In 2003, the Institute of Medicine described local health departments' (LHDs') critical role in ensuring conditions for a healthy community and emphasized LHDs as the backbone of the public health system.1 A large proportion of the public health workforce includes LHD employees,2 making it critical to understand and strengthen LHD workforce capacity. In 2001, the Council on Linkages Between Academia and Public Health Practice released the first set of Core Competencies for Public Health Professionals, defining foundational knowledge and skills the workforce should possess to effectively deliver the 10 Essential Public Health Services.3 Studies to better understand workforce size and composition have been undertaken to project workforce needs as we face public health challenges of the 21st century.2,4,5 Since 2008, economic and political factors have resulted in significant LHD job losses, weakening the capacity of LHDs to provide public health programs and services.5,6 As LHDs face continuing funding challenges, it is becoming increasingly important to implement strategies to recruit and retain public health workers.7,8 A recent study found that organizational factors such as strong leadership and management and professional development opportunities are linked to job satisfaction among the public health workforce.9 Recognizing the necessity of a strong public health workforce to effectively deliver public health programs and services that address the population's changing public health needs, the Public Health Accreditation Board (PHAB) integrated workforce development requirements into the accreditation process.
The Public Health Accreditation Board's national voluntary accreditation program seeks to advance the quality and performance of public health departments through a set of national standards, assessing delivery of the 10 Essential Public Health Services and general administration and governance of the health department. Version 1.5 of the PHAB Standards and Measures includes 5 measures for LHDs related to workforce development under Domain 8: Maintain a Competent Workforce.10 These requirements relate to ensuring a competent workforce through collaboration with educational programs, the development and implementation of a workforce development plan, provision of professional development opportunities to staff and leadership, and fostering of a supportive work environment. Domain 11: Maintain Administrative and Management Capacity includes standards and measures related to creating a supportive environment for the workforce, such as accessibility of standardized agency policies and procedures, processes for resolving ethical issues, and supportive human resources functions.10 Other measures throughout the PHAB standards explicitly require engagement of LHD leadership and staff to demonstrate certain measures. For example, Domain 9: Evaluate and Continuously Improve Processes, Programs, and Interventions requires documentation of staff training and engagement in performance management and quality improvement (QI) initiatives.10
Because the PHAB program is relatively new and the first cohort of LHDs was accredited in February 2013, limited data are available around the long-term benefits of achieving accreditation. As of August 2016, 130 of the nation's approximately 2800 LHDs have achieved national accreditation, with an additional 155 in the process.11 In addition, one integrated local public health department system in a centralized state with 67 LHDs has been accredited. Preliminary findings around both the tangible and intangible benefits of accreditation have been reported. In 2014, the National Association of County & City Health Officials conducted a survey among local health officials and accreditation coordinators from accredited health departments to understand the benefits of accreditation. Among the 26 respondent LHDs, some of the most commonly reported benefits relate to workforce development, including staff knowledge and morale.12 An evaluation survey of health departments that had been accredited for 1 year revealed that greater engagement in QI, improved management processes, and improved accountability was among the most common benefits of accreditation.13 The evaluation of the PHAB beta test found that the 30 health departments that participated in a pilot version of the process indicated increased staff morale.14 In addition, in a case report, 1 health department noted that
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.15
The existing findings were based on only the self-report of health departments and focused on the perception of staff directly engaged in the accreditation process—LHD leaders and accreditation coordinators. While these results are encouraging, they could not allow us to compare the experience of LHDs highly engaged in accreditation versus LHDs less engaged in accreditation, nor to assess whether staff in general have a similar perception about the benefits of this effort as those who directly work on the accreditation application. As LHDs face diminishing resources and recognize the costs of PHAB accreditation, it is important to research and communicate the benefits of accreditation to governmental public health departments, policy makers, and the communities they serve. To that end, PHAB developed a research agenda to encourage further studies about the benefits associated with accreditation. These research questions reflect a logic model that describes how inputs from PHAB, partner organizations, and participating health departments might lead to proximate, intermediate, and ultimate outcomes among applicant health departments and in the broader public health field. Included in this model are outcomes related to increased internal and external collaboration, a supportive culture for QI, and strengthened organizational capacity and workforce.16 The current study aims to examine the association between LHDs' engagement in accreditation and their staffs' perception of workplace environment and the overall satisfaction with their jobs.
Data for this study were drawn from the 2014 Public Health Workforce Interests and Needs Survey (PH WINS) and the 2014 Forces of Change (FoC) survey. PH WINS was conducted by the Association of State and Territorial Health Officials to explore workforce attitudes, morale, and training needs. Detailed information about the PH WINS methodology is reported in a supplement to the Journal of Public Health Management and Practice.17 The survey employed complex sampling design, targeting state and local public health practitioners: (1) employees of state health agencies, (2) employees of LHD members of the Big Cities Health Coalition, and (3) employees from LHDs in a 7-state local pilot (Arkansas, Georgia, Mississippi, South Carolina, Vermont, Washington, and Wisconsin). All respondents in the second and third sampling frames and respondents in the first sampling frame who reported working in a local office of a state agency were classified as local employees.
