final recommendations for a · 2018-12-11 · final recommendations for a voluntary national...

• 1

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

Final Recommendations for a

VOLUNTARY NATIONALACCREDITATION PROGRAM

State & LocalPublic HealthDepartments

for

FULL REPORTWINTER 2006-2007

EXPLORING ACCREDITATION

2 •

Patrick M. LibbeyExecutive DirectorNational Association of County and CityHealth Officials

The following individuals serve on the Planning Committeeof the Exploring Accreditation project:

This project was made possible with funding fromthe Centers for Disease Control and Prevention (U50/CCU313903-8-1)

and the Robert Wood Johnson Foundation Grant # 053182.

*This position was held by George E.Hardy, Jr., MD, MPH, former ASTHOExecutive Director, until July 1, 2006.

The time and effort contributed by the Planning Committee has been instrumentalto this process, and their support is greatly appreciated.

Georges Benjamin, MD, FACPExecutive DirectorAmerican Public HealthAssociation

Marie Fallon, MHSAExecutive DirectorNational Association of LocalBoards of Health

Paul E. Jarris, MD, MBA*Executive DirectorAssociation of State and TerritorialHealth Officials

http://www.apha.org

http://www.nalboh.org

http://www.astho.org

http://www.naccho.org

• 3


ACKNOWLEDGEMENTS ………………………………………………......................................... 4

EXECUTIVE SUMMARY ………………………………………………............................................ 5

Message from the Steering Committee ……………………………………………………... 7

How the Model was Developed…………………………………………………………........ 8-9

METHODOLOGY

Planning Committee………………………………………………....................................... 10

Steering Committee………………………………………………………............................. 10

Workgroups………………………………………………………………............................... 10-11

Multi-State Learning Collaborative……………………………………................................ 11

Communications………………………………………………………….............................. 11-12

Accreditation Consultant Expertise………………………………………............................ 12-14

Evaluation………………………………………………………………….............................. 14-15

Public Comment……………………………………………………………........................... 15-16

Business Case………………………………………………………………............................. 16-17

Logic Model…………………………………………………………………........................... 17

FINAL RECOMMENDATIONS AND RATIONALE

Governance ……………………………………………………………………………............. 18-21

Eligible Applicants …………………………………………………………………….............. 22-23

Principles to Guide Standards Development ……………………………………....……….. 24-27

Conformity Assessment Process ………………………………........………………………... 28-29

Financing ………………………………………………………………………………............. 30-34

Incentives ………………………………………………………………………….........……... 35-36

Program Evaluation and Research ……………………………………………………………. 37-38

PUBLIC COMMENT DISCUSSION …………………………………………………………….......... 40-43

THE BUSINESS CASE FOR ACCREDITATION………………………………………………............ 43-47

APPENDICES

A – Steering Committee, Workgroup, Project Staff, and

Funding Organization Representatives Rosters ……............................................... 48-52

B – Questions for Workgroups .………………………………………..........…................ 53-57

C – Exploring Accreditation Feedback Form ………………………………………………. 58-60

D – List of Presentations …………………………………………………………………….. 61-63

E – Examples of Standards and Measures…………………………………………………. 64-65

F – Logic Model…………………………………………………………………….............. 66-68

G – Business Case………………………………………………......................................... 69-76

H – Glossary…………………………………………………………………........................ 77-79

I – Public Comment Tables………………………………………………………............... 80-89

TABLE OF CONTENTS

4 •

ACKNOWLDEGEMENTS

The Planning Committee for the Exploring Accreditationproject would like to acknowledge the dedication andhard work of those involved with this project, and toexpress our gratitude for their time and effortthroughout the past year. Without the commitment andexpertise of each of these individuals, the level of successthis project has achieved could not have been reached.

The members of the Steering Committee andWorkgroups served as the backbone of this project. Weextend our thanks to you. As representatives of theirrespective sectors in public health, Steering Committeemembers offered their experience, insight, and time to‘leave no stone unturned’ as they proposed theframework for a national accreditation program for stateand local health departments. Also instrumental in thiseffort, were members of the Exploring AccreditationWorkgroups, whose thoughtfully preparedrecommendations facilitated the careful deliberations ofthe Steering Committee and informed the process atevery turn.

We would like to thank the following individuals for theirvaluable contributions to this project. Michael Hamm ofMichael Hamm and Associates lent invaluable expertiseand guidance in shaping all of the programrecommendations. Chuck Alexander and Francie dePeyster of Burness Communications facilitated projectcommunications and helped keep the field informed andengaged throughout the duration of the project. ShellyKessler and Jared Raynor of the TCC Group assisted indeveloping program evaluation principles and also inevaluating project activities.

The participants of the Robert Wood Johnson FoundationMulti-State Learning Collaborative (MLC) contributedsubstantially to the exploration of accreditation.Representatives of the MLC shared state-level programexperiences throughout the duration of the project, boththrough formal presentations as well as through timelyresponses to several inquiries. This information providedvaluable insights into the design of the model andhelped in the consideration of important aspects ofprogram implementation.

The framework for the national accreditation program forstate and local health departments was informed by avariety of perspectives, many of which represent theconstituencies to be accredited and include not onlythose mentioned here, but also those who providedfeedback during the public comment period. We wouldlike to thank those individuals, whose insight informedthe discussions and, ultimately, the finalrecommendations of the Steering Committee.

We would also like to thank the Exploring Accreditationstaff, without whom the success of this project could nothave been realized. Their time, effort and dedication hasbeen essential to this project in so many ways. Specialthanks to the following staff from the Association of Stateand Territorial Health Officials: Lindsey Caldwell, JacalynCarden, Sterling Elliott, Jennifer Jimenez, Pat Nolan(consultant), Adam Reichardt and Mary Shaffran; andfrom the National Association of County and City HealthOfficials: Priscilla Barnes, Penney Davis, Grace Gorenflo,Carolyn Leep, Jocelyn Ronald and Jessica Solomon.

Finally, we would like to give special thanks to theCenters for Disease Control and Prevention (CDC) andthe Robert Wood Johnson Foundation (RWJF) for theirsupport of this project, which allowed for thismonumental project to be carried out. Specifically, LizaCorso, Dennis Lenaway, Anthony Moulton, and EdThompson from CDC and Russell Brewer, Carol Chang,and Pamela Russo from RWJF.

• 5


EXECUTIVE SUMMARY

Every day in communities and states across the country,public health departments help millions of people leadhealthier lives. The Exploring Accreditation projectprovided an opportunity to consider whether and how avoluntary national accreditation program could lead tofurther improved health for their constituencies. TheExploring Accreditation Steering Committee and itsWorkgroups developed a draft model for such aprogram. After receiving extensive and thoughtfulcomments through presentations, web-based feedback,and formal surveys, the Steering Committee revised themodel. The Steering Committee also considered abusiness case for developing and operating the model.The Steering Committee concluded that it is desirableand feasible to move forward with establishing therecommended model program as it is presented here.

This voluntary national accreditation program should:

• Promote high performance and continuousquality improvement;

• Recognize high performers that meet nationallyaccepted standards of quality and improvement;

• Illustrate health department accountability tothe public and policymakers;

• Increase the visibility and public awareness ofgovernmental public health, leading to greaterpublic trust and increased health departmentcredibility, and ultimately a strongerconstituency for public health funding andinfrastructure; and

• Clarify the public’s expectations of state andlocal health departments.

The following is a brief summary of therecommendations.

GovernanceA new non-profit organization should be formed by thePlanning Committee organizations to oversee thevoluntary accreditation of state, territorial, tribal andlocal governmental public health departments. ThePlanning Committee should appoint the initial GoverningBoard of the new organization. Under its GoverningBoard, the organization would direct the establishmentof accreditation standards; develop and manage the

accreditation process; and determine whether applicanthealth departments meet accreditation standards. Theorganization would maintain the needed administrativeand fiscal capacity and would evaluate the effectivenessof the program and its impact on health departments’performance. The Governing Board and the organizationwould advocate for available training and technicalassistance for public health departments seeking to meetthe standards and to develop a culture of continuousquality improvement.

Eligible ApplicantsAny governmental entity with primary legal responsibilityfor public health at the local, state, territorial, or triballevels would be eligible for accreditation. Eligibility toapply for accreditation would be determined in a flexiblemanner, given the variety of jurisdictions andgovernmental organizations responsible for public health.

Principles to Guide Standards DevelopmentStandards should be developed to promote the pursuitof excellence among public health departments,continuous quality improvement, and accountability forthe public’s health. The process for establishingstandards should consider performance improvementexperience among state and local public healthdepartments.

The Steering Committee created 11 domains for whichstate, territorial, tribal and local health departmentsshould be held accountable. Standards should beestablished for each domain. Measures of compliancemay differ but standards should be complementary andmutually reinforcing to promote the sharedaccountability of public health departments at all levelsof government.

Conformity Assessment ProcessHealth departments seeking accreditation wouldundergo an assessment process. It should include areview to determine readiness, a self-assessment, and asite visit, resulting in a recommendation on accreditationstatus. The final decision on accreditation would bemade by the Governing Board. A public healthdepartment would be fully accredited, conditionallyaccredited, or not accredited. An appeals process wouldbe established to resolve disputes.

6 •

FinancingThe new organization will need initial start-up fundingfrom interested grant-makers, government agencies, andorganizations of state and local health departments,some of which may be in-kind support. Subsidies forinitial operations will be required, but this phase shouldbe funded in part by applicant fees and other revenues.It is important to attract the full spectrum of local andstate public health departments to the accreditationprogram, and applicant fees should not be excessive orpose a barrier to participation. As the new organizationapproaches self-sufficiency, subsidies should be directedmore toward applicant fees and costs in order toencourage broader participation.

IncentivesIncentives should be uniformly positive, supportingpublic health departments in seeking accreditation andachieving high standards. Incentives should support thegoal of improving and protecting the health of thepublic by advancing quality and performance of publichealth departments. Credibility with governing bodiesand the public, as well as access to resources forperformance improvement should encourageparticipation by health departments.

