It has been 5 years since the first public health departments became accredited through the Public Health Accreditation Board (PHAB).1 The accreditation process serves as an immense undertaking to demonstrate a health agency's commitment to improving and protecting the health of the public by advancing the quality and performance of the health department, as well as a clear desire to improve service, value, and accountability to stakeholders.2 Through achieving accreditation, nearly 200 health departments and systems, representing more than 203 million individuals, or 66% of the United States population, have established their capacity and role in modernizing and standardizing public health services.3
The overarching goal of accreditation is to improve and protect the public's health through the advancement of state health departments (SHDs), local health departments (LHDs), and Tribal and territorial health departments' performance and quality.2 , 4 During the accreditation evaluation process, health departments measure their performance against a set of nationally recognized, practice-focused, and evidenced-based standards.2 Accreditation is awarded to a health department after successful review of processes, services, outcomes, and progress towards specific goals and objectives guided by the PHAB Standards and Measures.5 The documentation requirements outlined in the Standards and Measures align with the 10 Essential Public Health Services, embody the 3 core functions of public health—assessment, policy development, and assurance, and describe activities that communities need to engage in to improve the public's health.6 , 7
The exploration and establishment of accreditation were largely influenced by significant studies, reports, and national initiatives addressing the changing public health landscape.2 All urged the field to focus on systems-wide performance improvement. The Institute of Medicine's 1988 and 2002 The Future of the Public's Health reports, the Assessment Protocol for Excellence in Public Health, Mobilizing for Action Through Planning and Partnerships framework, and the National Public Health Performance Standards assessment supported and recommended that a comprehensive and collaborative approach to public health would lead to increased coordination and an improved and strengthened public health infrastructure.6 , 8–11 This holds true as we move into Public Health 3.0—a movement encouraging deliberate collaboration and innovation in partnerships through the health department's role as Chief Health Strategist in their communities.12
Collaboration is a key component and common theme throughout accreditation standards, such as Standard 1.1: “Participate or lead a collaborative process resulting in a comprehensive community health assessment.”13 It is validated as critical for health department processes and activities to assess and improve the community's health, develop agency-wide strategic and workforce development plans, coordinate all-hazard operations, and engage in performance management (PM) and quality improvement (QI).12 System approaches to public health practice advocate that early and ongoing collaboration can increase the understanding of population needs, facilitate the identification of priorities, and inform the development and implementation of projects, programs, and policies that promote population health.13 , 14
As early as the PHAB accreditation beta test, health departments reported the process encouraged collaboration.15 , 16 They also identified that accreditation could facilitate improved communication with partners.15 Health departments are undoubtedly collaborating with one another, other governmental agencies, and community partners throughout their accreditation journey by designating staff members to act as liaisons, creating workgroups and learning communities, leveraging existing resources, and others.14–21 While the emphasis of collaboration in accreditation is one strategy to modernize a “disjointed” public health system, less is known about the extent to which accreditation has driven collaboration and improved or enhanced partnerships.22 The Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials (NACCHO) partnered to specifically learn more about how accreditation has impacted and even served as a catalyst for collaboration between SHDs, LHDs, and other government entities, as well as community partners. To better understand and explore this relationship, both organizations reviewed existing publications and sought insight from health departments that have achieved or are in the process of achieving accreditation through informal information gathering via an online form.
Feedback from both SHDs and LHDs showed that collaborations with other health departments and government entities were enhanced through the process of preparing for accreditation.17 Many shared that efforts to meet the accreditation standards strengthened internal and external communications, cultivated uniformity of efforts to implement public health programs and initiatives, and promoted formal partnerships between SHDs, LHDs, and other systems partners.16 , 17 , 23 One health department official, when describing the impact of accreditation on collaboration, shared that “overall, the process has opened up even more opportunities for state, local, and Tribal health departments to collaborate with each other and share success, lessons learned, and best practices for promoting public health and well-being.”17 The Figure summarizes the various areas that SHDs, LHDs, and other governmental agencies have collaborated throughout accreditation readiness and application, as shared by 24 SHDs and LHDs that have received accreditation or are registered in e-PHAB.
