The Centers for Disease Control and Prevention's Office for State, Tribal, Local, and Territorial Support (CDC-OSTLTS) has played a key role in advancing public health department accreditation. In her APHA presentation, CDC's Liza Corso, MPA, Senior Advisor for Public Health Practice and Accreditation in the Division of Public Health Performance Improvement, shared the many ways CDC-OSTLTS -- in addition to its many support initiatives -- has worked to build connections between accreditation and a range of programs and services.

 

 

Liza Corso

         From serving as a co-funder of PHAB and the national accreditation program, to supporting national partner organizations and health departments, to establishing incentives and building connections, the Centers for Disease Control and Prevention's Office for State, Tribal, Local, and Territorial Support has played a key role in advancing public health department accreditation.   

         "CDC has been a partner right from the start," said Liza Corso, MPA, CDC Senior Advisor for Public Health Practice and Accreditation in the Division of Public Health Performance Improvement's Office for State, Tribal, Local, and Territorial Support. "But we know that it's going to take a lot more than just supporting the accrediting body and the accreditation program itself to make this successful."

         The successful momentum in the field around public health department accreditation has been due in large part to the CDC-OSTLTS National Public Health Improvement Initiative (NPHII). Launched in 2010, the NPHII program has accelerated public health accreditation readiness, improved organizational efficiency and effectiveness through quality improvement activities, and increased performance management capacity by providing financial and technical support to state, tribal, local and territorial public health departments. Funded through the Affordable Care Act's Prevention and Public Health Fund, the initiative has provided funds totaling more than $141 million to approximately 75 awardees each year.

         Though intended to be a five-year initiative, NPHII funding ended after four years due to changes in federal appropriations from Congress. However, the vast majority of the grantees continued activities into the fifth year (which began in Fall 2014) through no-cost extensions.

         "So NPHII work continues, and of course we are looking for ways to sustain that," Corso told the audience. "But let me tell you what we've been able to accomplish with NPHII."

         Among NPHII's expectations has been a requirement that each funded state, territorial, local or tribal health department hire or identify a Performance Improvement Manager (PIM). Part of a national network of performance improvement professionals, each PIM leads or supports work funded through NPHII. Many PIMs play lead roles in preparing health departments for PHAB accreditation.   

          "The PIM was someone who would ideally sit at a senior level in the organization and play a cross-cutting role in advancing accreditation readiness or meeting the standards, or quality improvement and performance management," Corso added. "Some states and local jurisdictions had these individuals or offices prior to NPHII, so those grantees expanded that capacity in new ways."

          NPHII grantees also were expected to do a self-assessment against the PHAB standards to determine where standards had been met or not met. Grantees were able to use the information to pinpoint their biggest gaps, and then take action with their NPHII funding to fill those gaps.  

          "Not surprisingly, some of the biggest gaps are in the workforce development, performance management, and quality improvement-related standards," Corso said. "We certainly know that a lot of agencies are still working on developing workforce development plans and performance management systems, and still building a quality improvement culture and the quality improvement plan that's expected for PHAB."  

         NPHII also included a special objective around the PHAB prerequisites. Among the requirements for a health department's application for accreditation to be approved, the health department must submit, along with its application, three prerequisite documents: a community health assessment, community health improvement plan, and an agency strategic plan.  

        

         Another objective in NPHII was that all NPHII grantees were expected to undertake quality improvement projects, many of which addressed improvements in efficiency, or improvements in effectiveness. Improvements in efficiency have included time saved, reduced steps in a process, and costs saved. Improvements in effectiveness have included activities associated with increased customer/staff satisfaction, increased preventive behaviors, increased reach to a target population, quality enhancement of data systems, and quality enhancement of services and programs.  

          

 Building Connections, Strengthening Partnerships  

 

           Building on NPHII's strong foundation of accreditation support accomplishments, CDC-OSTLTS also provides funding to key national partner organizations for accreditation-related support. These partner organizations include the American Public Health Association, Association of State and Territorial Health Officials, National Association of County and City Health Officials, National Indian Health Board, National Network of Public Health Institutes, and the Public Health Foundation. Several of these organizations use CDC funding to support Accreditation Support Initiatives (ASIs).  