Program EvaluationEvaluation is critical in every stage of the developmentand implementation of an accreditation program. Theaccrediting entity should encourage research andevaluation to develop the science base for accreditationand systems change in public health.

ImplementationThe details of implementation will be developed by theleaders who take on the challenge of developing the neworganization. Implementation will be a multi-yearprocess requiring substantial external support in thedevelopment years. Implementation should includerigorous evaluation and process improvements in theaccreditation program to make it more successful andcost-effective.

In September 2006, the Exploring AccreditationSteering Committee released the document entitledFinal Recommendations for a Voluntary NationalAccreditation Program for State and Local Public HealthDepartments. The document describes the concludingrecommendations made by the Steering Committee fora national accreditation program.

It was agreed that following the release of the FinalRecommendations, a comprehensive report would bedeveloped to further explain the conclusions that weremade, including the rationale behind the decisions, andthe alternatives that were considered. In addition, thisreport would describe the parties and components thatinfluenced the development of the recommendationsincluding the Steering Committee, the Workgroups, thework of the consultants, a public comment period andreport, and a business case.

What follows is the comprehensive report describedabove. In essence, this document is an expansion of therecommendations released in September 2006. Thereare new sections on methodology, public comment, anda business case. Following each of the components ofthe recommended model (e.g. Governance, EligibleApplicants, etc.) is a discussion on the rationale behindit. There are also new appendices to accompany thesections that have been added.

• 7

A V

OLU

NTA

RY NATIO

NA

L AC

CRED

ITATION

PROG

RAM

FOR

STATE AN

D LO

CA

L PUBLIC

HEA

LTH D

EPARTM

ENTS

The 2003 Institute of Medicine (IO

M) report,

The Future of the Public’s Health, called for the

establishment of a national Steering C

omm

ittee toexam

ine the benefits of accrediting governmental public

health departments. W

ithin its Futures Initiative, theC

enters for Disease C

ontrol and Prevention (CD

C)

identified accreditation as a key strategy for strengtheningthe public health infrastructure. Several states currentlym

anage statewide accreditation or related initiatives for

local health departments. W

ithin this context, in 2004,the Robert W

ood Johnson Foundation convened publichealth stakeholders to determ

ine whether a voluntary

national accreditation program for state and local public

health departments should be explored further. The

consensus was to proceed, and the Exploring

Accreditation project was launched.

The goal of the Exploring Accreditation project was to

develop recomm

endations regarding whether it is

feasible and desirable to implem

ent a voluntary nationalaccreditation program

or some other m

ethod forachieving a system

atic approach for public healthim

provement. In order to achieve the goal, w

e (theSteering C

omm

ittee), designed a proposed model

program and vetted it through public health officials

across the nation. We also considered a business case for

the proposed model. In August 2006, w

e made changes

in the proposed model based on the feedback received

and concluded that the revised model is feasible and

desirable. We recom

mend m

oving forward w

ithim

plementation.

We believe the establishm

ent of a voluntary nationalaccreditation program

is desirable for many salient

reasons. Chief am

ong them is the opportunity to

advance the quality, accountability and credibility ofgovernm

ental public health departments, and to do so in

a proactive manner. At least 18 states are involved in

performance and capacity assessm

ent and improvem

entefforts, lending excellent experience to the design of anational program

. These experiences illustrate thesignificant benefits of engaging in accreditation andrelated efforts —

benefits that the national program is

designed to achieve. Chief am

ong them are quality and

performance im

provement, consistency am

ong publichealth departm

ents, and recognition of excellence. Thepublic com

ment solicited from

public health practitioners

in the field indicated support for a voluntary nationalprogram

. This program w

ill foster the concept of publichealth as a system

, and promote consistency and high

performance nationw

ide. It also will strengthen the

ability to clarify and articulate what public health does,

and set reasonable and achievable expectations to this end.

We feel that it is feasible to pursue a voluntary national

accreditation program because it is building upon the

mom

entum established by existing state accreditation

and performance im

provement program

s. By takingadvantage of know

ledge gained from standards

development, perform

ance measurem

ent methods,

technical assistance projects and other operationalcom

ponents of state-based programs, this program

canbe flexible, efficient and nim

ble. Funding is a major

factor in starting up and sustaining the new accreditation

body through the initial operational phases. We believe

the potential for funding a voluntary nationalaccreditation program

exists, and we plan to help

cultivate that potential. We understand that not all

health departments are prepared to becom

e accredited,and this has been factored into the design of a nationalprogram

(through recomm

endations to promote the

availability of technical assistance and other support forsuch health departm

ents). We recognize that a national

database could facilitate research and enhance theevidence-base regarding best practices and the utility ofaccreditation as a perform

ance improvem

ent method.

Finally, we acknow

ledge that long-term success w

illrequire m

aintaining the credibility of the accreditationprogram

and continuing interest in the quality of publichealth departm

ents.

Over 650 public health professionals took the tim

e toparticipate in public com

ment activities. This feedback

was an invaluable com

ponent of the exploration.

A summ

ary of the substantive changes that were m

adeto the proposed m

odel in response to the feedbackreceived include the follow

ing:

•G

uiding principles for the composition of the

Governing Board have been revised to provide

more flexibility to the Board of Incorporators by

listing general principles as to the composition

rather than specific slots (page 18).

MESSA

GE FRO

M TH

E STEERING

CO

MM

ITTEE

8 •

• Principles for relationships with state-basedaccreditation programs have been expanded,such that national accreditation is automaticallyconferred on health departments accredited bya state-based program that has received formalrecognition/approval from the national program(page 19).

• Territorial and tribal public health departmentsare specifically included in the definition of“eligible applicants” (page 22).

• While applicants are expected to demonstratecompliance with all domains for each programoffered, the conformance assessmentmeasurements will be applied on a samplingbasis (page 28).

Additional clarifications have been made throughout thisdocument in response to questions and commentsreceived. Public comment yielded both support andconcerns about a voluntary national accreditationprogram. This feedback influenced our finalrecommendations, and also will inform the program’sstructure and operation in an implementation phase. The details regarding public comment can be foundstarting on page 40.

Following the submission of our recommendations to thePlanning Committee, ASTHO, NACCHO and NALBOHeach moved to:

• Endorse the recommendations of the ExploringAccreditation Steering Committee for avoluntary national accreditation program.

• Lead, in cooperation with appropriate partners,in the development and implementation of sucha voluntary national accreditation program thatwill drive continuous quality improvement.

APHA also included language in their strategic plan tosupport the national program.

The Planning Committee also shared therecommendations with the Centers for Disease Controland Prevention and the Robert Wood JohnsonFoundation, both of which funded this effort and haveindicated interest in funding and supporting theestablishment and operation of the recommendedprogram.

Finally, we would like to thank the Planning Committeeand echo their sentiment in thanking the ExploringAccreditation Workgroup members, staff, and consultantswhose contributions were so vital to this effort. Theircollective commitment to this work has been vital to thesuccess of the project (see Appendix A for a full listing).

For up-to-date information on the voluntary nationalaccreditation program for state and local public health

departments, visit www.exploringaccreditation.org.

HOW THE MODEL WAS DEVELOPED

In August 2005, the Planning Committee established a25-member Steering Committee with representativesfrom public health practice organizations at the local,state and federal levels. The guiding philosophy ofthe Steering Committee was to leave no stoneunturned, considering all possible alternatives relatedto the issues at hand. Its decisions were informed bythe work of four Workgroups in the areas ofGovernance and Implementation, Finance andIncentives, Research and Evaluation, and StandardsDevelopment.

The Workgroups were comprised of public healthpractitioners from all three levels of government andmembers of academia. Throughout the duration ofthe project, the Workgroups developed reports thatincluded consensus recommendations, otheralternatives that were considered, and the rationalefor each decision. Subject matter experts were alsoconsulted for various issues. Discussion papers withinformation on accreditation in public health and inother sectors were developed to stimulate theWorkgroups’ discussions.

In April 2006, the Steering Committee met to considerall of the information that was gathered in theprevious months and to develop a proposed model.The proposed model was distributed for public commentfrom May through July 2006. During that time,comments were solicited through several mechanisms:

• Public presentations and feedback formsdistributed at those events;

• Conference calls;

• 9


Whyis thisfeasible?

Whyis thisdesirable?

Who paysfor theprogram’soperation?

Howwould theprogramrun?

ACCREDITATIONThe goal of a voluntarynational accreditationprogram is to improve

and protect the health ofthe public by advancing

the quality andperformance of state and

local public healthdepartments.

Quality andperformanceinprovement

Accountability/credibility

Recognition ofexcellence

Clarifyexpectationsand increasevisibility

Governance

NationalStandards

FinancingandIncentives

Evaluation

Applicantfees

In-kindcontributionsfromapplicants

Government

Grantmakers

Existingstate-basedprograms

Existing andevolving bestpractices

Interest offunders

Feedbackfrompotentialapplicants

A Proposed Model for aVoluntary National AccreditationProgram for State and LocalHealth Departments

• OperationsEvaluated

• OutcomesEvaluated

• ResearchEncouraged toDevelop Science

• Consortium of Funders

• Uniformly PositiveIncentives

• Recognition for HighPerformance

• Standards in 11Domains

• Promote Pursuit ofExcellence

• Connected toExisting Efforts

• ConformityAssessmentProcess

• New Non-ProfitOrganization

• Diverse GoverningBoard

• State and LocalApplicants, Territoriesand Tribes Eligible

• AccommodateState-Based Programs

• E-mail messages and an online survey on theproject Web site;

• A satellite broadcast; and• An opinion survey sent to state, territorial,

and local health officials.

See Appendix A for a full listing of the SteeringSee Appendix A for a full listing of the SteeringSee Appendix A for a full listing of the SteeringSee Appendix A for a full listing of the SteeringSee Appendix A for a full listing of the SteeringCommittee, WCommittee, WCommittee, WCommittee, WCommittee, Workgrorkgrorkgrorkgrorkgroup members, staff, consultants,oup members, staff, consultants,oup members, staff, consultants,oup members, staff, consultants,oup members, staff, consultants,and funding organization rand funding organization rand funding organization rand funding organization rand funding organization repreprepreprepresentatives.esentatives.esentatives.esentatives.esentatives.

