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Public Health Department Accreditation and Innovation: A Brief Report of the Approaches Used to Promote Innovation

Lang, Britt MPH; Rich, Naomi BS; Kronstadt, Jessica MPP; Harris, April MPH, CHES

Author Information
Journal of Public Health Management and Practice: July/August 2022 - Volume 28 - Issue 4 - p S138-S142
doi: 10.1097/PHH.0000000000001477
  • Open

Abstract

The Public Health National Center for Innovations at the Public Health Accreditation Board (PHAB) defines public health innovation as “the creation and implementation of a novel process, policy, product, program, or system leading to improvements that impact health and equity.” Tenets of public health innovation include the following: it is an ongoing, systematic process that can generate incremental or radical change; it requires both collaboration with diverse team members and partners and coproduction with people with lived experience who will be affected by the results of the innovation; and it is an open process lending itself to adaptation or replication.1 This article examines data from PHAB-accredited health departments to explore the approaches those health departments have taken to foster innovation. Innovation plays a critical role in the future of public health by encouraging the development of solutions to existing and emerging challenges, leading to transformation within the public health system.2

Approaches to Public Health Innovation

There are several factors that foster a culture of innovation in health departments, including leadership, internal collaboration, focusing on results, community connections, external partnerships, and creativity.3 Health departments may innovate through these factors intentionally or unintentionally; the following are examples of public health innovation that demonstrate the potential impact of several of those factors.

Leadership is critical to innovation within an organization because leaders can sustain efforts, manage risk, and impact staff morale.2 Many leaders who create space for innovation have teams that believe in “failing forward,” a willingness to try something that may not succeed and using that failure to learn from the experience.4 A 2019 case study of the Minnesota Department of Health's facilitation of a Health Equity Learning Community exhibits the role of leadership in fostering innovation. Local health department leaders developed policies and practices that could sustain more equitable work in their communities.3 Without leaders who were willing to participate and learn, emerging practices could not have been shared with local teams.

External partnerships with community members and local organizations enable innovators to tackle complex challenges by combining resources and expertise.2,5 The Colorado Department of Public Health and Environment, Office of Health Equity, implemented a Health in All Policies approach to develop multidisciplinary networks to advance health equity.6 Through this work, partnerships were used to expand reach, increase community trust and buy-in, and elevate community voices. These partnerships helped facilitate innovation by engaging individuals with the deepest familiarity with the challenges.

Link Between Accreditation and Innovation

One goal of accreditation is to promote high performance and continuous quality improvement (QI).7 While there are differences between continuous QI and innovation, the deliberate process of using information for the purpose of improvement can complement a department's culture of innovation.8 Health departments working on improvements for processes, products, programs, or policies may use similar tools for both QI and innovation, specifically for data collection, analysis, and understanding root causes.2

During the 2020 revision of the 10 Essential Public Health Services (EPHS), EPHS #9 has been revised to include innovation. It now reads: “Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.”9 This communicates the importance of both QI and innovation as foundations for building strong public health systems. Because the PHAB Standards and Measures are based on the EPHS framework, the inclusion of innovation in EPHS #9 is reflected in the newly released PHAB Standards and Measures (Version 2022).10 It connotes an expectation that accredited health departments will use both QI and innovation tools to allow them to more effectively and efficiently serve their communities.

Methods

One of the ways PHAB's accreditation program fosters health departments' commitment to QI and performance management (PM) is through its Annual Report process. Accredited health departments are required to submit Annual Reports, which include specific questions regarding innovation, components of QI, PM, and other ongoing processes. Previous analysis of Annual Report data has focused on QI, which provided results that complement studies conducted using data sources external to PHAB.11,12

This study used self-reported responses from accredited health departments to the Annual Report prompt:

PHAB defines public health innovation as the creation and implementation of a novel process, policy, product, program, or system leading to improvements that impact health and equity. Please describe the health department's approach to pursuing innovation and any innovations that have emerged since you were accredited.

