In the fall of 2011, the Public Health Accreditation Board (PHAB), the nonprofit organization that encourages continuous quality improvement through national accreditation of state, local, territorial, and tribal health departments, with support from a variety of national organizations, including the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation, launched the national voluntary accreditation program to promote accreditation among health agencies.1 Accreditation serves to underscore a public health department's accountability and commitment toward quality improvement.2 Research indicates that across sectors, accreditation programs improve service quality, service outcomes, and the operations of service providers.3,4 A public health agency can also begin to enhance performance by fulfilling key accreditation plans and systems such as a completed health assessment, health improvement plan, and agency strategic plan.5
In 2013, NORC at the University of Chicago began a 3-year evaluation of the PHAB accreditation program for both state and local health departments. Results of the evaluation found that after being accredited for 1 year, respondents reported experiencing increased quality and performance improvement opportunities, improved identification of strengths and weaknesses within the department, and greater accountability and transparency.6,7
While the benefits of public health agency accreditation have been documented, the perceived and anticipated benefits of accreditation solely from the perspective of state health agencies have until now remained unexplored. This study examines state health agencies' perceived benefits of accreditation by agency accreditation status according to whether the agency has already achieved accreditation or is in the process of becoming accredited.
Data from this study are from the Association of State and Territorial Health Officials (ASTHO) Profile of State and Territorial Public Health (Profile Survey). First conducted in 2007, the ASTHO Profile Survey is administered every 2 to 3 years to state and territorial health agencies to document the structure, functions, and resources of these agencies. The 2016 survey, fielded online to ASTHO's 59 member agencies in the spring of 2016, was completed by various agency personnel and had an overall response rate of 98%.
The Performance and Quality Improvement section of the Profile Survey, generally filled out by a staff member involved in performance improvement, gathers information on public health agencies' accreditation status as well as activities related to performance and quality improvement. The 2016 survey also included a new set of close-ended questions on agency perceptions of the benefits of accreditation. Respondents were asked to indicate their experience of a series of potential accreditation benefits, using the following 4-point scale: “already experienced,” “anticipate agency will experience,” “do not anticipate experiencing,” and “do not know.” All agencies interested or involved in the accreditation process answered the same question about the potential benefits of accreditation. Frequencies and cross tabulations were conducted using IBM SPSS (version 21) statistical software. Because the US territories and freely associated states did not receive the questions on the benefits of accreditation, they were excluded from subsequent analyses.
This study measured benefits of accreditation at the organizational level and so was not subject to review by an institutional review board.
At the time of survey completion, 20 (40%) state health agencies had achieved accreditation, 11 (22%) had submitted an application for accreditation, 2 (4%) had registered in e-PHAB to pursue accreditation, 13 (26%) planned to apply for accreditation but had not yet registered in e-PHAB, 2 (4%) had not decided whether to apply, and 2 (4%) had decided not to apply for accreditation. As of September 2017, 8 additional state health agencies had achieved accreditation.8
For the purposes of this study, the 20 agencies that had already achieved accreditation at the time the survey was completed were classified as “already accredited” whereas the 11 agencies that had submitted an application plus the 2 that had registered in e-PHAB have been classified as “in-process” agencies. Agencies at other stages of the accreditation process were not included in this analysis.
The Figure depicts the top perceived benefits of accreditation reported by accredited and in-process agencies. Among accredited agencies, the most frequently endorsed perceived benefits of accreditation included stimulating quality and performance improvement opportunities (95%), strengthening the culture of quality improvement (90%), and stimulating greater collaboration across departments/units within the agency (90%). In addition to the benefits they already reported experiencing, accredited agencies most frequently anticipated the following benefits: increasing the extent to which information from a performance management system informs decisions (40%); improving agency capacity to provide high-quality programs and services to customers (35%); increasing the extent to which agency uses evidence-based practices for public health programs and business practices (30%); and improving agency financial status (30%).
Among in-process agencies, the most frequently experienced benefits included strengthening relationships with key partners in other sectors (77%), stimulating quality and performance improvement opportunities (69%), and stimulating greater collaboration across departments/units within the agency (69%). In-process agencies' most frequently anticipated benefits were increasing the extent to which information from a performance management system informs decisions (69%), increasing the public's working knowledge of agency roles and responsibilities (54%), improving agency financial status (54%), and improving agency capacity to provide high-quality programs and services to customers (46%).