Extensive feedback was received, and the SteeringCommittee met in August 2006 to consider all publiccomment as well as a business case developed by theFinance and Incentives Workgroup. As a result of thefeedback, the model was revised, consensus emergedthat the revised model is feasible and desirable toimplement, and the Steering Committeerecommended that a voluntary national accreditationprogram be implemented accordingly.

10 •

METHODOLOGY

Planning CommitteeThe Executive Directors of the American Public HealthAssociation (APHA), Association of State and TerritorialHealth Officials (ASTHO), National Association of Countyand City Health Officials (NACCHO), and NationalAssociation of Local Boards of Health (NALBOH)comprised the Planning Committee for the ExploringAccreditation project. The Planning Committee providedexecutive oversight to the project and offeredrepresentation of their respective memberships. Inaddition, the Planning Committee established a 25-member Steering Committee in August 2005 to developrecommendations for the voluntary nationalaccreditation program and determine whether they weredesirable and feasible to implement.

Steering CommitteeThe Steering Committee was comprised of public healthpractitioners from all levels of government. SteeringCommittee members served as experts andrepresentatives from their respective sectors as theydeliberated the desirability and feasibility of a nationalaccreditation program. Their guiding philosophy was to“leave no stone unturned” and consider all possiblealternatives related to the issues at hand.

The Steering Committee conducted their deliberationsseveral times in person and by conference call fromSeptember 2005 through August 2006. Theirdiscussions were informed by the suggestions developedby the Workgroups and subject matter experts andconsultants also provided guidance and information. Onoccasion, when the Steering Committee felt it wasunable to make a decision based on the informationprovided, the Workgroups were asked to revisit some oftheir recommendations, explore additional issues, and/orgather more information.

In April 2006, the Steering Committee met to considerall of the Workgroup recommendations that had beengenerated in the previous months and, based on thisinformation, developed A Proposed Model for aVoluntary National Accreditation Program for State andLocal Public Health Departments. The proposed modelwas widely distributed for public comment from Maythrough July 2006. During this time, the Finance andIncentives Workgroup developed a business case to

support the proposed model, and the Research andEvaluation Workgroup completed their recommendationsas well.

When the Steering Committee held its final meeting inAugust 2006, they reviewed the public comment,considered the business case, reviewed the final Researchand Evaluation Workgroup recommendations, andrevised the proposed model accordingly. FinalRecommendations for Voluntary National AccreditationProgram for State and Local Public Health Departmentsreflects consensus among the Steering Committeemembers, and is based on Workgrouprecommendations, subject matter expertise, and thepublic comment that was received.

WorkgroupsThe Steering Committee’s decisions were informed bythe efforts of four Workgroups in the areas ofGovernance and Implementation, Finance andIncentives, Research and Evaluation, and StandardsDevelopment. The Governance and ImplementationWorkgroup was charged with developing governancerecommendations for a voluntary national accreditationprogram for state and local public health departments.The Finance and Incentives Workgroup was charged withexamining the possible ways in which a voluntarynational accreditation program could be financed. TheResearch and Evaluation Workgroup was charged withdeveloping research principles and a framework for thenational program. The Standards DevelopmentWorkgroup was charged with developing principles toguide standards development for the national program.

The Workgroup chairs were Steering Committeemembers selected by the Planning Committee. TheWorkgroups were comprised primarily of public healthpractitioners, and also included members of academia.Workgroup members were nominated and selected bythe Steering Committee, and were chosen based onexperience and expertise in the four issue areas. The useof Workgroups ensured that a broad perspective ofalternatives was considered for each issue area.

Each of the Workgroups met several times from October2005 through July 2006 to discuss pre-identified issuesthat were relevant to their group and developrecommendations based on their deliberations (SeeAppendix B for a list of questions the Workgroups were

• 11


asked to address). Subject matter experts also wereconsulted, and discussion papers with information onaccreditation in public health and in other sectors weredeveloped to inform the Workgroups’ discussions.Following each of these meetings, consensus reportswere developed that included the Workgroups’recommendations, alternatives that were considered, andthe rationale for each decision. These were shared withthe Steering Committee (at a January 2006 meeting andvia conference calls in between meetings), who, onoccasion, asked the Workgroups to revisit some of theirrecommendations, explore additional issues, and/orgather more information.

The Multi-State Learning CollaborativeIn July 2005, the Robert Wood Johnson Foundationprovided funding to the National Network of PublicHealth Institutes and the Public Health LeadershipSociety to establish the Multi-State LearningCollaborative on Performance and Capacity Assessmentor Accreditation of Public Health Departments (MLC).Five states were funded for new work to enhance theirexisting public health performance and capacityassessment or accreditation programs for local publichealth departments, and, in one state, also the statepublic health department. The long term goal of theMLC is to maximize the effectiveness and accountabilityof governmental public health agencies. The five MLCstate programs ranged from mandatory accreditationprograms, with or without dedicated funding forapplicants, to voluntary participation in performanceimprovement programs. A common feature among allof them was an established set of standards specific toeach state, and a process to assess health departmentperformance against the standards. (It should be notedthat 18 states applied to be a part of the MLC, illustrativeof the commitment from a wide variety of statesinterested in accreditation and performance improvement.)

The work of the MLC contributed to the work of theSteering Committee in several ways. Each state wasrepresented on the Steering Committee, and at least onestate was represented on each Workgroup, whichprovided an excellent venue for sharing their experiencesand influencing the recommendations. The ExploringAccreditation staff visited each MLC state to gather inputand wisdom. Additionally, a representative from eachstate made a presentation to the Steering Committee

and also provided thoughtful feedback on a variety ofissues that arose during the year-long exploration,lending their lessons learned and other experiences tothe deliberations of the Steering Committee. Finally, amatrix of attributes of each of the MLC states’ programswas developed that provided specific details of eachprogram and allowed the Steering Committee tocompare and contrast various features (includingprogram goals and objectives; voluntary vs. mandatorynature of the program; development of standards andmeasures, including what domains were used and theprocess for updating/revising the standards; processes forscoring and developing criteria; funding sources; costs ofthe program; participation rates; and program outcomesand impacts). To these ends, the MLC states have servedas a learning laboratory, and all the information provided(including site visit reports developed by ExploringAccreditation staff) has greatly assisted in informingdecisions around the framework for the national program.

The opportunity to learn from operational accreditationand related programs for local health departments andone state health department allowed for more fullyinformed discussions to take place and for the pros andcons of each program to be reflected in the finalrecommendations put forth by the Steering Committee.

CommunicationsFrom the outset, the Exploring Accreditation (EA)project leadership committed to an open process ofcommunication regarding the work of the SteeringCommittee and its four Workgroups. The project’sleaders also sought to provide a robust public inputprocess that would inform, as well as seek commentfrom, a broad range of interested individuals andorganizations regarding the proposed accreditationmodel. With those objectives in mind, BurnessCommunications was engaged to oversee communicationsefforts around the work of the Steering Committee.

The overall goals of the project’s communicationefforts were to inform key stakeholders, interestedorganizations, and the public about the project; seektheir ideas and learn from them by providing multipleopportunities for feedback during the project andspecifically on the proposed model; and finally, to informinterested parties about the project’s final recommendations.

12 •

These goals were accomplished through:

• Provision of strategic advice on content,methods, and timing of communications;

• Development and promotion of messages in theform of fact sheets, press releases, “Updates” fora stakeholder distribution list; development ofPowerPoint presentations on the proposedmodel and final recommendations; coordinationof a CDC Satellite Broadcast; and developmentof newsletter articles;

• Consultant participation in Steering Committeeand Workgroup meetings;

• Editorial support to project staff in the review ofproject materials; and

• Logistical support for scheduling of the publicmeetings and member presentations.

Throughout the project, Burness staff worked closelywith project staff to discuss, recommend, and implementcommunication strategies. Near the outset of theproject, a two-phase strategy was developed to reach keyaudiences before and after the Steering Committee’sApril 2006 meeting where a draft accreditation modelwas formulated. Also during the project, guidance wasprovided on the structuring of an effective town hallpresentation for local health officials as well as otheroptions to consider for outreach to variousconstituencies. Near the end of the project, acommunication plan for the Final Recommendations andFull Report was created.

Developing and promoting effective messages for theproject’s communications was critical. At the verybeginning of the project, a website was created, and afact sheet and press release were created to informstakeholders about the project’s activities. A stakeholderdistribution list for e-mail communications was alsodeveloped and included two “Updates” about theproject as well as the press release announcing the FinalRecommendations. Another major communicationsproduct was the PowerPoint on the proposed model forpresentation at the nationwide public meetings. Thisproduct was modified over time to reflect updatedinformation including the project’s FinalRecommendations.

Another important tool for communicating about theproject was the satellite broadcast held at the Centers forDisease Control and Prevention on July 20, 2006,entitled: “Will it Work? Exploring a Voluntary NationalAccreditation Program for State and Local HealthDepartments.” The idea of a satellite broadcast evolvedfrom discussions at the Steering Committee’s April 2006meeting as a means of reaching an extended audience ofstate and local public health leaders to inform themabout the proposed model and seek their input. CDCrepresentatives offered to coordinate the broadcast atCDC headquarters in Atlanta, Georgia, as an adjunct tobriefings for CDC leaders on the proposed model. Theproduction was recorded on DVD, distributed to SteeringCommittee members, and made available to the publicfor viewing via a link on the project Website.

Although the original project plans anticipated fourpublic comment meetings and one meeting for electedofficials, this schedule expanded to more than 25 publicmeetings or conference calls held nationwide from mid-May through the end of July 2006. This revised strategyreflected the project leaders’ commitment to conduct thebroadest possible outreach and the willingness ofmembers to prepare for and give these presentations.The Steering Committee’s deliberations clearly benefitedfrom the feedback obtained from these additional publiccomment sessions. (For more details on the publiccomment process see page 40.)

With this communication process, the project ensuredthat ample and appropriate information conduits were inplace for the exchange of information betweenstakeholders and the Steering Committee, Workgroupsand project staff. Regular use of these communicationschannels contributed to an enhanced final product andimproved strategies to share the Final Recommendations.

