January 2010

Grant Results

SUMMARY

From June 2005 through December 2008, the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention (CDC) co-sponsored Exploring Accreditation. The project considered whether and how a voluntary national accreditation program for state, local, territorial and tribal public health departments could advance quality and performance, and developed a model for such a program.

Exploring Accreditation, jointly managed by the National Association of County and City Health Officials (NACCHO) and the Association of State and Territorial Health Officers (ASTHO) used a consensus-building process that engaged representatives of key national public health organizations and also of public health entities at many levels of government. More than 650 public health professionals provided comments on the proposed model developed by a 25-member steering committee and its workgroups (see Exploring Accreditation report (page 48) for a list of members).

Key Results

  • The Exploring Accreditation steering committee concluded that a voluntary national public health accreditation program for state, local, territorial and tribal public health departments was both desirable and feasible.
  • Exploring Accreditation: Final Recommendations for a Voluntary National Accreditation Program for State & Local Public Health Departments, released in the winter of 2006-07, provided a blueprint for developing an accreditation program.
  • The Public Health Accreditation Board, incorporated in May 2007 and initially guided by the Exploring Accreditation Planning Committee, began to develop the voluntary national public health accreditation program, which is scheduled to launch in 2011. RWJF and CDC are co-funding the board.

Funding
RWJF funded the work done by NACCHO and CDC funded the work done by ASTHO on Exploring Accreditation. RWJF gave NACCHO three grants totaling nearly $1.53 million (ID#s 053182, 056262 and 058881). CDC provided $1.18 million to ASTHO.

 See Grant Detail & Contact Information
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The Problem

Accreditation is an accepted way to foster quality improvement and accountability in many fields. In 2002, the Institute of Medicine (IOM) noted in The Future of the Public's Health that although health care organizations had mechanisms for accreditation and quality assurance, public health did not. According to the report:

Accreditation mechanisms may help to ensure the robustness and efficiency of the governmental public health infrastructure, assure the quality of public health services, and transparently provide information to the public about the quality of the services delivered.

The Future of the Public's Health called for establishing a national steering committee to explore the potential benefits of accrediting public health departments and to determine how such a system should function.

In 2004, RWJF followed up on this recommendation by convening public health stakeholders to decide whether to explore a voluntary national accreditation program for state and local public health departments (Grant ID#s 051173 and 052159, managed internally by RWJF). The consensus was to proceed.

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RWJF Strategy

One of the main strategies of RWJF's Public Health Program Management Team is performance improvement of the public health system so it can fulfill its important role in ensuring the safety and health of the public. In order to drive fundamental improvements in the quality, performance and impact of public health agencies, the team's funding seeks to advance efforts to help public health agencies improve the services they provide and increase accountability to the communities they serve.

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The Project

From June 2005 to December 2008, RWJF and CDC co-sponsored Exploring Accreditation. The project considered whether and how a voluntary national accreditation program could advance the quality and performance of state, local, territorial and tribal public health departments, and developed a draft model for such a program.

The National Association of County and City Health Officials (NACCHO), in Washington, and the Association of State and Territorial Health Officers (ASTHO), in Arlington, Va., co-directed Exploring Accreditation. NACCHO represents local health departments. ASTHO represents state health departments (as well as health departments in U.S. territories and the District of Columbia).

For administrative simplicity, RWJF funded the work done by NACCHO and CDC funded that done by ASTHO. RWJF awarded NACCHO three grants totaling nearly $1.53 million (ID#s 053182, 056262 and 058881). CDC provided $1.18 million to ASTHO.

A Web site, developed in September 2005 (and no longer active), included project background, links to relevant resources, a mechanism for public comment and regular project updates.

A Consensus-Building Process

Exploring Accreditation used an open, consensus-building framework to explore voluntary national accreditation of public health departments. Executive directors of four national public health organizations served on the planning committee:

  • American Public Health Association (Washington), which represents public health professionals across the country
  • Association of State and Territorial Health Officials
  • National Association of County and City Health Officials
  • National Association of Local Boards of Health (Bowling Green, Ohio)

The planning committee established a 25-member steering committee (see Exploring Accreditation (page 48) for a list of members) to consider whether it was desirable and feasible to implement a voluntary national accreditation program. Members included representatives of public health agencies, departments and organizations at the local, state and federal levels. From September 2005 to August 2006, members met in person four times and also worked through conference calls.

Four workgroups informed the work of the steering committee:

  • Governance and Implementation Workgroup, which developed governance recommendations
  • Finance and Incentives Workgroup, which examined ways to finance an accreditation program and identified potential incentives to encourage participation in this voluntary program
  • Research and Evaluation Workgroup, which developed principles for research on the program and a framework for evaluating the program
  • Standards Development Workgroup, which developed principles to guide standards development

More than 40 public health professionals and academics participated in the workgroups, consulting subject matter experts as needed to inform the efforts.