         "The Accreditation Support Initiative is really all about putting out small amounts of funding to advance accreditation readiness," Corso added. For example, since 2011 the CDC-NACCHO Accreditation Support Initiative has provided $3.7 million through 88 awards to advance accreditation readiness at local health departments. Approximately 25 percent of awardees used the funds to pay up to 50 percent of PHAB fees.  

         "It's wherever that needle needs to be moved," she noted. "Some health departments have used this to pay part of their PHAB fees. Others have used funds to advance quality improvement, health improvement planning, or workforce development. The support has really cut across a variety of domains."

         Similarly, since 2012 the CDC-APHA Accreditation Support Initiative has also assisted health departments on their journeys toward accreditation. The competitive mini-grants, which have been less than $10,000 each, support APHA affiliates' efforts to advance the accreditation readiness of the health departments in the affiliates' states. APHA affiliates are generally state public health associations.

          "Statewide associations can often play unique roles," Corso explained. "What I really like about this initiative is that it has also helped to advance the dialogue in some states where there hasn't been as much accreditation momentum."

         Thanks to the CDC-APHA initiative, hundreds of public health professionals have been able to benefit from training workshops, regional meetings, webinars, conferences, educational videos, and resources on community health improvement and organizational strategic planning.

         "And this year I am really pleased to note that we have provided funding to the National Indian Health Board (NIHB) for an Accreditation Support Initiative that will be focused on tribal public health departments," said Corso, noting that NIHB recently announced the selection of five tribal health departments for the Tribal Accreditation Support Initiative. Slated to run through June 2015 and totaling more than $50,000, the awards will support the tribes' accreditation readiness efforts through technical assistance, educational resources, and trainings.  

         In addition to its many support initiatives, CDC is also working to build connections between accreditation and a range of programs and services, such as the Preventive Health and Health Services Block Grant. To that end, CDC is exploring how programs and services are reflected in the PHAB standards and how funded programs and activities aid in meeting PHAB standards. CDC has also incorporated consistent PHAB accreditation-related language into its standardized Funding Opportunity Announcement (FOA) guidance. To date, 58 domestic, non-research FOAs in 2013 and 2014 have included this language. Relevant language has been included in both the Organizational Capacity Statement area, where applicants are encouraged to describe their current accreditation status, and in the Budget Narrative Guidance section, where applicants can -- if it is consistent with the statutory authority and spirit of that FOA -- request to use the funds in ways that mesh with the FOA's purpose but also help to fill gaps in meeting those standards.

          "So really we are talking about leveraging our investments in ways that make sense," Corso said. 

 

 

The Robert Wood Johnson Foundation has provided generous funding and content expertise to PHAB since its incorporation in 2007. In her presentation to APHA, Robert Wood Johnson Foundation Senior Program Officer Pamela Russo, MD, MPH, reflected on the foundation's reasons for supporting national public health department accreditation. She also shared some qualitative findings that are providing early signals of accreditation's impact and helping to inform future measurement.

 

        

Pamela Russo

          In 2003, the Institute of Medicine released a groundbreaking report titled The Future of the Public's Health in the 21st Century. The report found that public health was in "disarray," just as an earlier report had found in 1988, said Pamela Russo, MD, MPH, a Senior Program Officer for the Robert Wood Johnson Foundation. One of the report's recommendations was that a National Steering Committee be formed to examine the potential benefits of national accreditation for public health departments.  

         The report noted that public health departments across the nation varied greatly in terms of authority, resources, capabilities, division of labor, size of the population served, size of the health department, the services offered, and governance. According to Russo, the variations sparked a popular saying at the time that suggested, "If you've seen one health department, then you've seen one health department."