The 2014 FoC survey was an organization-level study conducted by the National Association of County & City Health Officials and was administered to top executives from a statistically representative sample of 957 LHDs in the United States. Local health departments were stratified by 2 variables: size of the population served and state. A total of 648 LHDs completed the survey, with a response rate of 68%. The PH WINS data were linked with FoC data using unique LHD IDs documented by the National Association of County & City Health Officials.
Employees' perception of workplace was assessed with 20 items in PH WINS using a 5-point Likert scale from strongly agree to strongly disagree. Higher scores reflected better perceived workplace environment. Principal components analysis showed that 3 factors existed. Only 1 item “Employees learn from one another as they do their work” did not load within any of the 3 groups of factors, so it was excluded from further analysis. Reliability analyses were then conducted among all other items. Six items measured supervisor support, with Cronbach α of 0.91, which indicates excellent internal consistency. Sample items were “Supervisors/team leaders in my work unit support employee development” and “Supervisors/team leaders work well with employees of different backgrounds.” Seven items measured organizational support, with Cronbach α of 0.87, which indicates good internal consistency. Sample items were “My training needs are assessed” and “My workload is reasonable.” Six items measured employee engagement, with Cronbach α of 0.83, indicating good internal consistency. Sample items include “The work I do is important” and “I am inspired to meet my goals at work.” The items within each factor were then averaged to form measures of supervisor support, organizational support, and employee engagement, respectively.
Job satisfaction was assessed with the Job in General (JIG) score,18 a validated measure calculated from responses to 9 questions about employees' opinions about their jobs, with a range from 0 to 48. A higher score indicates higher job satisfaction.
Local health departments' level of engagement in PHAB accreditation was assessed with a question in the FoC survey—“Which of the following best describes your LHD with respect to participation in the Public Health Accreditation Board's accreditation program for LHDs?” Local health departments were classified as “formally engaged” in the PHAB accreditation process if they had achieved accreditation, submitted an application, or submitted a statement of intent. Local health departments were classified as “less formally engaged” if they planned to apply but had not submitted a statement of intent, had not decided, decided not to apply, or the state health agency would apply as an integrated system that included LHDs. This is consistent with the classification used in previous work.19,20
Some individual demographic characteristics measured in PH WINS were used as independent variables, including age, gender, race/ethnicity (non-white, white), educational attainment (associate, bachelor, master, doctoral, no college degree indicated), years in public health practice (0-5, 6-10, 11-15, 16-20, 21 and above), and supervisory status (without supervisory role, with supervisory role).
Statistical analyses were conducted using Stata 14.0 (StataCorp LP, College Station, Texas). Descriptive statistics included computation of frequency and percentage for respondents by individual and agency characteristics. The Student t tests were used to examine differences in workplace environment characteristics and job satisfaction between employees from LHDs with different levels of accreditation engagement. Multivariable linear regression analyses were conducted to assess the extent to which LHDs' engagement in accreditation is associated with their employees' perceived workplace environment and overall job satisfaction, after controlling for individual demographics and agencies' jurisdiction size.
A total of 1884 LHD employees were included in the analysis. Descriptive statistics of the sample's individual characteristics and agency-level characteristics were conducted (see Table, Supplemental Digital Content 1, available at http://links.lww.com/JPHMP/A318, which presents descriptive statistics of respondent characteristics by frequency and percentage). More than 80% of respondents were females and about two-thirds were non-Hispanic white. Slightly less than half of respondents were older than 50 years. Nearly a fourth had more than 20 years' experience in public health practices. Most respondents were from medium or large LHDs, with only 11% from small LHDs. Approximately one-third of respondents were from agencies that have been actively engaged in accreditation.
Table 1 shows the results of t tests that compared the mean ratings for workplace environment and job satisfaction by their agencies' level of engagement in accreditation. Employees from LHDs formally engaged in accreditation gave higher ratings in supervisor support, organization support, and employee motivation/morale. These employees also reported significantly higher JIG score, indicating a higher level of job satisfaction when compared with employees from agencies less engaged in accreditation.
Multivariable linear regressions were conducted to examine the relationship between agencies' level of accreditation engagement and LHD employees' perceived workplace environment and job satisfaction, accounting for individual characteristics and agency's jurisdiction size (Table 2). The coefficients indicate that the scores of reported supervisory support, organization support, and employee motivation/morale were 0.22, 0.22, and 0.12 points higher, respectively, for workers from LHDs that were formally engaged in accreditation than those for workers from LHDs that were not formally engaged. Similarly, the agency's level of accreditation engagement was a significant predictor for overall job satisfaction, with JIG score 2.974 points higher among workers from LHDs formally engaged in accreditation.