The collaboration among the four national public health organizations and public health practitioners at all levels "brought a vast array of knowledge and expertise to bear on the exploration," said a report to RWJF.

The Multi-State Learning Collaborative

To inform the steering committee about existing public health accreditation practices, RWJF established a national program called the Multi-State Learning Collaborative on Performance and Capacity Assessment on Accreditation of Public Health Departments.

Launched in July 2005, the Multi-State Learning Collaborative (renamed Lead States in Public Health Quality Improvement), brought together five states—Illinois, Michigan, Missouri, North Carolina and Washington—to share information and enhance their capacity to assess the performance and capacity of their local public health departments. One state also assessed its state public health department.

The scope of the existing programs in the five states ranged from mandatory accreditation to voluntary participation in performance improvement. A common feature among them at the beginning of the collaborative was an established set of state standards and a process to assess performance against those standards. The collaborative served as a "learning laboratory," with members participating on the Exploring Accreditation steering committee and workgroups, hosting site visits, and describing the characteristics of their programs.

In 2006, RWJF expanded the learning collaborative to 10 states. See Appendix 1 for information about the second and third phases of the program.

Preparing Local Health Departments for Accreditation

NACCHO supported efforts in Kansas and Massachusetts to bring smaller health departments together to prepare for accreditation. Sixty percent of local health departments served fewer than 50,000 people in 2008, and most cannot provide the full scope of essential public health services. NACCHO provided technical assistance and tools to promote regional collaboration so that local public health departments were better positioned to participate in the national effort to promote accreditation standards.

For more information about these efforts, see Appendix 2.

Communications and Accreditation Expertise

RWJF funded Burness Communications and accreditation consultant Michael S. Hamm to support the Exploring Accreditation project.

Burness Communications, a public relations company based in Bethesda, Md., that helps nonprofit organizations achieve social change, developed and implemented a communications plan to update and inform public health stakeholders about Exploring Accreditation activities and recommendations (ID# 053373; June 2005 to September 2006). The company's activities included:

  • Providing advice on communications
  • Developing fact sheets, news releases, updates, PowerPoint® presentations and newsletter articles
  • Coordinating a satellite broadcast of a proposed accreditation program
  • Reviewing project materials

Hamm, of Michael Hamm and Associates in Rockville, Md., provided expertise on accreditation issues and on how an accreditation program in public health could work (ID# 053374; July 2005 to July 2006). Hamm educated steering committee and workgroup members about accreditation by preparing background materials and participating in meetings and conference calls. He did market research through telephone interviews with 22 public health professionals and an online survey and also assessed the feasibility of the proposed accreditation program.

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Results

Exploring Accreditation produced the following results, according to reports from the steering committee and NACCHO.

  • The Exploring Accreditation steering committee concluded that a voluntary national public health accreditation program for state, local, territorial and tribal health departments was both desirable and feasible. The committee's report, Exploring Accreditation: Final Recommendations for a Voluntary National Accreditation Program for State & Local Public Health Departments (released in the winter of 2006–07), stated that: We believe the establishment of a voluntary national accreditation program is desirable for many salient reasons. Chief among them is the opportunity to advance the quality, accountability and credibility of governmental public health departments, and to do so in a proactive manner.
  • Exploring Accreditation: Final Recommendations for a Voluntary National Accreditation Program for State and Local Public Health Departments provided a blueprint for developing a voluntary national public health accreditation program. The steering committee initially drafted the model in April 2006, then sought public comment from May through July 2006 through presentations, opinion surveys and mechanisms for Web-based feedback.

    The final report, which was revised with input from more than 650 public health practitioners, said an accreditation program should:
    • Promote high performance and continuous quality improvement
    • Recognize high performers that meet nationally accepted standards of quality and improvement
    • Illustrate health department accountability to the public and policy-makers
    • Increase the visibility and public awareness of governmental public health, leading to greater public trust and increased health department credibility, and ultimately a stronger constituency for public health funding and infrastructure
    • Clarify the public's expectations of state and local health departments
    The report provided recommendations for governance, eligibility, conformity assessment, standards development, financing, incentives and evaluation (see Recommendations).
  • The Public Health Accreditation Board was incorporated in May 2007 and began to develop the voluntary national public health accreditation program. Establishing a new, not-for-profit organization to oversee the accreditation program was one of the recommendations in the Exploring Accreditation report.