Accreditation Consultant ExpertiseThe Planning Committee, Steering Committee,Workgroup members and project staff had strongexperience in public health policy and practice;however, with the exception of those from states withaccreditation programs, they had limited experiencespecific to accreditation programs. For this reason, theproject hired Michael Hamm, of Michael Hamm andAssociates, to lend general expertise on accreditationissues and to specifically advise on the potential fit of anaccreditation program in the public health field.

• 13


Accreditation expertise was provided by: educating theSteering Committee, Workgroups, and staff on variousaspects of accreditation; conducting market research;and assessing the feasibility of the proposed model andfinal recommendations.

The project staff and various groups working on thisproject were informed of the general principles andconcepts about accreditation, what it can and cannotachieve, and what accreditation system(s) might workbest in a national program designed to serve the needsof state and local public health departments. This wasaccomplished through preparation of backgroundmaterials for, and participation in, face-to-face meetingsand conference calls with the Steering Committee,Workgroups, and project staff.

Market research regarding the acceptability of a nationalaccreditation program for public health departments wasconducted with potential applicants and latersummarized. One of the first steps in determining thefeasibility of any new accreditation program is thecollection of sufficient marketing data to determine thepotential interest of various stakeholders in the proposedcredentialing program.

Telephone surveys conducted by a neutral third party areone method of collecting market data on the reactionsand responses to proposed new credentialing efforts. Aseries of scripted telephone interviews were conductedwith 22 individuals in March 2006.

ASTHO and NACCHO staff contributed to the selectionof potential candidates for these interviews. An effortwas made to include individuals who were notrepresented on the Steering Committee or Workgroupsof the Exploring Accreditation project and who were notinvolved in the Multi-State Learning Collaborative.Representation included national public healthassociations, senior officials from state and local healthdepartments, state and local board of health members,and states with existing standards/accreditationprograms.

Twenty-two interviews were conducted with:

• Seven national public health associationrepresentatives

• A state and a local board of health member

• Nine state health department representatives

• Four local health department representatives

Some of the key questions that emerged included:

• What are the benefits to high performing healthdepartments?

• What are the incentives to attract small healthdepartments?

• Is it really voluntary?

• What resources are available to apply for andmaintain accreditation?

• What capacity levels are needed to receiveaccreditation?

• How does this affect existing state accreditationprograms?

• What is the federal government’s role?

• What will accreditation cost?

• How will it impact categorical programs?

• How will varying governance structures beaccommodated?

The results of the interviews were shared with theSteering Committee when they met in April 2006, andthe findings informed the development of the draftrecommendations.

The second market survey tool utilized was an onlinesurvey of potential applicants. An Internet survey wasused to evaluate perceptions about accreditation and thepotential market for the proposed model developed bythe Exploring Accreditation project. Companion onlinesurveys were prepared for both state and local healthdepartments and were administered in late June/earlyJuly of 2006. The state and local surveys were similar,but each survey contained some questions specific totheir respective audiences. ASTHO and NACCHO staffcontributed to the development of the surveyinstrument, administered the surveys, and contributed tothe conclusions expressed in this summary report.

The online surveys were distributed to ASTHO andNACCHO members by their respective staff. Invitationsto participate were sent to 57 state and territorial healthdepartments and approximately 2,900 local healthdepartments. A total of 38 complete responses weresubmitted by state health departments. This responserate was described as “good” for a survey of thisaudience. Two-hundred-fifteen completed surveys weresubmitted in response to the invitation by local health

14 •

departments. While an 8.6 percent response rate mightseem low, staff noted that NACCHO rarely conductslarge scale surveys over a short time frame, so theresponse rate may not be unusually low. Results fromthis work are discussed in the Public Comment section,starting on page 40.

The Steering Committee and the Workgroups spent aconsiderable amount of time discussing the results of themarket research. The Steering Committee was advisedthat some opposition is always present in anyaccreditation opinion study. The challenge for the futureGoverning Board of the accreditation program is todevelop a program that addresses the issues thatemerged from the market research (and the publiccomment period/vetting process – see page 40) to themaximum extent possible.

Finally, Mr. Hamm helped assure that the proposedrecommendations were reasonable and feasible for a newnational accreditation effort. While some of therecommendations may prove to be controversial, headvised that they are reasonable, defensible andconsistent with accreditation programs in other disciplines.

EvaluationCritical tasks for the Exploring Accreditation project wereto develop recommendations on evaluation and researchrelated to the national accreditation program. As littleresearch currently exists around the benefits ofaccreditation for state and local health departments, anational program presents an opportunity for expandingthe literature available in this area. Evaluation will benecessary to ensure that the program functionseffectively. The evaluation data may also help informaccreditation research and help frame appropriateresearch questions.

In addition to convening the Research and EvaluationWorkgroup (Workgroup), the project contracted withTCC Group (TCC) to support the Workgroup and toevaluate components of the project itself. TCC hadseveral tasks for the project, the first of which was toassist the Research and Evaluation Workgroup withdeveloping their recommendations to the SteeringCommittee. This included summarizing backgroundinformation for the Workgroup, developing an evaluationframework, and providing expertise as needed.Additionally, a framework was created to assess the

collaboration between ASTHO and NACCHO for theirwork as staff of the project.

To fulfill the task of developing background informationon accreditation, methods of evaluating accreditationprograms were researched by conducting a literaturereview and interviewing experts in the field.Accreditation programs outside the health field wereincluded in an effort to transfer knowledge andexperiences outside of healthcare for use in the project.The review of accreditation in other industries includedin-depth investigations of programs viewed as havingelements similar to those of a potential public healthaccreditation program. These included:

• American Association of Museums

• American Forest & Paper Association’sEnvironmental, Health & Safety PrinciplesProgram

• American Psychological Association Councilon Accreditation

• The American National Standards Institute(ANSI)

• American Zoo and Aquarium Organization

• The Chemical Industry’s ResponsibleCare Program

• Council on Accreditation

• DIN (German Institute for Standardization)

• Green Globe 21

• Fair Trade Labeling Organization

• Ecotel

• International Accreditation Forum Inc

• The International Electrotechnical Commission

• International Organization for Standardization

• ISO Environmental management systems

• Commission on Accreditation for LawEnforcement Agencies

Reviews of these organizations included program aspectsand a particular focus on finances. A grid showing thefeatures of other industries’ related efforts was developedand the information was presented to the Workgroupthrough phone calls and e-mail exchanges, andultimately in-person. Through the process, TCC and theWorkgroup thought through important elements of

• 15


evaluation and research and their differences, anddeveloped preliminary thoughts about prioritization ofevaluation and research questions.

An evaluation framework and initial outline of potentialmeasures and indicators for consideration wasdeveloped. This was a collaborative and iterative processbetween TCC and the Workgroup. Building on thisprocess, a revised logic model was created. The revisionssplit the process for creating an accreditation programfrom the actual implementation of a potential program.Each is reflected in the logic model. In its finalrecommendations, the Steering Committee refined thestrategies and outcomes, making a distinction betweenorganizations pursuing accreditation and the publichealth field in general. Ultimately, the inputs of anaccreditation program were more clearly defined.

Finally, an evaluation tool was developed to assess thecollaboration aspect of the project. To assess theeffectiveness of the collaboration, a framework withspecific indicators was developed for ASTHO andNACCHO and assistance was provided to them withperforming the self-assessment using the framework.This approach had several benefits. First, it allowed TCCto highlight best practices identified through pastcollaboration evaluations, placing them in the context ofthe ASTHO-NACCHO collaboration. Second, the self-assessment reduced the amount of resources necessaryto meet this evaluation need, allowing for more of thebudget to go towards the primary goal of helping theWorkgroup. Third, the facilitated process enabledASTHO and NACCHO to learn from their collaboration,enhancing reflection and improving strategies for futurecollaboration beyond the timeframe of this scope of work.

Public CommentThroughout the Exploring Accreditation project, severalmechanisms were used to solicit feedback from thepublic on the Steering Committee’s proposedrecommendations. Information on demographics andcurrent participation in performance, certification, oraccreditation initiatives was also collected. The datawere analyzed and summarized in a way that helped toinform the final recommendations. Below is a briefdescription of the ways in which information was gathered.

In addition to telephone interviews of 22 individuals inMarch 2006, an online opinion survey of state and local

health officials, developed by project consultant MichaelHamm, was fielded in June and July 2006 to collect dataon their views of accreditation. The survey containedboth closed and open-ended questions.

An important finding to note from the surveys wasthat high percentages of both state health departments(SHDs) and local health departments (LHDs) (47 percentSHDs and 42 percent LHDs) indicated that they are“very likely” to apply for accreditation assumingprocedures, fees and timetables are acceptable.

The collective perceived benefits of a proposed accreditationprogram noted from both the telephone and Internet surveyinformation included the following:

• Credibility;

• Maximizing financial resources (which will be ofparticular interest to legislators);

• Accountability (also of particular interest tolegislators);

• Standardization of practices and developing anational standard;

• Improving public trust in health departments;

• Meeting public expectations; and

• Facilitating access to federal funds.

Collective perceived drawbacks included these issues:• Variations in health department structure/

operation;

• Skepticism about potential standards and theaccreditation review process;

• Loss of credibility for non-accredited agencies;

• Challenges of achieving accreditation withlimited public health capacity;

• Political issues such as securing approval foraccreditation from legislatures;

• Defending departments that are not accreditedor their budgets from opponents;

• Potential role of accreditation in influencinghow money is spent in public health;

• Concern about potential federal mandates/requirements for accreditation;

• Time and money needed to apply for andachieve accreditation; and

• Public health officials with already complex andextensive work demands.

16 •

From the telephone interviews and the Internet survey itwas concluded that while accreditation is a concept thatis viewed with some skepticism by some of the publichealth department community, a significant proportionof respondents perceive benefits of this process and arewilling to participate in a future program dependingupon the final details of the standards, the accreditationprocess, and the required fees. The highest degrees ofskepticism and concerns were expressed in the telephoneinterviews by the small and rural public healthdepartments, states that include large numbers of theseentities, and some national organizations focused onmeeting health department needs in these specificcommunities.