         Much of the variation had negative implications, including fragmented and dysfunctional systems and inequitable health protection and promotion. But at the same time, "Some variation is positive if it is to tailor and adapt the services offered to the population that the health department serves," Russo noted. Thus, a first challenge for those who were exploring public health accreditation was to strike the balance between having a set of standards that would reduce undesirable variation and achieve conformity, but at the same time, "not rigidly prescribe exactly how to meet those standards in order to allow the desirable variations that fit different contexts to occur."
         Among the challenges was the need to decide where to set a performance bar that not every health department could meet without pursuing improvement. Thus, as the Robert Wood Johnson Foundation considered the proposal to support accreditation, one senior leader at the foundation remarked, "'It's got to have teeth,' but at the same time there was agreement that the bar could not be set too high initially," Russo explained.
         The goal was to raise the standards over time, she said, continuously transforming practice to a higher level and refining the standards and measures based on new evidence. Other goals included improving accountability and transparency to the public, to the governing body, to peer agencies and community partners, and creating a platform for continuous quality improvement. In addition, an "aspirational goal" was that accreditation be used as a vehicle to drive transformation of the field so that it could respond to evidence on new best practices or to changes in the landscape, such as health reform, and that it could lead to more efficient and effective practice.
         With the goals in place, RWJF in 2004 commissioned Glen Mays, PhD, MPH, to study the impact of accreditation in other service industries. Mays found that accreditation programs appeared to develop in response to rising pressure to improve the quality and value of services, much like the situation in public health. Mays concluded that "Limited but encouraging evidence exists to suggest that accreditation programs produce positive effects on service quality, service outcomes, and the operations of service providers."           

PHAB Board of Directors Chair Leslie Beitsch, left, RWJF Senior Program Officer Pamela Russo, center, and CDC Senior Advisor for Public Health Practice and Accreditation Liza Corso were among the speakers at PHAB's special session at APHA in November.

          

         RWJF also commissioned Lee Thielen, MPA, to provide a scan of the state-based public health accreditation and accreditation-like programs, which provided valuable empirical evidence. Both papers provided background for a meeting convened by RWJF in December 2003 that brought together federal, state, local and tribal public health leaders. At the meeting, it was decided that an independent committee should be established to examine the desirability and feasibility of a national accreditation system. In 2004, RWJF and CDC funded the committee, which was chaired by Kaye Bender. At the same time, RWJF launched the multi-state collaboration for accreditation and quality improvement.

         "Known affectionately as the 'MLC,' it started with five of the states that had state-based accreditation-like systems," she said. "With that, RWJF had made a landmark decision to invest in accreditation for the long haul." 

         Three years later, in 2007, PHAB was established, and RWJF set a strategic goal that by the end of 2015, 60 percent of the U.S. population would be served by an accredited health department. The goal was adjusted to also include health departments moving through the application system, given the data showing that 99 percent of those starting completed the process.
         "That goal was met last year and the percent continues to climb, now nearing 70 percent," Russo said. "So given our goal, our first indicator of impact was that there was demand for accreditation."
         Once PHAB opened its doors for applications in 2011, the demand exceeded all expectations as the applications and those accredited continued to rise steadily. Added Russo, "We also have an answer for where the bar had been set. The bar was set high enough because in every review there are some health departments that don't sufficiently meet the standards and must submit an action plan to rectify the deficits reported by the site visit team and the review committee...accreditation does have teeth."

 