Accredited agencies reported having already experienced 8 of the 12 benefits more frequently than in-process agencies, including strengthening the culture of quality improvement (90% of accredited, 54% of in-process), increasing the extent to which the agency has identified and addressed gaps in employee training/workforce development (75% of accredited, 38% of in-process), and increasing the extent to which information from a performance management system informs decisions (60% of accredited, 31% of in-process).
There were, however, several benefits that in-process agencies reported experiencing more frequently than already accredited agencies: strengthening relationships with key partners in other sectors (77% of in-process agencies, 65% of accredited agencies); increasing the use of evidence-based practices for public health programs and/or business practices (62% of in-process agencies, 45% of accredited agencies); and improving agency financial status (15% of in-process agencies, 5% of accredited agencies).
Implications for Policy & Practice
- Data from this study on the perceived benefits of accreditation are consistent with the findings from other evaluations using self-report measures, which reflect favorably on self-report data related to accreditation benefits.
- An exploration of the benefits of accreditation can assist in demonstrating the value of accreditation, which, in turn, provides opportunities for organizational quality improvement.
- Identifying benefits of accreditation can help further motivate states at the earlier stages in the process to continue to work toward accreditation.
- The commitment to continuous quality improvement and accreditation reflects well on the state governmental public health system. State health agency leadership and proponents of accreditation can use these data when making the case for accreditation within their health agencies. Policy makers can work with state legislatures to ensure that state health agencies have the political support and resources necessary to pursue accreditation.
- PHAB and other organizations can emphasize those benefits experienced when encouraging agencies to seek accreditation. In addition, understanding which benefits are not as frequently experienced can serve to direct any future quality improvement work in order to ensure that those benefits are being realized. Specifically, PHAB may want to place less emphasis on the direct financial benefits of accreditation, focusing instead on how other benefits of accreditation, such as improved capacity to provide high-quality programs, can indirectly lead to financial benefits as both population health and organizational efficiency improve.
- By strengthening their own capabilities, state health agencies become better equipped to help others such as local and tribal health departments do the same—helping further foster a culture of continuous improvement. Gathering more information on the benefits of accreditation will also be helpful to the insular areas—the 2 US territories and 6 US-affiliated Pacific Islands that are a part of ASTHO's membership—as these health agencies decide whether to pursue accreditation.
Results indicate that state health agencies that are accredited or are in the process of accreditation have experienced or expect to experience a multitude of the potential benefits of accreditation. All agencies but one indicated that their agency had experienced at least 1 accreditation benefit; the single agency that reported not yet experiencing any benefits indicated that it expected to experience some of those listed in the future. Often the benefits that agencies most frequently anticipate experiencing upon accreditation are the same benefits reported by accredited agencies, such as the stimulation of quality and performance improvement activities and collaboration.
The results of this study corroborate the perceived benefits of accreditation that have been reported by PHAB. Stimulating quality and performance improvement opportunities was the most frequently reported benefit of accreditation. This finding aligns with PHAB's mission and further demonstrates the value of PHAB accreditation—which works to establish a culture of continual improvement that does not stop after an agency receives its accreditation status.
One notable exception was the finding that in-process agencies more frequently experienced or anticipated experiencing an improvement in agency financial status than accredited agencies; an improvement in agency financial status was the least frequently reported benefit of accreditation. This may be a particular area for PHAB and others to work on, cultivating more opportunities for financial improvement to make sure that this goal is achieved.
The results of this study also show that agencies report experiencing benefits of accreditation even before officially achieving accreditation. This may be because in-process agencies have more recently worked to meet the national standards for accreditation and as a result have seen the benefits that accreditation can bring, especially when it comes to stimulating partnerships, cross-departmental collaboration, and quality and performance improvement opportunities with the agency.
There are several limitations to the current analyses worth noting. The use of close-ended questions does not allow for the measurement of the degree to which agencies have experienced or anticipate experiencing benefits—some agencies may have experienced benefits to a greater extent than others. In addition, the questions do not measure the time frame during which these benefits were experienced—while the idea behind accreditation is to continually improve quality and performance, it is unclear how long these benefits actually continue after accreditation. Finally, these are perceived benefits of accreditation that agencies are reporting and do not reflect any quantifiable or objective benefits experienced. Despite these limitations, the current study is an important first step in a deeper exploration of perceptions of the impact of accreditation. Directions for future research include additional measures of benefits, such as whether agencies are making measurable improvements, as well as the degree and duration of these benefits. Future research could also expand on these analyses to examine the perceived benefits reported by agencies at earlier stages of accreditation, as well as those who have chosen not to apply, in order to determine whether these agencies perceive the benefits of accreditation differently.
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