Four additional mechanisms were developed and used bystaff to receive public comment. Numerouspresentations were made on the proposedrecommendations from May through July 2006 (seeAppendix D). These presentations were delivered inperson, via conference call, and through a satellitebroadcast. Speaker and participant feedback formsdistributed during the in-person meetings were used tocollect comments on the draft recommendations. TheExploring Accreditation Web site also providedopportunities for comment. Visitors could access anonline survey which asked the same questions as thosepresented on the participant feedback form. Additionallythere was an e-mail address accessible on the Web sitethat users could utilize to submit feedback or askquestions.

The participant feedback forms and the online surveywere identical (see Appendix C). There were threeclosed-ended questions using a Likert scale, four open-ended questions, a request for demographic information,and a question regarding current participation inperformance, certification, or accreditation initiatives.The e-mail responses were analyzed in a mannerconsistent with the questions posed on the participantfeedback forms.

The 540 responses (a combination of participantfeedback forms, the online survey, and comments via thee-mail address) were analyzed collectively, with bothquantitative and qualitative analyses.

The full analysis of the public comment can be found onpage 40. A list of the presentations given during thistime can be found in Appendix D.

Business CaseWith information from a variety of sources and assistancefrom consultant Michael Hamm, the Finance andIncentives Workgroup (Workgroup) developed anoperational description of a business model that could beused to implement the proposed voluntary nationalaccreditation program. The business model and thebudget related to it were refined in the SteeringCommittee deliberations as decisions were madeconcerning the final recommendations. The businesscase as refined is useful in answering the question, “If wemove forward with this model, what will it cost?”Varying the options in the business case can helpimplementers evaluate the changes in cost that will becreated by changes in the operational model and topredict their effect on the potential to attract applicantsand revenues that will support this business model.

The Workgroup began with an assessment of the needfor a voluntary national accreditation program drawnfrom the Steering Committee work. With the assistanceof surveys conducted by Michael Hamm and Associatesand using summaries of public input, the Workgroupanalyzed the market for accreditation and projected thelikely penetration of the market, then examined thecompetitive environment. The findings from examiningother accreditation programs’ experiences and publiccomments were integrated with the modelrecommended by the Steering Committee to describethe business environment for a voluntary nationalaccreditation program in the next nine years. TheWorkgroup projected the market for the proposedaccreditation program’s product, the volume of work inthe development and initial operation phases, and thepotential revenues generated from services.

To understand the financial feasibility of the proposedbusiness case, the Workgroup reviewed the model andidentified operating options compatible with the model.The Workgroup then identified the components of costfor the developmental period (from incorporationthrough pilot testing of the standards and theconformance process) and the initial operating period(five years of actual operation) of the accreditation

• 17


program and the options which affect the ranges ofthese costs. Then the Workgroup projected costs of thedevelopmental period and the initial operating period bygenerating a range of options for key variables andpricing a “preferred set of options” based on the modelitself. As described in the finance and incentive sectionsof this document, preferred options were based onassessments of best outcomes for the program,balancing efficiency and cost control with transparency,full participation by the public health field, andaccountability to the public.

A positive business case depends upon demonstratingthe potential for the proposed accreditation program togenerate revenues to cover its costs within a reasonabledevelopmental and operational period. The SteeringCommittee identified several potential revenue sourcesand provided guidance through its deliberations aboutsources not acceptable within its model. The Workgroupintegrated the Steering Committee guidance into theestimates of both work and revenues in the developmentand operating periods, projecting a range of options.

The Steering Committee reviewed the operationaldescription in the business case and made refinements intheir final recommendations. Their deliberationsprovided opportunity to incorporate key issues thatsurfaced through the public comment process and toshape the final recommendations while considering costsand operational impacts. These deliberations wereparticularly important in making the decision about thefeasibility of the recommended model for a voluntarynational accreditation program.

The business case was then revised to reflect the finalrecommendations and the final version is included aspart of this full report.

Logic ModelingThe Research and Evaluation Workgroup developed aseries of logic models to guide thinking about evaluationof on-going work in both the design and implementationof a voluntary national accreditation program for state

and local public health departments. The Workgroupcreated separate logic models for:

• evaluating the Exploring Accreditation project,and

• evaluating the implementation and operation ofa national accreditation program.

Taken together, these logic models are intended toprovide a framework for evaluation and to promoteresearch on the public health impact of the work.

These logic models facilitate the identification of keyevaluation questions for each stage of the project and adeveloping national program (see Appendix F). Thelogic models illustrate both intermediate and long termoutcomes to encourage research questions that wouldelucidate the role of accreditation in achieving theseoutcomes. The Workgroup intended its work as astarting point for developing an evaluation strategy andresearch agenda.

18 •

FINAL RECOMMENDATIONS ANDDISCUSSION

This section of the report includes the recommendationsas they appear in the Final Recommendations for aVoluntary National Accreditation Program for State andLocal Public Health Departments. Each recommendationsection is followed by a discussion that includes therationale for all decisions made.

GOVERNANCEA new, not-for-profit entity should be created to overseethe accreditation of state and local governmental publichealth departments by adopting standards and makingfinal conformance decisions. Having a new, independententity would promote impartiality and avoid real orperceived conflict of interest should the process beconducted by an existing organization. The PlanningCommittee should provide an incorporation process(articles of incorporation, bylaws, Governing Boardnominations process) that establishes the legitimacy andcredibility of the accrediting entity.

Accrediting EntityThe accrediting entity should:

• Be a recognized legal entity and a tax-exemptorganization under Section 501(c)(3) of theInternal Revenue Code.

• Be separate and independent of the influence ofany single organization.

• Provide relevant accreditation services and avoidactivities that could conflict with accreditationactivity.

• Orient applicants to the application andassessment processes.

• Develop and maintain partnerships.

• Assess conformance.

• Train assessors to assure a consistent and fairprocess.

• Work with partners to ensure the availability oftraining and technical assistance.

• Encourage research and evaluation to improvethe accreditation program.

Governing BoardThis new entity should have a Governing Board thatwould obtain incorporated status, develop bylaws, andhire staff. The responsibilities of the Governing Boardshould include, but not be limited to, the following:

• Approving standards.

• Awarding and revoking/suspending status.

• Overseeing the appeals process.

• Ensuring adequate representation of keystakeholder interests.

• Including public representation in all decisionmaking.

• Establishing clear and effective controls againstconflict of interest.

• Ensuring ongoing evaluation and continuousquality improvement of the accreditationprogram.

• Overseeing the development and maintenanceof a national database for performanceimprovement and research purposes.

• Promoting research that would improve theaccreditation program.

• Maintaining the administrative and fiscalcapabilities to successfully operate a nationalaccreditation effort.

• Working actively with partners to promote theirdevelopment of positive incentives.

• Working with partners to advocate for andpromote training and technical assistance andassure that they are accessible and available toapplicants.

The Planning Committee should appoint the GoverningBoard. Membership of the Governing Board shouldinclude both organizational representatives andindividuals with relevant experience and expertise.While specific slots are not being recommended, thefollowing principles should be applied in determiningthe composition:

• Members with recent experience in state orlocal public health should comprise themajority.

• Members should include those with recentexperience on public health governing boards.

• 19


• Diversity of ethnicity, experience, andgeographic location is important.

• Terms and term limits should be specified.

• Members should include academics, state andlocal elected officials, health care providers,representatives from federal agencies, andothers with a public health background.

• One or more public members should beappointed.

• Members should include representatives of thefounding organizations and other key publichealth organizations.

Relationships with State-Based Accreditation andPerformance Improvement ProgramsThe goal of the voluntary national accreditation programis to establish quality and consistency that is recognizedat federal, state, and local levels. Existing state-basedaccreditation and performance improvement programsare providing a laboratory for a national program andnational standards. It is important that state and nationalprograms continue to learn from and maintain goodrelationships with each other.

A national program should complement state-basedefforts to establish performance standards for publichealth departments. This may be accomplished by arecognition/approval process through which stateaccreditation programs could demonstrate conformitywith national accreditation standards and processes.Such a process should not preclude states from havingadditional requirements over and above those in thenational program. If a state accreditation program is notso recognized, it may seek to act as an agent.

Agents/ContractorsThe accrediting entity may use agents (such as statebased accreditation programs and public healthinstitutes) to provide training, preparatory services, sitevisits, and other services. The accrediting entity isresponsible for developing policies and proceduresregarding relationships with agents. The agent mustdemonstrate to the satisfaction of the Governing Boardthat its services are consistent with those of theaccrediting entity. When agents are used, the GoverningBoard still makes the final accreditation determination.

ConfidentialityConfidentiality of information is important to achievingthe quality improvement and continuous performanceimprovement goals of the voluntary nationalaccreditation program. The accrediting entity maypublicize the accreditation status of applicants, butshould hold all background information from the processas confidential except as required by law.

GOVERNANCE DISCUSSIONThe Governance and Implementation Workgroup wastasked with developing governance recommendationsfor a voluntary national accreditation program for stateand local public health departments to be considered bythe Exploring Accreditation Steering Committee.

For several of the governance recommendations, theSteering Committee and the Governance andImplementation Workgroup found value in the guidelinesfor an accreditation system outlined by the InternationalOrganization for Standardization (ISO). ISO has setstandards and guidelines for many accrediting bodies.These international standards specify the generalrequirements for accrediting bodies and as such mayrepresent the fundamentals for a model system. Further,these guidelines could eventually serve as a frame ofreference for best practices in accreditation.

A single national body that sets standards and assessesconformance was determined to be the best governanceplan to promote an understanding and appreciation ofthe work done by state and local public healthdepartments. A national body provides the publichealth field an enhanced ability to identify what publichealth is, what public health departments do, and howthey function to achieve improvements in the public’shealth. By establishing conformance with acommon set of standards, this model provides externalvalidation of services offered, capacities required, andquality of performance. External validation by a singlebody is a means of improving public health servicesthroughout the United States more efficiently thanindependent, non-linked systems at state and local levels.