    The Exploring Accreditation planning committee developed a plan for establishing the accreditation board, submitted funding proposals to RWJF and CDC and managed the start-up activities, which included:
    • Incorporating and governing the board
    • Beginning the process of recruiting an executive director
    • Drafting Web site content
    RWJF and CDC have been funding the Public Health Accreditation Board, which is scheduled to launch an accreditation program in 2011. For more information, see After the Grant.

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Recommendations

Exploring Accreditation: Final Recommendations for a Voluntary National Accreditation Program for State & Local Public Health Departments included the following recommendations for a voluntary national public health accreditation program:

  • Governance: Establish a new, not-for-profit entity to oversee the accreditation of state and local public health departments. The planning committee should appoint the initial governing board. The organization should:
    • Direct the establishment of accreditation standards
    • Develop and manage the accreditation process
    • Determine whether applicant health departments meet accreditation standards
    The organization would maintain administrative and fiscal capacity and evaluate the program's effectiveness and its impact on health departments' performance. The governing board and the organization would advocate for training and technical assistance for public health departments seeking accreditation.
  • Eligible Applicants: Any government entity with primary legal responsibility for public health at the state, territory, tribal or local level would be eligible for accreditation. Eligibility would be determined in a flexible manner, given the variety of jurisdictions and governmental organizations responsible for public health.
  • Conformity Assessment Process: Health departments seeking accreditation would undergo an assessment process. This should include a review to determine readiness, a self-assessment and a site visit by representatives of the accrediting organization, resulting in a recommendation on accreditation status.

    The accrediting organization's governing body would make the final decision on accreditation. A public health department could be fully accredited, conditionally accredited or not accredited. An appeals process would be established to resolve disputes.
  • Standards Development: Standards should be developed to promote the pursuit of excellence among public health departments, continuous quality improvement and accountability for the public's health. The process for establishing standards should consider health departments' performance improvement experience.

    The steering committee created 11 domains (see Appendix 3) for which health departments should be held accountable and stated that standards should be established for each domain. Measures of compliance may differ between state and local public health departments but standards should be complementary and mutually reinforcing to promote shared accountability.
  • Financing: The new organization would need initial funding from grantmakers, government agencies and state and local health departments (including in-kind support). This start-up phase should be funded in part by applicant fees and other revenues. Fees should not be excessive or present a barrier to participation in the accreditation program.

    As the new organization approaches self-sufficiency, subsidies from grantmakers, etc. should be directed more toward applicant fees and the participation costs for public health departments in order to encourage broader participation.
  • Incentives: Incentives should be positive, supporting public health departments in seeking accreditation and achieving high standards. Incentives should support the goal of improving and protecting the public's health by advancing the quality and performance of public health departments. Credibility with governing bodies and the public, as well as access to resources for performance improvement, should encourage health departments to participate.
  • Evaluation: Evaluation is critical at every stage of the accreditation program's implementation and development. The accrediting organization should encourage research and evaluation to develop the science base for accreditation and systems change in public health.

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Significance to the Field

The National Association of County and City Health Officials (NAACHO) believes that Exploring Accreditation has helped to transform the way in which state and local public health departments view and approach accountability and quality improvement. "Local health departments across the country are seeking to understand what standards will be in play and consider what they need to position themselves to achieve accreditation," according to NAACHO's report to RWJF. A new emphasis on capacity and quality improvement appears to have taken hold.

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Lessons Learned

Lessons About Deliberations

  1. Facilitate efficient decision-making by setting a finite time for deliberations. The steering committee had a set period of time—14 months—to deliberate about public health accreditation, which meant efficient decision-making was a must. (Project Director)
  2. Use subject matter experts to provide insights and ensure well-informed deliberations. The accreditation expert who facilitated this project provided valuable insight to the steering committee and ensured that members discussed relevant issues in a well-informed manner. (Project Director)

Lessons About Communications

  1. Establish and maintain communication with all stakeholders and facilitate their participation. Project staff updated members of the public health community on the project and invited their input through the project Web site (no longer active), presentations and surveys. The steering committee and the workgroups also provided substantial opportunities for stakeholders to participate.

    "The feedback obtained provided the project's leaders with an opportunity to explicitly address concerns from the field…. When the report was released, the public health community was fully aware of the momentum being generated around accreditation and the likelihood of a new, voluntary national program," said a report to RWJF. (Project Director)
  2. Use many methods to provide information to key project participants and schedule several opportunities for them to get that information. The project staff for Exploring Accreditation had to present a lot of information to steering committee members in a short period of time, and could have thought more strategically about how best to do so. Repeating learning sessions and conducting presentations and meetings by webcast prior to in-person meetings would have made it easier for busy people to participate. (Project Director)
  3. Keep project stakeholders informed through a continually updated and well-publicized Web site. The Exploring Accreditation Web site (no longer active) contained information on the project's history, steering committee and workgroups; a project timeline; and publications and resources for health department staff. The proposed accreditation program model was posted, along with a request for feedback during the public comment period, as was the final project report.