          With dozens of health departments now accredited, there is increasing pressure from various sources to examine the impact of accreditation -- "the 'so what' question," Russo said. However, comparing accredited health departments to non-accredited health departments on certain measures of performance or outcomes would not yield valid results at this time "because it is too early in the life cycle of accreditation, there are insufficient numbers with which to do quasi-experimental studies, and there is a selection bias in that the earliest adopters were stronger to start with," she addded.
         Measuring the impact of accreditation on population health status -- the so-called "holy grail" -- is even more difficult to assess, "and we will need multiple years of data, pre- and post-pursuit, and achievement of accreditation to begin to even answer that question," Russo told the audience.
         The current evidence that accreditation yields benefits is largely based on qualitative findings -- stories at this point -- that can give early signals of impact and help to inform future measurement, Russo explained. One such story illustrates how accreditation standards provide priorities that can guide the reorganization of health departments.
         "When Karen DeSalvo became the New Orleans Health Commissioner, she didn't have a public health background, and she told us that she turned to the accreditation standards to redesign the department," Russo explained.
         Using PHAB's accreditation standards as a road map, DeSalvo, MD, MPH, MSc, who is now the Acting Assistant Secretary of Health for the U.S. Department of Health and Human Services, transformed the outmoded New Orleans health department into one that in 2014 achieved national accreditation through PHAB.
                "It's odd, but it wasn't common in many health departments prior to accreditation to seek the evidence base, and much less to document the evidence base underlying decisions," Russo said.
         Other qualitative reports illustrate how accreditation improves the understanding of the mutual roles of state and local health departments, she said, noting that it was a deliberate choice in the development of the PHAB standards to mirror the respective roles.
         "An example from Oklahoma was that prior to engaging in accreditation, when there was an outbreak at the local level, the state swept in, the locals were cast aside, and the local staff and infrastructure weren't strengthened," she said. "Post accreditation, they now handle outbreaks as a true partnership, and the learning accrues at the local level."
         Accreditation also has been known to improve risk management. For example, finding documentation to satisfy certain measures identifies policies that are out-of-date or missing, and pushes updates, she said.
          "One state health official said that, as they were preparing for accreditation, they realized their human resources policies had not been looked at for years," Russo explained. "The state's attorney said the updating was one of the best risk-management processes they'd ever seen."
         Other qualitative findings suggest that accreditation helps assure more stable funding.
          "Elected officials don't usually like to threaten the viability of an accredited agency or program," Russo noted. Also, becoming accredited puts the health department on that same playing field as other governmental and health-related services -- hospitals, schools, child care centers, home health, police and fire departments.
         "In closing," Russo summarized, "let me say that from the point of view of the millions of dollars that the foundation has invested in supporting accreditation and quality improvement, we sincerely hope that 10 years from now an Institute of Medicine committee will find that public health is much more 'arrayed' than it was in 2003, and hopefully by then we will have an operational definition for how to measure 'array' and 'disarray.'"

   

Quality improvement is embedded into the accreditation process on many different levels, not just for health departments seeking accreditation through PHAB, but for PHAB itself. In his presentation to APHA, Leslie M. Beitsch, MD, JD, chair of PHAB's Board of Directors and chair of the Department of Behavioral Sciences and Social Medicine at Florida State University College of Medicine, shared the various ways PHAB is committed to modeling quality improvement.

 

        

Leslie Beitsch

          Mirroring the expectations of the health departments it serves, PHAB models quality improvement as an organizational commitment and embeds quality improvement into the accreditation program across multiple levels and layers, said Leslie M. Beitsch, MD, JD, chair of PHAB's Board of Directors.  

         "If we are asking health departments all around the country to up their game, to do quality improvement on a continuous level, then we at PHAB need to be doing that too," Beitsch told session attendees at APHA's November 2014 annual meeting. "If we are asking you to become quality organizations, we are dedicated to doing that too, and we are doing it in a very systematic, organized fashion. We want you to do that as well, and if we can model that behavior to make it easier for everyone, we are going to do that, too."

         PHAB's Evaluation and Quality Improvement Committee provides guidance in the ongoing development and implementation of PHAB's internal and external evaluation plans and activities, said Beitsch, who co-chairs the committee with PHAB Board of Directors member William Riley, PhD. In addition to providing oversight and feedback for the PHAB evaluation process, the committee also works with PHAB's Accreditation Committee to review the Annual Reports of accredited health departments.

          "We are very much in the formative stages of what the feedback and report that can be most valued needs to look like," Beitsch told session attendees. "We are doing quality improvement on that part of the process (to learn) what can be most instrumental in giving a health department both kudos and credit for the things they are doing well, and yet guide them on areas where they may do better."