PHAB staff first compiled all Annual Report data from January 2019 through December 2020. Data were cleaned in Microsoft Excel before analysis was performed. For this study, the unit of analysis is the health department. If the same health department provided a response related to their approach to innovation in both 2019 and 2020, the responses were combined to create a more holistic description of the health department's innovation approach. All 4 authors reviewed the data and identified all responses that positively described an approach to innovation. Using a priori and inductive coding, themes were defined. Upon reviewing the themes as a group, each response was then coded. Responses with different codes were compared, discussed, and resolved collectively. Responses that described an innovation approach were subsequently reviewed and coded to 1 or more of the relevant themes. The coded data were then tallied to determine how many health departments were coded to each theme. Annual Report data were merged with PHAB administrative data to include the health department type (state or local) and the size of the population served.

Results

A total of 205 health departments submitted Annual Reports between 2019 and 2020. Of those, 75 health departments (37%) described elements of the health department's approach to fostering innovation. This was more common among larger health departments (serving populations of ≥500 000), of which 48% described their approach, compared with health departments serving populations of less than 50 000 (21%). Similarly, 48% of state health departments described their approach compared with 35% of local health departments.

Several themes emerged in the descriptions of health departments' approach to innovation. The most common was the emphasis on partnership, with 44 health departments (or 59% of those health departments that described their innovation approaches) describing engagement with a wide range of organizations to pursue innovation. The next most common theme was leadership, described by 20 health departments (27%). Among these health departments, leaders often articulated how innovation was a component of the health departments' strategic plan or strategic priorities.

Other common elements—mentioned by at least 20% of health departments that provided their innovation approach—include funding, internal collaboration, training, and devoting time to innovation. The Table provides a list of all themes identified in the Annual Reports of at least 10 health departments. It includes a description and an illustrative quote for each theme.

TABLE - Elements of the Approach to Innovation Included in the Annual Reports of at Least 10 Health Departments
Element Number of Health Departments (%) Description Example
Partnerships 44 (59) Engaging a wide range of partners including health care organizations, community-based organizations, academic institutions (eg, creating an academic health department with a school of public health), other government agencies “Tap into partners and cultivate use of external experts as a source of new ideas.”
Leadership 20 (27) Having the health official and other members of the leadership team emphasize the importance of innovation, often by including innovation in the strategic planning “The department's new director is a visionary and strategic thinker who does not accept status quo and who seeks creative, customer-centric, and impactful solutions. Innovation is now one of five organizational values and will be reflected throughout the development of outcomes and strategies in the coming months.”
Funding 18 (24) Seeking diversified funding, including a variety of grants to support innovative activities “For innovative ideas that require substantial funding, [Health Department] staff have three major opportunities to direct City funds to new innovations.”
Internal collaboration 17 (23) Developing structures, including intranet pages and cross-functional teams, to facilitate staff learning from each other “[Health Department] ‘de-siloed’ knowledge and information flows between four of its branches and has a core, cross-functional team that meets at least weekly.”
Training 17 (23) Providing training in innovation approaches (eg, design thinking) or other related training “We increased support for staff training and participation in efforts to address public health issues. We believe that true innovation will happen within programs once staff has the exposure to emerging practices, the vision of change in our community and freedom to try something new.”
Devoting time to innovation 15 (20) Offering time for health department staff to pursue innovative strategies “[Health Department]'s approach is to foster innovation through promoting a learning culture, investing in training and time for staff to meet and plan, and engaging with outside partners who offer spaces of innovation [...] Teams that are especially innovative are protected to the degree possible, with time allowances and other considerations.”
Sharing results/resources 14 (19) Sharing and learning from others through state and national conferences or convenings with other health departments “[Health Department] is developing a [community health assessment (CHA)] best practices toolkit for rural communities. The expectation is that this toolkit can be shared with other small, rural or frontier counties so that they have a roadmap for producing a high quality and usable CHA.”
Staff buy-in 12 (16) Fostering staff understanding of the health department's commitment to innovation and encouraging staff to suggest innovative projects and recognize others' innovative work “Staff and programs are recognized and rewarded for innovation and creativity through features in the internal weekly newsletter ... weekly cabinet reports to the Governor's office, public news releases, social media posts, nominations for the State employee of the quarter, and other methods.”
Dedicated person/team 12 (16) Identifying a staff member or a team with a stated purpose to promote innovation (often in conjunction with performance management/quality improvement or research and evaluation) “In May 2019, the Office of Performance and Innovation (OPI) was established, in part, to more directly and visibly engage in innovation. The creation of figurative and physical space that is supported with staff, has expectations of creating and employing novel approaches and products, is illustrative of the department's commitment. Once fully operational in this ‘space,’ OPI will focus on change management, design thinking, continuous quality improvement, and overall enterprise-wide project management that demonstrates the best of innovative practice and outcome.”
Performance management system 12 (16) Using performance management and other data systems to identify priorities for innovation “Vision and direction provided by public health modernization and the [health improvement plan] are tracked and held to account through the performance system. Through the performance system [health department] leadership and staff can identify opportunities for improvement in the methods by which we work to achieve health.”
Pilot testing 11 (15) Experimenting with innovative potential solutions on a small scale before implementing them more broadly “In an effort to gain more meaningful and actionable feedback from our customers, [health department] piloted a LEAN Business (LEAN Startup) approach to testing program assumptions around customer needs. The primary tool used is known as Customer Discovery Interviewing or CDI [....] The results of this process, which additionally provide a framework for innovation, provided clarity around how interviewees functionally interacted a particular public health concern and how the department's program could potentially intersect with that need in the community.”