    Each of the partner organizations publicized the Exploring Accreditation Web site. For example, NACCHO used its monthly electronic publication, NACCHO Dispatch, as well as "News from NACCHO" e-mail blasts, to publicize the site to its members. NACCHO also provided a link from its Web site to that of the project. (Project Director)

Lessons About Collaboration

  1. Build relationships and enhance collaboration through face-to-face meetings. NACCHO did not realize the importance of interpersonal relationships with staff from ASTHO when the project began. "We never took the time to do an ice-breaker or go out to lunch, and get a better feeling of who our partners were and how they think, how they work," said Project Director Grace Gorenflo. Differences in organizational cultural and staffing patterns had to be overcome in order to collaborate effectively. Now, NACCHO holds periodic face-to-face meetings when it collaborates with other organizations, even if they are not essential to the work itself. (Project Director)
  2. Establish a Memorandum of Understanding or a similar agreement to enhance collaboration. It is critical at the outset to outline mutual expectations about how work will occur, who is responsible for decision-making and how to resolve conflicts. NACCHO and ASTHO developed "principles of collaboration" to guide them, and help them work through differences in organizational cultures and staffing patterns. (Project Director)

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After the Grant

With funding from RWJF and CDC, the Public Health Accreditation Board continues to develop and implement a voluntary national accreditation program for state, local, territorial and tribal pubic health departments. The board has an active Web site.

ASTHO, NACCHO, the National Association of Local Boards of Health (NALBOH), and workgroups of state and local public health professionals worked closely with the accreditation board to develop standards and measures. In July 2009, the board adopted:

  • 30 accreditation standards and 111 measures for state health departments
  • 30 accreditation standards and 102 measures for local health departments

The accreditation program is scheduled to launch in 2011. RWJF and CDC have committed to providing up to $10 million each in the Public Health Accreditation Board through 2012.

Testing the Accreditation Program

In fall 2009, the Public Health Accreditation Board began to test the accreditation program with 30 health departments: 19 local, eight state and three tribal. Representing the diversity of health departments across the country, the 30 vary in size, structure, population served, governance, geographic region and degree of preparedness for accreditation. Massachusetts is one of the test sites for regional efforts within the state, and will inform the approach to regionalized accreditation applications involving a number of cities and counties.

RWJF is funding NACCHO (Grant ID# 066077; June 2009 to June 2011) and ASTHO (Grant ID# 066647; September 2009 to June 2010) to provide technical assistance to help local and state health departments meet the accreditation standards, and to engage in a quality improvement process for an area of weakness identified through the assessment process.

As of September 2009, a Tribal Accreditation Workgroup was working with the Public Health Accreditation Board to determine the applicability of the state and local standards in Indian country. The workgroup will be monitoring the experience of the three tribal health departments involved in the beta test.

Continuing the Multi-State Learning Collaborative

In 2008, RWJF expanded the Multi-State Learning Collaborative from 10 to 16 states and renamed the program Lead States in Public Health Quality Improvement. For more information, see Appendix 1.

Expanding Resources for Local Health Departments

NACCHO also received continued annual funding from CDC (started in 2004) to support various accreditation-related activities ($300,000; June 2009–May 2010), such as:

  • Continuing the webcast series about accreditation and quality improvement
  • Publishing accreditNATION, an electronic newsletter about accreditation and quality improvement
  • Expanding the NACCHO Web site, including adding:
    • New content on an interactive map that allows users to see current accreditation-related activities by state and local health departments
    • Examples of documentation of standards and measures from the Public Health Accreditation Board
    • Links to resources on quality improvement

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GRANT DETAILS & CONTACT INFORMATION

Project

Exploring Accreditation: Developing recommendations for a national public health accreditation system to build state and local public health agency capacity

Grantee

National Association of County and City Health Officials (Washington,  DC)

  • Amount: $ 742,377
    Dates: June 2005 to August 2006
    ID#:  053182

  • Amount: $ 35,743
    Dates: December 2005 to February 2006
    ID#:  056262

  • Amount: $ 749,528
    Dates: December 2006 to December 2008
    ID#:  058881

Contact

Grace G. Gorenflo, R.N., M.P.H.
(202) 507-4219
ggorenflo@naccho.org

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APPENDICES


Appendix 1

Multi-State Learning Collaborative/Lead States in Public Quality Improvement

To inform the steering committee about existing public health accreditation practices, RWJF established a national program called the Multi-State Learning Collaborative on Performance and Capacity Assessment on Accreditation of Public Health Departments.