SHDs actively serving as a model for LHDs are also central to the success of collaborative partnerships and meeting PHAB requirements (J. Wehle, oral communication, September 2017).16 , 17 , 21 An LHD shared, “Technical guidance from the [SHD] was instrumental in helping the department meet the PHAB requirement for putting new infrastructure in place for PM/QI and workforce development planning documentation. The [TA] has greatly contributed to growth of a quality culture within the organization.”17
Health department collaboration is prominently underscored in accreditation requirements to engage and seek input from a range of partners and stakeholders, including the community during the health assessment and improvement process.13 , 21 All accredited health departments that provided insights (N = 24) shared that they worked with their SHD or LHD to develop their community health assessment (CHA).17 A common practice among health departments is to develop workgroups to inform their CHA and community health improvement plan (CHIP).14 , 17 , 18 , 23 One health department official shared, “The collaborative efforts that were birthed from the assessment and health improvement planning process have proved to be most beneficial to how we function as a health department, and most importantly to [improving] the health of our communities.”17 When asked how the accreditation process had enhanced collaboration with LHDs, another state official described workgroups as “effective collaborations that develop the [CHIP] and work toward the goals and objectives set for their work group.”17
In addition to the CHA and the CHIP, other accreditation-related activities bolstered collaboration and relationship building, including those focused on performance improvement and planning.14 , 16 , 17 An official noted,
The state's accreditation pursuit has vastly improved the collaboration between [LHDs] and the [SHD]. Performance management, quality improvement, and strategic planning activities have been shared by the state with local health departments. This has allowed for greater uniformity ... across the state.17
Several SHDs and LHDs asserted the importance of the state in leading these processes and supporting locals through the provision of technical assistance and direct financial support to LHDs.17
Collaboration during the delivery of public health services creates an opportunity to build social capital, reinforce community resilience, and leverage resources and assets.13 This is particularly important during times of budget cuts to public health spending.18 The consolidation of resources and consultation of various partners help identify the most effective interventions, leading to improved population health.12 , 22 One health department official shared that while undertaking accreditation requirements, it improved coordination of services for people, engaged new partners, empowered community ownership and comprehensive planning for maximum impact, forged stronger relationships within the local public health system, and emphasized continuous QI.17 Another shared,
The accreditation process enhanced a continually evolving effort between our health department and other government entities by strengthening our relationships and our commitment to population health. We continue to work together through the use of innovative, proactive, and collaborative approaches to ensure conditions in which all people of [the county] can be healthy.17
As a result of accreditation, health departments have reported experiencing several benefits, such as an increased capacity to identify and address health priorities and strengthened relationships with key partners. From their perspective, not only is collaboration important and critical to the mission of public health, but also accreditation plays a significant role in initiating and sustaining essential collaborative efforts and relationships.17 , 24 , 25 This peek into collaborative accreditation efforts helps validate the value of collaboration, thereby reinforcing the key assertion of Public Health 3.0, a blueprint for the future of public health: “Public health is what we do together as a society to ensure the conditions in which everyone can be healthy. We often think of the health care industry when we think of health, but building health communities requires strategic collaboration across all sectors.”12 (p3) Not only are collaborations the cornerstone to successful public health improvement, but they also are a key component to PHAB accreditation.13
While there is a gap in the field of formal evaluative studies to examine the extent to which accreditation has enhanced or improved relationships, it is evident that those closest to it note that accreditation has been a driver to facilitate meaningful partnerships.4 , 14 , 16–18 , 21 , 26–28 Both ASTHO and NACCHO recommend continued research and studies to demonstrate the true impact accreditation has had on enhancing relationships.
3. Public Health Accreditation Board. Public Health Accreditation Board's national program to improve and protect the health of the public continues its nationwide expansion [press release]. http://www.prweb.com/releases/prweb14722550.htm
. Accessed September 29, 2017.
4. Shah GH, Leep CJ, Ye J, Sellers K, Liss-Levinson R, Williams KS. Public health agencies' level of engagement in and perceived barriers to PHAB national voluntary accreditation. J Public Health Manag Pract. 2015;21(2):107–115.
8. Institute of Medicine. The Future of Public Health. Washington, DC: The National Academies Press; 1988.
9. Institute of Medicine. The Future of Public Health in the 21st Century. Washington, DC: The National Academies Press; 1988.
10. National Association of County & City Health Officials. Assessment Protocol for Excellence in Public Health (APEX). Washington, DC: National Association of County & City Health Officials; 1991.
11. National Association of County & City Health Officials, Centers for Disease Control and Prevention. Mobilizing for Action Through Planning and Partnerships. Washington, DC: National Association of County & City Health Officials, Centers for Disease Control and Prevention; 2001.
14. Association of State and Territorial Health Officials. Collaborative partnerships for accreditation preparation highlighting promising practices among state, local, and Tribal public health and key system partners. http://www.astho.org/AccredtationCollaborationWhitePaper.pdf
. Accessed November 20, 2017.
16. Marshall J. Oklahoma State Department of Health: insights from a newly accredited state health department. J Public Health Manag Pract. 2014;20(1):70–72.
17. Association of State and Territorial Health Officials, National Association of County & City Health Officials. Environmental Scan of Accredited or e-PHAB Registered State and Local Health Departments: State/Local Collaborations. Arlington, VA/Washington, DC: ASTHO/NACCHO; 2017.
20. Centers for Disease Control and Prevention. Advancing Public Health: The Story of the National Public Health Improvement Initiative. Atlanta, GA: US Department of Health and Human Services; 2017.
22. Fraser M, Castrucci BC. Beyond the status quo: 5 strategic moves to position state and territorial public health agencies for an uncertain future. J Public Health Manag Pract. 2017;23(5):543–551.
24. Association of State and Territorial Health Officials. ASTHO Profile of State and Territorial Public Health. Vol 4. Washington, DC: Association of State and Territorial Health Officials; 2017.
25. Kronstadt J, Meit M, Siegfried A, Nicolaus T, Bender K, Corso L. Evaluating the Impact of National Public Health Department Accreditation—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:803–806.
26. Gerding J, Carlson V, Wilcox R. Public health department accreditation and environmental public health: sustaining the collaboration. J Environ Health. 2013;76(1):56–57. https://www.cdc.gov/nceh/ehs/docs/jeh/2013/july-aug-accreditation.pdf. Accessed November 20, 2017.
27. Davis MV, Cannon MM, Stone DO, Wood BW, Reed J, Baker EL. Informing the national public health accreditation movement: lessons from North Carolina's accredited local health departments. Am J Public Health. 2011;101(9):1543–1548.
28. NORC at the University of Chicago. Final Report: Initial Evaluation of the Public Health Accreditation Program. Bethesda, MD: NORC at the University of Chicago; 2016.