Discussion

Identifying approaches to innovation for accredited health departments is an important way to gain insight into how accreditation may influence innovation. Partnerships were the most common approach to innovation, demonstrating that innovation work does not occur in a silo. Leadership, funding, internal collaboration, and training were the next most common approaches.

Health departments often described deploying a combination of strategies to promote innovation. For example, one accredited health department shared: “[The Health Department]'s approach is to foster innovation through promoting a learning culture, investing in training and time for staff to meet and plan, and engaging with outside partners who offer spaces of innovation.”

Notably, only 37% of health departments analyzed for this study identified elements of their health department's approach to foster innovation, raising the question as to whether the remaining 63% of health departments are not fostering innovation or merely failed to understand what the prompt requested. Several questions within the Annual Report, including this one, were made optional starting January 2019 to minimize repeated efforts by the health departments, which in conjunction with the health departments' efforts regarding the COVID-19 pandemic, may be the cause of the low response rate. Furthermore, failure to include approaches to innovation within their Annual Report does not mean that the health department is definitively not fostering innovation but rather that these data may have merely been absent from their Annual Report. Like any process that requests self-report, the Annual Report process does not provide a complete view of the health department.

Notably, both larger health departments and state health departments were more likely than smaller health departments and local health departments to describe elements of their approach in fostering innovation. This suggests that health departments serving larger jurisdictions may have access to resources and flexibility regarding staff availability that are integral for providing health departments with both the time and staff necessary to promote innovation. One limitation of this study is the low response rate, likely due to health departments' response to the COVID-19 pandemic. Another limitation is that we are unable to determine whether the innovations provided are due to accreditation. Although recent data show that when surveyed 1 year after becoming accredited, more than 96% of respondents agree or strongly agree that accreditation has stimulated QI and PM opportunities, a known impetus for innovation, within their health departments13; we are unable to confirm a causal relationship between accreditation and increased innovation. In addition, because of the potential for linkages between health departments' resources and accreditation status, health department resources may be a potential confounder for innovation. A strength of this study is that by using a large sample of accredited health departments and examining their self-reported approaches regarding innovation, we can learn the ways that health departments are self-identifying ways to promote innovation. Ultimately, further analyses using a more rigorous study design should be implemented to assess the causal effects of accreditation on innovation as well as to foster innovation. In addition, we encourage additional analyses about health departments' approaches to fostering innovation—specifically regarding the incorporation of equity into the approach—correlate to innovation outcomes. More in-depth case studies about how health departments have been successful in fostering a culture of innovation could also generate lessons learned to support other organizations, related to such topics as funding models to support innovation, strategies to mentor leaders, or frameworks for partnerships that focus on innovation.