Phase 1
The collaborative was launched in July 2005 and brought together five states—Illinois, Michigan, Missouri, North Carolina and Washington—to share information and enhance their capacity to assess the performance and capacity of their local or state public health departments. Members also participated on the Exploring Accreditation steering committee and workgroups, hosting site visits, and describing the characteristics of their programs.

Phase 2
Ten states participated in the second phase of the Multi-State Learning Collaborative, which began in December 2006. Phase 2 was designed to advance the quality improvement efforts of states already conducting systematic performance and capacity or accreditation of their local and state public health departments.

All of the original states in the collaborative continued to participate (Illinois, Michigan, Missouri, North Carolina and Washington) and five new states were added (Florida, Kansas, Minnesota, New Hampshire and Ohio).

RWJF contracted with researchers at the Institute for Health Policy at the University of Southern Maine to evaluate this phase of the Multi-State Learning Collaborative. In a report to RWJF, they wrote that grantees, project staff, consultants and partners perceived the second phase "very favorably" and that:

"The collaborative provided a forum for peers to learn and exchange resources and the resource helped to further the assessment accreditation efforts in 10 states. Most importantly, the MLC-2 [Multistate Learning Collaborative, phase 2] was seen as a critical platform for advancing quality improvement infrastructure and capacity at the state and local public health levels."

Phase 3
The third phase of the learning collaborative, renamed Lead States in Public Health Quality Improvement, began in April 2008. Building on the momentum of two previous phases, the third phase is designed to:

  • Prepare local and state health departments for national accreditation
  • Contribute to the development of the national voluntary accreditation program
  • Advance the use of quality improvement methods in health departments

Phase 3, lasting three-years, includes 16 states. In addition to nine states from the second phase (all except Ohio), the participants are Indiana, Iowa, Montana, New Jersey, Oklahoma, South Carolina and Wisconsin.

Researchers at the University of Southern Maine are also evaluating Phase 3.


Appendix 2

NACCHO Regionalization Efforts in Kansas and Massachusetts

Kansas worked with local health departments in two regions (with eight counties in one and 13 counties in the other). The health departments conducted self-assessments to identify areas for regional collaboration and developed plans to work together. They also participated in a regionalization summit to educate county commissioners about public health and the benefits of regionalization.

A statewide task force in Massachusetts was established to examine and advocate for regionalization within the state. The task force explored the financial and statutory aspects of regionalization, identified potential regional models, began to define what regions would be expected to provide and encouraged local health departments to support regionalization.

NACCHO shared information about these regionalization efforts within states through case studies of Kansas and Massachusetts, resources and tools used by the states and other communication products. NACCHO posted the case studies on its regionalization Web page.


Appendix 3

Domains for which Health Departments Should Be Held Accountable

Health departments should be accountable in 11 domains:

  1. Monitor health status and understand health issues
  2. Protect people from health problems and health hazards
  3. Give people information they need to make healthy choices
  4. Engage the community to identify and solve problems
  5. Develop public health policies and plans
  6. Enforce public health laws and regulations
  7. Help people receive health services
  8. Maintain a competent public health workforce
  9. Use continuous quality improvement tools to evaluate and improve the quality of programs and interventions
  10. Contribute to and apply the evidence base of public health
  11. Govern and manage health department resources (including financial and human resources, facilities and information systems)

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Exploring Accreditation: Final Recommendations for a Voluntary National Accreditation Program for State & Local Health Departments (Full Report). Washington: Exploring Accreditation Steering Committee, Winter 2006–2007. Available online.

Healthy People Build Strong Communities: The Kansas Public Health Story Fact Sheet. Topeka, KS: Kansas Association of Local Health Departments, November 2008.

Kansas Functional Regionalization Fact Sheet. Topeka, KS: Kansas Association of Local Health Departments, May 2008.

World Wide Web Sites

www.phaboard.org. The Web site of the Public Health Accreditation Board contains information about Exploring Accreditation and the project's steering committee and workgroups. It also has information about the voluntary national public health accreditation program.

www.naccho.org/topics/infrastructure/regionalization. This portion of the National Association of City and County Health Officials' Web site has information on the RWJF-funded regionalization work, as well as information about the projects in Kansas and Massachusetts.

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Report prepared by: Lori De Milto
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: Angela K. McGowan
Program Officer: Russell Brewer
Program Officer: Carol S. Chang
Program Officer: Pamela G. Russo

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