Table 3 shows associations between accreditation engagement and employee job satisfaction after including workplace environment in the analysis. Employees who reported a higher level of organizational support or with high motivation/morale were more satisfied with their jobs. Having a supervisory role at work or being white was associated with a higher JIG score. After adding workplace environment in the model, an agency's accreditation engagement was still marginally associated with employees' job satisfaction.
The PHAB national accreditation program puts a heavy emphasis on workforce development, aiming to strengthen the current public health workforce and strategically foster a strong future workforce.21 Findings from this study confirm observations of the positive influence accreditation has on the workforce. Engagement in public health accreditation is associated with perceptions of increased supervisory support, organizational support, and morale but it is also linked to overall job satisfaction.
Previous literature suggests that strong organizational leadership creates a supportive work climate, inspires and motivates employees, and has a positive impact on job satisfaction.22,23 Accreditation provides a framework for a health department to improve management and develop leadership. This study provides some evidence that engagement in accreditation is related to perceived leadership and organizational support, which is supportive of the prior findings on postaccreditation improvements in performance, management processes, accountability, and transparency.13
One important area for future research is to examine the mechanisms by which accreditation could affect job satisfaction and perceptions of the workplace. A series of case reports suggests several possible ways that accreditation could contribute to improved satisfaction, including the following:
- Specific accreditation measures require training and a workforce development plan. One health department noted that it conducted an employee satisfaction survey because it was working to demonstrate conformity with a PHAB measure. This led to the development of a plan for the health department to work on the concerns commonly raised in the survey.24
- Achieving accreditation fosters a sense of pride and accomplishment among health department employees.15
- Preparing for accreditation breaks down siloes within health departments and encourages greater collaboration.24,25
Each of these hypotheses could be more systematically examined. In addition, evaluation findings emphasize the relationship between accreditation and health department engagement in QI. Research in other fields suggests that organizational participation in QI is associated with greater job satisfaction.26,27 Therefore, it merits study whether accreditation may bolster job satisfaction in part by incorporating QI standards.
Finally, Measure 8.2.4, which calls for a “work environment that is supportive to the workforce,”8 is the measure that speaks most directly to the workforce environment. This measure was included for the first time in Version 1.5 of the Standards and Measures. Given that July 2014 was the first time health departments could apply under Version 1.5, it is likely that most of the participants in the PH WINS survey that indicated that they were engaged in accreditation were using the earlier version. As more LHDs are being accredited under Version 1.5, it will be interesting to study whether the inclusion of that new measure has a further effect on employee satisfaction.
There are several limitations to this study. First, this is not a representative sample of LHD employees. In particular, larger health departments were disproportionately represented in the PH WINS data set. Second, the health departments that were considered to be “less engaged” in PHAB vary in terms of involvement of accreditation-related work. While some are not engaged at all, others may have already begun reviewing the PHAB Standards and Measures and preparing for accreditation. Third, because accreditation is a voluntary process, there is concern about selection bias. It is not clear to what extent stronger perceived leadership and organizational support are results of accreditation engagement or whether organizations with strong leadership and organizational support are more likely to engage in accreditation. Further research is necessary to explore this.
Health department workforce is a primary vehicle for delivering public health services to communities. High job satisfaction and positive perceptions of the workplace environment may be significant drivers for improved work performance and retention. Both of these factors may impact delivery of the 10 Essential Public Health Services and reduce costs related to workforce turnover, as well as help attract new talent and further strengthen workforce capacity. To the extent that accreditation helps foster a positive work environment and greater employee satisfaction, it is an important tool in strengthening the public health workforce.
As health departments continue to have limited budgets and resources to address the public health issues within the communities they serve, the benefits of accreditation must be demonstrated and communicated to justify allocating resources to earning accreditation status. If accreditation leads to improvements in workforce development, this could be a significant driver in promoting accreditation among health departments that remain undecided or resistant to accreditation.
Implications for Policy & Practice
- Engagement in public health accreditation is associated with overall job satisfaction, including health department staff reporting higher levels of perceived supervisory support, organizational support, and morale.
- Several hypotheses might explain this link:
- Meeting the accreditation standards and achieving national recognition could bolster staff satisfaction.
- Having higher job satisfaction might make a health department more likely to apply for accreditation.
- Further research is needed to explore this relationship.
- Gaining a greater understanding of the causes and correlates of high job satisfaction is particularly critical now, as many health departments face constrained financial resources.
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accreditation; local health departments; workforce
Supplemental Digital Content
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