It was recommended that the national entity be a neworganization. A new entity that is not affiliated with anexisting public health organization will safeguard theobjectivity and impartiality of its activities. Further, it will

20 •

assure that no single party or party interestpredominates. A new entity could also eliminate theperception of a conflict of interest, assure that states withexisting accreditation/accreditation-like programs canparticipate, and protect conformity assessmentinformation and confidentiality. Using existingorganizations was considered. The Workgroupacknowledged that this option could be less costly byoffsetting operating expenses. It could also save time forgetting the national program started if a neworganization did not need to be created or an existingorganization could be used to handle administrativefunctions while a new entity was waiting to beestablished. In the end, the Workgroup felt that assuringimpartiality was important and therefore agreed that itwould be most appropriate for the governing entity tobe supported by a new organization. However, it wasrecognized that the new organization may need someassistance with administrative functions during its startupphase, and for this purpose an existing organizationcould be used.

To further ensure that there is no perceived conflict ofinterest, it was determined that the accrediting entityshould not be the direct provider of technical assistanceto applicants, nor should they be directly responsible forcarrying out research and external evaluation. TheSteering Committee recognized that it would not beappropriate for the accrediting entity to assist healthdepartments with meeting the standards. Yet, to ensurethat applicant health departments receive the supportneeded to effectively achieve the program standards, theSteering Committee felt that it was the responsibility ofthe accrediting entity to ensure that technical assistanceresources were available from the outset. For similarreasons, it was agreed that the accrediting entity shouldnot be the organization responsible for performingresearch on its own program. The Steering Committeeagreed that while the entity should regularly assess itsown performance, it should encourage others outside ofthe organization to analyze the strengths and weaknessesof the accreditation program. As little research exists inthis area, this is an important opportunity to build theevidence base for quality and performance improvementprograms by collecting and sharing data. Theaccrediting entity will be responsible for ensuring that allof its operations and its performance are evaluated on anongoing basis. The Steering Committee recommended

that funding for evaluating the accrediting program beincluded in the business plan. This would include fundsfor the accrediting entity to develop an evaluation of theentity’s effectiveness, the accreditation process, customersatisfaction, and performance improvement of the healthdepartment. Applicants who go through the process ofaccreditation would be asked to participate in theevaluation. The results would help to improve theprogram as it is updated periodically.

The Planning Committee of the Exploring Accreditationproject will be responsible for the initial incorporation ofthe national program. They have led the ExploringAccreditation project since the inception. As such, theyare familiar with the thought processes behind therecommendations and therefore are best able to ensurethat these are carried out efficiently in the developmentof the new program. The Planning Committeeorganizations also represent the future applicants andkey stakeholders for the national accreditation programand are therefore the logical organizations that would beimportant to getting buy-in to the program.Incorporation responsibilities will include, but not belimited to, establishing the new organization (GoverningBoard, bylaws and articles of incorporation, businessplan, staff), and beginning the groundwork of theprogram (developing standards and incentives).

Since the Planning Committee will be the initialincorporators of the new organization, the SteeringCommittee felt that it made sense for them to appointthe first Governing Board. Several suggestions for boardcomposition were explored. For the accreditationprogram to be sustainable, the board needs to assure themaintenance of effective and efficient relationshipsamong federal, state, and local levels. The SteeringCommittee felt that both public health organizationparticipation and the inclusion of individuals with specificexpertise were important. Having representatives fromwell-respected organizations on the board will contributeto the credibility of the program. In order tocounterbalance the interests of the organizationsrepresented on the board, and to ensure expertise inspecific areas is included, it was agreed that individualexpert representation would also be needed on theboard.

• 21


In the proposed model recommendations, specificcharacteristics of membership on the board wereidentified. However, many concerns were raised duringthe public comment period about this recommendation.One theme was the perception of imbalance amongrepresentatives from certain domains. Another concerncentered on what the most appropriate number ofrepresentatives for the Governing Board should be. Forthe Final Recommendations, the Steering Committeedecided not to recommend specific slots for the board,and instead they have recommended principles to guidethe Planning Committee in their selection of boardmembers. The Steering Committee felt strongly that themajority of the members on the board should haverecent state or local governmental public healthexperience. Recent experience was seen as importantbecause health departments are constantly changing andthis representation would ensure that the views ofapplicants are well represented while avoiding a directconflict of interest. Boards of health representatives werealso seen as key members since many state and localhealth departments must report to or seek the guidanceof their board. Additional recommendations for boardmember representation include academics, state andlocal elected officials, health care providers, federalagency staff, and members of the founding organizationsof the national accreditation program.

In addition to the board, the Steering Committee hassuggested that ad hoc committees may need to beperiodically developed beyond the Governing Board todeliberate certain issues (i.e., the assessment process,standards, and nominations for the Governing Board).These committees would help reduce the burden on theGoverning Board as well as provide additional expertiseon specific issues.

The Steering Committee recognized the importance ofacknowledging those states with existing accreditation orrelated programs. During the public comment periodseveral states raised questions about how their existingor emerging programs would tie into the national one.It was agreed that states should receive some sort ofrecognition or approval if they demonstrate conformitywith the national accreditation program. This should notimply that any existing state program would begrandfathered into the national program. Whatever therequirements are of their own programs, states would beexpected to meet those of the national program. This

would avoid duplication of effort on the states’ part, andrecognizes that states cannot forgo their currentprograms given that they may have specific legalrequirements they need to meet.

The recommendations for agents/contractors to thenational program are in line with those of ISO. It wasagreed that some entity or entities within states shouldbe allowed to act as agents or contractors under thenational program. Agents could include the state healthdepartments or the public health institutes that arecurrently responsible for assessing conformance in theirstate. Using agents would lessen the burden on thenational accrediting entity by having fewer assessmentsto conduct. The use of state agents/contractors,however, does not alter the expectation that the nationalGoverning Board will make the final accreditationdetermination.

During the public comment period, the most citedbenefit to a national accreditation program wasrecognition of health departments. While accreditedagencies would want their status publicly recognized, theSteering Committee has recommended that allbackground information collected during the conformityassessment process be kept confidential. The oneexception to this recommendation would be if a legalrequest were made to review this information, e.g., if acourt requests the information because a healthdepartment is being sued. Assuring applicants’confidentiality is critical in the accreditation process.This assurance should be built into the development ofthe governance structure. Not only would this apply tothe accrediting entity, but all agents, vendors andcontractors would also be expected to protect access tospecific accreditation data.

22 •

ELIGIBLE APPLICANTSThe governmental entity that has the primary statutoryor legal responsibility for public health in a state, aterritory, a tribe or at the local level is eligible foraccreditation. To be eligible, such entities must operatein a manner consistent with applicable federal, state,territorial, tribal, and local statutes. The determination ofeligibility to apply for accreditation should be flexible,recognizing the variety of jurisdictions with local publichealth departments and the variety of state, territorial,tribal and local governmental agencies that may carrythe primary responsibility for public health.

State and Territorial Health DepartmentThe governmental body recognized in the state’s orterritory’s constitution, statutes, or regulations orestablished by Executive Order, which has primarystatutory authority to promote and protect the public’shealth and prevent disease in humans, is eligible toapply. Umbrella organizations and collaborations amongstate or territorial agencies may apply for accreditation ifthe primary entity is a part of the organization orcollaboration. Where the state or territorial healthdepartment operates local and/or regional healthdepartments, a single applicant or a number ofindividual applicants may choose to apply. Compliancewith local-level standards must be demonstrated for eachlocal/regional unit.

Local Health DepartmentThe governmental body serving a jurisdiction or group ofjurisdictions geographically smaller than a state, which isrecognized in the state’s constitution, statute, orregulations or established by local ordinance or throughformal local cooperative agreement or mutual aid, andwhich has primary statutory authority to promote andprotect the public’s health and prevent disease inhumans, is eligible to apply. The entity may be a locallygoverned health department, a local entity of acentralized state health department, or a regional ordistrict health department. An entity that meets thisdefinition may apply jointly with other local-level eligibleentities for accreditation status if some essential servicesare provided by sharing resources and the manner inwhich this occurs is clearly demonstrated.

Tribal Health DepartmentThe governmental health department serving arecognized tribe that has primary statutory authority topromote and protect the public’s health and preventdisease in humans is eligible to apply. Applicationsshould include an opportunity to describe situationswhere statutes or other legal mechanisms delegateauthority for governmental public health functions to anagency other than the applicant health department.The applicant health department should demonstratecollaboration with other agencies with respect to thosefunctions or, in some instances, may request exemptionsfrom those standards that are being met in a differentgovernmental agency. The designation of accreditationshould note any exemptions provided. Additionally, theapplicant health department may include another entitywith statutory authority to perform some public healthfunctions in its application, and the other entity may beaccredited or recognized solely for the standardsthat it meets.

Applications should include an opportunity to describesituations where statutes or other legal mechanismsdelegate authority for governmental public healthfunctions to an agency other than the applicant healthdepartment. The applicant health department shoulddemonstrate collaboration with other agencies withrespect to those functions or, in some instances, mayrequest exemptions from those standards that are beingmet in a different governmental agency. Thedesignation of accreditation should note anyexemptions provided.

Additionally, the applicant health department mayinclude another entity with statutory authority toperform some public health functions in its application,and the other entity may be accredited or recognizedsolely for the standards that it meets.

The purpose of the voluntary accreditation program is toimprove the quality and performance of public healthdepartments without regard to their structure. Healthdepartments may wish to explore cooperativearrangements to help ensure compliance withaccreditation standards.

• 23


ELIGIBLE APPLICANTS DISCUSSIONThe definition of eligible applicants is intended to be asinclusive as possible, understanding that healthdepartments vary widely. The Steering Committee hasidentified eligibility criteria for state and territorial healthdepartments, local health departments, and tribal healthdepartments. The governmental entity that has theprimary statutory or legal responsibility for public healthin a state, a territory, a tribe or at the local level is eligiblefor accreditation. This description captures the notionsof entities being governmental in nature, havingstatutory responsibility, and providing the essentialservices (as opposed to a list of programs), and itaccommodates the many types of governance structuresthat exist. It also recognizes the fact that some healthdepartments ensure the provision of some, but perhapsnot all, essential services. The process of identifying theeligible entities required significant discussion given thevariation in how state and local health departments aregoverned (e.g., in some states the local healthdepartments operate as separate entities from thestate health department, and in other states theyoperate as one unit).

