
Several prominent leaders in tribal health are active in promoting and supporting accreditation activities, including Joe Finkbonner (Lummi Nation), Executive Director of the Northwest Portland Area Indian Health Board, who has been a member of the PHAB Board of Directors for the past 6 years; and Stacy Bohlen (Sault Sainte Marie Tribe of Chippewa Indians), NIHB Executive Director, who serves as an ex-officio member of the PHAB Board of Directors.
One central question on the potential impact of tribal public health accreditation is “What does public health mean in Indian country?” At the tribal level, the integration of public health and clinical care is seen as a strength of the Indian health system and leads to improved individual and community wellness. However, the very nature of the integrated system means that tribes rarely have a stand-alone public health department.
If public health accreditation is to be embraced at the tribal level, public health itself must be clearly defined, supported, and understood. Continued lack of clarity about how public health accreditation is distinct from clinical accreditations through bodies such as the Accreditation Association for Ambulatory Health Care or The Joint Commission may pose a challenge in gaining tribal participation in public health accreditation. For example, tribal leadership may question the need for separate accreditation and may view public health accreditation as duplicative and unnecessary. As noted in a commentary published in this journal in 2014, the experience that tribes have in quality assurance/improvement and clinical accreditation demonstrates that THDs have the capacity to pursue public health accreditation.1 There is a need for continued education and advocacy to tribal leadership, tribal health program staff, and other decision makers to provide clear messaging around the benefits of public health accreditation and the importance of continuing to build and support tribal public health infrastructure. As more tribes seek and achieve public health accreditation, their advice on gaining the support of tribal leadership and stories from their journeys will be critical to increasing momentum toward accreditation of more THDs.
On August 17, 2016, tribal public health accreditation reached an important milestone when Cherokee Nation Health Services achieved public health accreditation. “Achieving accreditation is important to Tribes, as we must focus on the strengths we possess in our communities for solving problems and improving the health status of our People. We must focus on prevention, protection, and promotion of our resources and our Elders. Accreditation helps us examine our public health practices and improve the quality of the services we have been entrusted with to deliver to our communities,” said Lisa Pivec, MS, Senior Director of Public Health for Cherokee Nation.2
As of September 2017, 4 additional THDs submitted applications to begin the accreditation process. Based upon the number of tribes currently exploring accreditation, tribal applicants, and, ultimately, of accredited THDs, accreditation will continue to grow slowly but steadily. The potential for the impact of public health accreditation on tribal public health practice is vast and still largely untapped in that, as of 2017, there are a total of 567 federally recognized tribes. Additional funding, technical assistance, training, support from tribal leaders, and efforts by tribal health program staff and their partners are needed to ensure that the many tribes with interest and capacity to pursue accreditation have the ability to do so.
There is general recognition in the field that public health accreditation may not be—and perhaps should not be—the ultimate goal for all THDs. However, the standards and measures of accreditation, as well as the tools and prerequisites, are valuable in their own right as tribes seek to improve, expand, and enhance the quality of their services and the health of their communities. PHAB recognizes the challenges of accreditation for small health departments, defined as those serving populations less than 50 000, which includes the vast majority of THDs, and has committed to providing support for these smaller jurisdictions. As we continue into the second decade of exploring public health accreditation, tribes have a clear opportunity to promote and document excellence in public health practice.