In 2011, the Public Health Accreditation Board's (PHAB's) national voluntary accreditation program was launched, offering nationally recognized standards to assess the performance of state, local, Tribal, and territorial health departments against the 10 Essential Public Health Services. The inherent value of pursuing PHAB accreditation lies not in the accreditation status itself but in the program's theoretical and practical grounding in performance improvement (PI). PHAB's requirements of a community health assessment (CHA) and a community health improvement plan (CHIP) are designed to strengthen the local health department's (LHD's) cross-sector partnerships and stimulate community engagement, both of which are essential in addressing a community's specific, and largely complex, population health challenges. Married with these requirements are those focused on an internal strategic plan, performance management system, and continuous quality improvement (QI). These requirements not only specify alignment with the CHIP—diverting organizational strategic priorities and resources to the most pressing community needs—but also inspire a PI skill set previously limited across the public health workforce.1,2
A Culture of Performance Improvement: Managing Change on a National Scale
As with any transformational change, PI and accreditation have been met with a measure of trepidation and skepticism. What are the benefits of accreditation? Who has time or the skills to do this work? The National Association of County and City Health Officials (NACCHO) joined federal and national partners to manage the impending change and ensure the field was properly equipped with the necessary skills. With funding from the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation, and the Health Resources and Services Administration, NACCHO administered multiple rounds of demonstration site projects,3 administered 162 grants to LHDs through the Accreditation Support Initiative,4 trained hundreds of communities in its flagship community health improvement framework, Mobilizing for Action through Planning and Partnerships (MAPP), and launched a PI webinar series, to name a few.
In accordance with change management principles, many of these resources assisted the field with the “technical” aspects of PI, but equal consideration was directed toward the “human” side. NACCHO launched an Accreditation Coordinators Learning Community providing a neutral peer support system for LHDs to share their accreditation strategies and grievances. In response to a limited understanding of a culture of QI, NACCHO developed the Roadmap to a Culture of Quality,5 taking a nebulous and ambitious vision and breaking it down into precise guidance. In 2014, NACCHO tailored Adaptive Leadership, a framework designed to assist individuals and organizations in addressing systemic change and confronting the status quo,6 for population health practitioners. Most of NACCHO's Adaptive Leadership participants address PI-related challenges during these interactive trainings.
Look How Far We've Come
As of March 2019, 79% of the US population is covered by an accredited health department, with a total of 218 LHDs and 1 statewide local public health system.7 By 2016, the field observed an increase in assessment and planning efforts, with more than three-fourths of LHDs completing a CHA, two-thirds completing a CHIP, and approximately half completing a strategic plan. By 2016, 54% of LHDs reported implementation of formal QI.8 Research suggests that engaging in PI efforts may have a positive impact on an LHD's capacity to address population health through an increase in multisectoral collaboration9 and enhanced internal strategy.10 The use of QI methods has demonstrated increased efficiency in public health service delivery11,12 and enhanced quality of services.13,14 Recognizing that not all LHDs have the capacity to pursue accreditation, NACCHO is committed to working with PHAB as the standards evolve and supporting all LHDs with accreditation and PI more broadly. The field should be motivated by this movement; however, there remains opportunity to build on these successes as public health priorities evolve.
Moving Forward: Performance Improvement, Public Health 3.0, and Health Equity
Alongside emerging public health threats such as Zika virus disease and the opioid epidemic over the past decade, a more pervasive issue has taken hold of the field at large: health equity. This is defined as the state in which everyone has a fair and just opportunity to be as healthy as possible through the removal of obstacles to health, such as poverty or discrimination. Public health is evolving to take a more holistic approach to population health by focusing on the social determinants of health (SDOH)—the conditions in which people are born, live, work, and age, and which are shaped by the distribution of money, power, and resources.15 The PI movement has created fertile ground to forge ahead into the era of Public Health 3.016 as NACCHO affirms the value in the LHD being its community's Chief Health Strategist,17 providing the leadership and skills necessary to bridge multisectoral partnerships. LHDs are poised to take on this role, as partnerships and community engagement are fundamental to CHA/CHIP processes. NACCHO's 2018 Forces of Change study revealed that more than 70% of LHDs acted as either a leader or a convener in partnerships to address food insecurity, hunger, and family and social supports.18
Aligned with the old public health adage, “What gets measured, gets done,” the collection and use of data related to SDOH comprise another critical component of a multipronged strategy to address health equity. Approaching health equity through PI processes requires collection of performance data to identify health inequities, framing goals and objectives to address health inequities, integrating community voice into performance indicators, and selecting “upstream” interventions. To help communities identify a range of interventions, from the individual to community and policy levels, NACCHO developed the Community Health Improvement Matrix.19 Founded on principles of community engagement and multisectoral partnerships, NACCHO has more explicitly integrated health equity into every phase of its MAPP process, offering guidance around creating alliances with those with power and influence, measuring social, economic, and health inequities, and facilitating dialogue about health inequities. In 2011, NACCHO debuted Roots of Health Inequity,20 a free online course designed for group dialogue around the users' personal knowledge and experiences. The course has been used by several thousand participants across 8 countries and multiple sectors.
Health inequities are founded on decades of historical oppression, systemic racism, and imbalanced power structures. LHDs must expand beyond traditional public health services and ask themselves difficult questions. How might the LHD be perpetuating health inequities? How can the LHD help address inequitable access to quality housing or education? How can different sectors align strategy? There is no single formula that will quickly undo this; however, successes from the recent PI movement has set the stage for a nimbler public health workforce and system. PI professionals are now positioned to help create optimal health for all.
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2. Davis M, Cornett A, Mahanna E, See C, Randolph G. Advancing quality improvement in public health departments through a statewide training program. J Public Health Manag Pract. 2016;22(2):E21–E27.
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18. National Association of County and City Health Officials. 2018: The Forces of Change in America's Local Public Health System. Washington, DC: National Association of County and City Health Officials; 2018. http://nacchoprofilestudy.org/forces-of-change
. Accessed: May 13, 2019.