While it may not have been explicitly stated in the draftrecommendations, the intent of the Steering Committeeis for the accreditation program to be open to tribalhealth department participation. As a result of feedbackreceived during the public comment period on thisissue, the Steering Committee agreed that the finalrecommendations should state clearly that tribal healthdepartments are also eligible entities for the nationalprogram.

The Steering Committee was also reminded during thepublic comment period that it is not uncommon forpublic health services to be provided by non-governmental members of the public health system.As such, they have recommended that applicant healthdepartments be allowed to demonstrate these situationsduring the conformity assessment process in order tohelp them to meet the required standards.

In addition, the Steering Committee recommended thatjoint applications for local health departments beallowed. It is expected that being able to apply jointlywould motivate local health departments with fewerresources to consider ways in which their existing assets

might be shared more effectively, with the end result ofachieving accreditation standards and better serving thepopulation. This notion of joint applications is a primeexample of demonstrating quality improvement. Byapplying jointly, local health departments can show thatthey are able to combine resources rather than duplicatethem, in order to provide services to the community.

Some states delegate authority for public healthfunctions to governmental entities other than the healthdepartment. This can occur at the state and/or locallevel, and in these instances the health departmentcannot be held accountable for functions performed byother governmental entities. Ideally, these othergovernmental entities would have their functionsassessed to ensure that they are providing qualityservices. If the other governmental entity chose to apply,they would be accredited only for those service(s)provided. While the Steering Committee doesrecommend that applicant health departments make anattempt to work with the other governmental entities inthe accreditation process, they do understand that thiscould be difficult if the other agency is not willing toparticipate. For this reason, the Steering Committee hasrecommended that health departments be able to claimexemption for the functions for which they are notresponsible.

24 •

PRINCIPLES TO GUIDE STANDARDSDEVELOPMENTA voluntary national accreditation program is a tool toadvance the pursuit of excellence, continuous qualityimprovement, and accountability for the public’s health.Standards should be developed in a way that promotesthese attributes.

Standards should address process, capacity, andindicators of outcomes. As the evidence is established,outcome standards that address improved healthindicators could be added; in the shorter term, outcomesshould address achievements such as establishingprograms and implementing new policy. Standardsshould focus on outcomes that can reasonably beinfluenced by health departments, understanding thatpublic health is inextricably linked to many systems andoccurrences that affect health status.

NACCHO’s Operational Definition of a Functional LocalHealth Department should serve as the foundation ofstandards (and associated measures) for local healthdepartments. ASTHO is undertaking a review of statepublic health services that may inform the standardsdevelopment process for state health departments.Existing performance standards for state and local healthdepartments should also be considered.

National Public Health Performance Standards Program(NPHPSP) model standards and measures could be usedin developing health department standards, recognizingthat NPHPSP standards have been developed to assesssystems, not departments.

State, territorial, and local health departments should beheld accountable to the 11 domains listed on thefollowing page, with standards under each domain thatare specific to their respective responsibilities.Additionally, the standards should be complementaryand mutually reinforcing to promote the sharedaccountability between state/territorial and local healthdepartments. The Governing Board will determine whichset of standards is applicable to tribal health entities.

One or more standards should be associated with eachdomain and at least one criterion should be used tooperationalize each standard. Measures, or the objectivemeans to determine whether, and the extent to which

each criterion is met would be established for eachcriterion. Measures allow an observer to characterize thelevel of quality achieved for each criterion.

Collectively, standards and their associated criteria definethe capacity expected of an accredited department.These criteria should be reflected in the day-to-day workof individual health department programs but are notmeant to be illustrated only through programs since thecapacity of a local health department to meet the needsof its community is represented by its ability to addressnew or emerging situations as well as those associatedwith day-to-day operations.

Program specific standards and criteria exist separatelyand are outside the scope of the voluntary nationalaccreditation process since programming varies fromstate to state and locality to locality.

Standards should be designed to assure public healthprotection while improving the public’s health. Allapplicant health departments should be held to the samestandards. However, different measurements may beused to recognize the variety of ways in which thestandards are met by health departments with differentcapacities, governance structures, statutory authorities,other quality improvement processes and health status ofthe population served. The program should promotecontinuous quality improvement, and over time, thelevel of acceptable performance should be increased asthe norm of performance rises.

Selected principles espoused by the American NationalStandards Institute (ANSI) should be applied todeveloping and updating standards:

• Consensus on a proposed standard by a groupor “consensus body” that includes subjectmatter experts and representatives frommaterially affected and interested parties.

• Broad-based public review and comment ondraft standards.

• Consideration of and response to commentssubmitted by voting members of the relevantconsensus body and by public reviewcommenters.

• Incorporation of approved changes into a draftstandard.

• 25


Standards should reflect input from all levels ofgovernment. Further, they should be updated andrefined on a regular basis to reflect the best availableevidence.

Standards need to be sensitive to laws governing state,territorial, tribal and local public health entities, andapplicants should be permitted to request a waiver ormodification of an accreditation standard if compliancecould put them at risk of violating state, territorial, tribalor local law.

In order to promote a common agenda and linkagesamong all levels of government, those involved indeveloping and updating standards and measures in avoluntary national accreditation program should workclosely with entities supporting other national goals,standards and measures for public health.

Careful consideration should be given to how standardsfor health departments can be applied in an efficient,non-duplicative and non-conflicting manner, and theGoverning Board should consider ways to use alternativemeasures of meeting standards, e.g., when a standardessentially has been demonstrated to have been metthrough reporting requirements for contracts, or state orfederal grants.

STANDARDS DEVELOPMENT DISCUSSIONThroughout its deliberations, the Steering Committeeemphasized that the national program should promotequality and performance improvement, and stressed theneed for standards to reflect this emphasis. This was anoverarching theme for the Steering Committee andStandards Development Workgroup’s discussions. Inaddition, the Workgroup provided additional detail intheir recommendations that went beyond the level ofdetail sought by the Steering Committee. Theseadditional details may be useful during the programimplementation and will be available to the accreditingentity.

The Steering Committee made a very deliberate decisionat the outset of its work not to recommend particularstandards for the program, but rather principles to guidethe development of standards. They recognized up frontthe importance of engaging the practice community andsubject matter experts as standards are developed, andfelt it would be too ambitious, as well as out ofsequence, to initiate such an effort as part of thisexploration. The American National Standards Instituteprinciples referenced in the final recommendationsclearly speak to the inclusive developmental process thatthe Steering Committee recommends as a nationalprogram is implemented. It was agreed that acombination of capacity, process and outcome standardsis desirable as the basis for an accreditation programbecause it is likely to be the most effective way ofaddressing improvement in governmental public healthagencies.

Health outcome standards were viewed as the mostdesirable with respect to demonstrating the impact ofpublic health interventions – particularly to governingboards, elected officials, and the general public.Although a robust evidence base to support suchstandards does not exist, the Steering Committee also

DomainsDomainsDomainsDomainsDomains*

1. Monitor health status and understandhealth issues.

2. Protect people from health problems andhealth hazards.

3. Give people information they need tomake healthy choices.

4. Engage the community to identify andsolve health 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 healthworkforce.

9. Use continuous quality improvement toolsto evaluate and improve the quality ofprograms and interventions.

10. Contribute to and apply the evidence baseof public health.

11. Govern and manage health departmentresources (including financial and humanresources, facilities, and informationsystems).

* * * * * See Appendix E (page 64) for examples ofSee Appendix E (page 64) for examples ofSee Appendix E (page 64) for examples ofSee Appendix E (page 64) for examples ofSee Appendix E (page 64) for examples ofstandarstandarstandarstandarstandards and measurds and measurds and measurds and measurds and measures.es.es.es.es.

26 •

did not want the field to shy away completely fromhealth outcomes standards. It is not unusual for thepublic health field to limit the use of health outcomestandards since there are many factors beyond theinfluence of governmental public health departmentsthat influence health status, thus making it difficult tolink public health interventions to improved healthstatus. The conclusion was that health outcomestandards should be added as the evidence base expandsto support them, and in the interim, other indicators ofoutcome (as described in the final recommendations)could be effectively incorporated.

Process measures can serve as a good internalmanagement tool, particularly when they are shown tobe linked to outcomes. Process measures are also moreresponsive to change. In addition, the Workgrouprecommended that a standard be included regarding theprocess undertaken by state and local healthdepartments to assess health problems and achievehealth-related goals. This type of standard would attendto the desire to address health outcomes as part of theaccreditation process.

Additionally, capacity measures are useful toadministrators to help define infrastructure needs, defendprocurement decisions, and make budget decisions.They also present an opportunity to tie capacity tooutcomes, and are also more responsive to change thanoutcome measures.

By using a combination of standards that measurecapacity, process and outcomes, the strengths found inone set of measures could help offset deficiencies inothers. Furthermore, this comprehensive approachwould cover many bases with respect to what anaccreditation system may seek to accomplish and thetarget audiences for accreditation results. This approachwill also help demonstrate the connections betweencapacity, process and outcomes – all of which must beconsidered to improve agency performance andultimately public health.

The Steering Committee views existing standards as thecornerstone to developing standards in the nationalprogram. Several sources in particular were identifiedthat should receive special consideration in order toavoid “re-inventing the wheel.” As discussed in the

context of recognizing existing state-based accreditationand related programs, various states offer a learninglaboratory with respect to the standards they have in usefor performance and quality improvement. In addition,NACCHO’s Operational Definition was recognized as aframework for local health department standards, as itwas developed through an extensive vetting process andreflects perspectives from public health professionals atall three levels of government, as well as local and stateelected officials.