         Touching on some of PHAB's evaluation efforts, Beitsch noted that PHAB has engaged an external social science research organization -- NORC at the University of Chicago -- to gain an understanding of the accreditation program's strengths, opportunities for improvement, and impacts. The three-year evaluation of the national public health accreditation program will assess ongoing accreditation activities and processes, and the quality of the accreditation process through applicants' experiences and the achievement of outcomes.

         "We are not only looking at ourselves, we have third-party evaluators examining certain parts of our activities," Beitsch said of PHAB's contract with NORC, "much as we are third-party assessors of health departments."

        

Evaluation and Quality Improvement Committee Co-Chairs Leslie Beitsch, left, and William Riley preside over an April 2, 2015 meeting at PHAB's Learning Center in Alexandria, Virginia.

 

           

         In addition, the PHAB standards themselves -- built on a solid foundation of standards, metrics, and benchmarks that were already available in the field -- are emblematic of how quality improvement is front and center at PHAB. Developed through an iterative process by public health practitioners and vetted by the field, the standards will continue to evolve over time as they adapt to the current state of affairs within public health practice. For example, Version 1.5 of the PHAB Standards and Measures, released in January 2014, improved them by clarifying the wording of certain requirements, stipulating the number of examples that are required for each measure, and specifying the time frame for each measure. Additionally, a number of noteworthy public health issues that are emerging as important forces in the advancement of public health are included in the new version.

         "Version 1.5 of the PHAB Standards and Measures is an example of PHAB trying to again hone and refine the standards and measures as circumstances on the ground -- the actual practice of public health -- change and move forward," Beitsch said.

        

Embedding Quality Improvement  

 

         While quality improvement opportunities exist within each standard, evaluation and quality improvement is central to Domain 9. Standard 9.1 discusses using a performance management system to monitor achievement of organizational objectives and Standard 9.2 details the development and implementation of quality improvement processes integrated into organizational practice, programs, processes and interventions. Keeping with PHAB's goal to model quality improvement as an organizational commitment, Standard 9.1 "is one of, if not the most critical standard, and certainly the one that really underscores what we are talking about here, which is using a performance management system to monitor achievement of organizational objectives," Beitsch said. "So whether that enterprise is a health department or PHAB itself, there has to be a performance management system in place to be sure that all the things that you are doing are in alignment and are working together to achieve the key priority outcomes of the organization."

         Quality improvement is also "heavily embedded" into PHAB's strategic map, Beitsch said, with key goals dedicated to ensuring continuous quality improvement, integrating systematic evaluation, continuously improving the accreditation process, continuously improving the standards and measures, and improving customers' experiences by increasing efficiencies. Revised by PHAB's Board of Directors every three years, the map underscores PHAB's central challenges during the three-year period and serves as a one-page pictorial of where PHAB will go as an organization during that time frame.

          "The quality improvement aspects for that are critical," Beitsch said. "They might not dominate every aspect of the strategic map, but they are heavily embedded into it."

         Similarly, PHAB's operational logic model serves as another important tool for helping researchers and evaluators understand the goals of accreditation so that they can systematically test the links between the work of the accreditation system and the various outcomes, Beitsch said. The logic model also serves as a visual reminder of how stakeholders in the accreditation enterprise can work together to achieve PHAB's goals. With inputs from PHAB, national partners, funders, the research community, and public health departments that have gone through the accreditation process, the logic model presents a logical framework of how their inputs and strategies may lead to outcomes for PHAB, participating health departments, and the public health field.

         Another quality improvement activity that PHAB promotes, and is likewise reflected on its strategic map, is the importance of adopting a metrics approach to accreditation evaluation. Public health metrics, which Beitsch called a "metaphor for health outcomes," refers to the importance of linking accreditation and improved performance with better health.

         "For PHAB to be relevant, it's got to encompass and incorporate the dynamics occurring in public health practice," Beitsch told the audience. "Eventually performance has to be shown to relate in some way to improving health outcomes or we really diminish the role that PHAB can and should play in terms of transforming public health practice."