This study builds our understanding of the strategies that health departments can deploy in promoting innovation, laying the groundwork for innovative approaches within governmental public health.

Implications for Policy & Practice

  • Flexible resources may be an important factor in allowing health departments to devote the time and staffing to pursue innovation.
  • Funders and national and state-based organizations could facilitate sharing of innovative practices by creating spaces for health departments to learn from each other.
  • More research is needed to better understand how to best foster innovation in governmental public health.

References

1. Public Health National Center for Innovations. About innovations. http://phnci.org/innovations/about-innovations. Accessed July 6, 2021.
2. Rich N. 10 Learnings from the public health Innovation Summit. JPHMP Direct. 2021. https://jphmpdirect.com/2021/10/11/10-learnings-from-the-public-health-innovation-summit. Accessed October 11, 2021.
3. Public Health National Center for Innovations. Public health innovation playbook. http://www.phnciplaybook.com. Published 2018. Accessed July 21, 2021.
4. Public Health National Center for Innovations. Health equity learning community: Minnesota Department of Health. Innovation learning community case studies. https://phnci.org/uploads/resource-files/PHNCI-Case-Study-Minnesota.pdf. Published March 2019. Accessed July 29, 2021.
5. Public Health National Center for Innovations. Adopting participatory budgeting in Pierce County, Washington. Innovation learning community case studies. https://phnci.org/uploads/resource-files/PHNCI-Case-Study-Tacoma-Pierce-County.pdf. Published April 2019. Accessed July 29, 2021.
6. Public Health National Center for Innovations. Sustaining equitable outcomes via partnerships, policy, and practice. Innovation learning community case studies. https://phnci.org/uploads/resource-files/PHNCI-Case-Study-Colorado.pdf. Published February 2019. Accessed July 29, 2021.
7. Public Health Accreditation Board. Standards and Measures Version 1.5. https://phaboard.org/wp-content/uploads/PHABSM_WEB_LR1-1.pdf. Published December 2013. Accessed July 28, 2021.
8. Keathley J, Merrill P, Owens T, Meggarrey I, Posey K. The innovation imperative. In: O'Mara PD, ed. The Executive Guide to Innovation: Turning Good Ideas Into Great Results. Seattle, Washington: ASQ Quality Press; 2013:3–9. https://asq.org/quality-press/display-item?item=E1453. Accessed July 28, 2021.
9. 10 Essential Public Health Services Futures Initiative Task Force. 10 Essential Public Health Services. https://phnci.org/uploads/resource-files/EPHS-English.pdf. Published September 9, 2020. Accessed July 28, 2021.
10. Public Health Accreditation Board. Version 2022. https://phaboard.org/version-2022. Accessed August 4, 2021.
11. Public Health Accreditation Board. Analysis of PHAB Annual Reports: Section II Data. Alexandria, VA: Public Health Accreditation Board; 2021. https://phaboard.org/wp-content/uploads/Annual-Report-Quantitative-Summary.pdf. Accessed August 4, 2021.
12. Beitsch LM, Kronstadt J, Robin N, Leep C. Has voluntary public health accreditation impacted health department perceptions and activities in quality improvement and performance management? Supplement, Impact of Public Health Accreditation. J Public Health Manag Pract. 2018;24(suppl 3):S10–S18.
13. NORC at the University of Chicago. Evaluation findings: assessing outcomes from public health accreditation. https://phaboard.org/wp-content/uploads/NORC-Evaluation-Slides.pdf. Published June 2021. Accessed August 6, 2021.
Keywords:

accreditation; innovation; leadership; partnership

© 2022 The Authors. Published by Wolters Kluwer Health, Inc.