The merits of the National Public Health PerformanceStandards Program (NPHPSP) model standards andmeasures also were recognized as a source for healthdepartment standards. It is important to clearlyrecognize that NPHPSP standards have been developedto assess public health systems, not individual publichealth departments, so any standards used would needto be adapted in order to accommodate this difference.Moreover, the Workgroup noted that assessment of thepublic health system using the NPHPSP instrumentscould be a recommended “self study” in preparing for ormaintaining accreditation. Such attention to the publichealth system, in a manner that complements healthdepartment-specific standards, could serve to emphasizethe important role of external relationships anddocument the role that health departments play increating such a system.

The Steering Committee identified 11 domains, orcategories, of standards that should be included in anational program. They are intentionally worded to beunderstood by all intended audiences, including futureapplicants, governing bodies, policymakers, funders andthe public. Using the same set of domains, but differentstandards, for state/territorial and local healthdepartments builds into the system a degree of synergybetween these two levels of government, whilerecognizing that state responsibilities are different fromlocal ones. Such an approach also creates incentives forbetter working relationships. Until specific standards andmeasures have been identified, it will be difficult todetermine which set applies to tribal health entities, andtherefore this decision will be made by the GoverningBoard.

• 27


The level of performance that the standards are intendedto describe generated a great deal of discussion, duringwhich the following themes emerged:

• If health departments are essentially receiving a“seal of approval” through accreditation, thepublic will expect that a gold standard of sortshas been achieved.

• Continuous quality improvement has beenhailed as the cornerstone of the accreditationprogram, and therefore it should be expectedthat health departments will “reach and stretch”as they work toward achieving higher levels ofperformance.

• If the standards are set too low, and most healthdepartments easily achieve accreditation status,then this effort has missed a critical opportunityto serve as a catalyst in strengthening thenation’s public health infrastructure.

Within this context, the Steering Committee agreed thata moderate level of performance should be sought, withthe understanding that continuous quality improvementaspects would be built in. However, great caution needsto be exercised in selecting terms used to describe thislevel. In lieu of stating “moderate” (which was viewed ashaving the potential to suggest a substandard level ofperformance), the language chosen reflects thephilosophy in the Operational Definition, i.e., everyoneshould reasonably expect that their health department isperforming in a manner that assures public healthprotection while improving the public’s health. This mid-level does not describe a “gold standard,” but ratherstrikes an important balance between being realisticabout what can be achieved and leaving room for healthdepartments to improve. Furthermore, as the number ofaccredited health departments grows, and as the normof expected performance rises, standards and measureswill need to be updated and revised accordingly.

Another important theme emerged both in the SteeringCommittee’s initial deliberations and the publiccomment period around the need to make sure that thestandards are relevant and applicable to healthdepartments of all sizes. The national system needs tobe attractive to more robust health departments in orderto be credible, yet it must not be out of reach of healthdepartments with fewer resources or those constrainedby state statutes. However, the desire to include health

departments with fewer resources should notcompromise the level of standards. This issue wasaddressed by agreeing that while all health departmentsshould be held to the same standards, differentmeasurements may be used to recognize the variety ofways in which the standards are met by healthdepartments with different capacities, governancestructures, etc. For example, every community needs tobe served by epidemiological expertise. Larger healthdepartments may need to have an epidemiologist onstaff, while smaller health departments may need todemonstrate that they have ready access to anepidemiologist if needed, e.g., through anepidemiologist who is employed on a regional basis,through a mutual aid agreement with another localhealth department, or from the state health department.

The Workgroup provided more detailedrecommendations regarding how frequently standardsshould be updated, in order to make sure that thestandards in play during any accreditation cycle are asrelevant as possible for the entity being accredited.Therefore, the duration of accreditation status and thelength of time that it takes to become accredited shouldbe factored into the interval for updating standards. TheWorkgroup recommended that once an applicationprocess has begun, the standards used, from initialapplication through any conditional accreditation period(should one be used), should remain the same. It alsowas recommended that standards should be updatedmore frequently in the initial stages of a nationalprogram in order to make corrections, reassess how wellthey are working, and reestablish the process as neededto maximize the effectiveness of the standards.

Finally, another key issue discussed by the SteeringCommittee and raised during the public commentperiod was the need to develop standards in a mannerthat avoids duplication of effort to the extent possible. Apotential barrier to accreditation is the perception thatthe conformity process will entail additional paperwork,and the Governing Board should consider ways topromote accredited status as a proxy for otheraccountability measures, e.g., accreditation status couldbe used in lieu of reporting requirements for grantors orcontractors. This notion is consistent with the potentialincentive of streamlining reporting requirements forgrant funds.

28 •

CONFORMITY ASSESSMENT PROCESSThe conformity assessment process should begin withthe health department undertaking training and areadiness review. If the health department determinesthat it is ready, it secures application materials andcompletes a self assessment. The application shouldinclude confirmation that the applicant’s elected official/governing body supports the application. The applicantsubmits their completed self assessment to theaccreditation staff who review it. When it is accepted ascomplete, a site visit is arranged.

Applicants are expected to be in compliance with alldomains for each program offered. Performanceassessment measurement will be applied on a samplingbasis to determine compliance.

A team conducts the site visit, writes a report, and makesa recommendation based on the findings and the selfassessment. There will be an opportunity for theapplicant to address any deficiencies that are noted. Thesite visit team includes peers without conflicts of interestand other subject matter experts/consultants, all ofwhom meet training and performance requirements ofthe accrediting entity.

The Governing Board reviews the recommendation andvotes on whether to award accreditation status. As aresult of the assessment, the applicant may be fullyaccredited, conditionally accredited, or not accredited. Ifthe applicant is conditionally accredited, it should begiven a specific length of time to improve performanceas required to achieve full accreditation status.

If an applicant doesn’t agree with a decision made on awaiver request or during the accreditation process (e.g.,it believes it should have a different status or met acertain standard that the reviewers determined they didnot meet or partially meet), it should be able to appealto an appeals board.

The accrediting entity should offer pre-qualifyingpreparation assistance that includes the orientation ofapplicant staff to the accreditation process, provision ofreadiness review and self-assessment tools that aredevelopmental in design and use, and references foravailable consultation on avenues to meeting andexceeding standards.

If the accrediting entity learns about an applicant notmeeting a standard or requirement after the applicanthas been accredited, the accrediting entity should beresponsible for investigating and determining whether ornot the accreditation status should be revoked. Healthdepartments that lose their status should be permitted tore-apply after a period of time.

CONFORMITY ASSESSMENT PROCESS

Readiness Review

SelfAssessment

AccreditationStaff Review

AccreditationTeam Site Visit

RecommendationsReport

FinalDetermination Appeals Process

• 29


CONFORMITY ASSESSMENT DISCUSSIONThe recommended six-step conformity assessmentprocess is fairly standard and was considered by theSteering Committee to be appropriate for public health.The first step is a readiness review which utilizes achecklist describing what is needed and what should bereviewed before completing the self-assessment. Thesecond step is a self-assessment to make as muchinformation as possible verifiable prior to a site visit. Thisstep ensures that only agencies that are ready will bereviewed. At the third step, the accreditation staffdetermines whether the health department is ready forassessment. The site visit is the fourth step, which isnecessary to validate the health department’s self-assessment and thus assure that the process is perceivedas one that is credible. Individuals who make up the sitevisit teams would need to be trained and have definedcredentials and could be either paid or volunteerreviewers. While paid reviewers can provide stability andquality control in the assessment process, usingvolunteers is highly valued and can help control costs.At the fifth step, the site visit team holds an exitinterview during which they share their findings with thehealth department staff, and generate arecommendations report. The exit interview alsoprovides an opportunity for the applicant to sharethoughts or concerns about the review process.The last step of the conformity assessment process isthe final determination. This decision is made by theGoverning Board.

The Steering Committee agreed there should be levels ofaccreditation status – fully, conditional and notaccredited. The decision to allow for conditionalaccreditation status, ultimately, was based on thenational program’s goal to improve health departmentperformance. This goal will be met to the extent thathealth departments volunteer to participate in thesystem and are successful at becoming fully accredited.Providing for conditional accreditation is likely to attracta larger pool of applicants, as those who are uncertain oftheir chance of achieving accreditation would be morelikely to apply. Therefore, this provision can be a goodstrategy to engage health departments in the process.The national program also could work to make specifictechnical assistance available for those that receiveconditional recognition, thus providing anothermechanism to achieve the program’s goal of qualityimprovement.

Expecting that there will be times when an applicantmay want to contest a decision made during any step ofthe accreditation process, including accreditation statusor a waiver request, the Steering Committee decidedthat an appeals process should be established. Optionsfor creating a deciding body were discussed, but finaldetermination was not made. One of the optionsexplored included developing an appeals committeecomprised of Governing Board members, externalmembers, and an arbitrator, with the accrediting entitymaking the final decision. A second option was to havean independent committee review the appeal and sharetheir findings with the accrediting entity that would stillmake the final determination. The Steering Committeefelt that the specifics regarding the appeals board shouldbe decided by the new Governing Board.

It is important that accredited health departmentsmaintain a certain level of performance. If theaccrediting entity learns or has reason to suspect that ahealth department has fallen out of compliance, they willbe re-reviewed to determine whether their status shouldbe revoked. If their status is revoked, the healthdepartment would be allowed to reapply; however, thelength of time before they are able to do so is not yetdetermined. Such consequences help ensure that theaccrediting entity and the national program are viewedas credible.

30 •

FINANCINGFinancing the development and operation of theaccreditation program can be considered in threephases. In the initial development phase, a consortium offunders interested in promoting public healthimprovement should be sought to fund the start-uporganization itself. In the initial operating phase, fundingshould be a mix of direct support from funders foroperations and revenue from services, such as applicantfees and training fees. Over time, more of the fundingshould come from the applicants, assuring a customerfocus in the accreditation program. In full operation, thegoal is for the accreditation program to be self-sustainingwith reasonable fee revenues from the application feesand accredited departments. Support for applicant feescould still come from other sources. The accreditationprogram should advocate for and promote incentivesand capacity building in health departments.

Financing the Initial Development and Operationsof the Accreditation ProgramThe goal of the start-up phase should be to maximize thecredibility of the accrediting entity and its costeffectiveness. It will be important to simplify processeswherever possible to promote efficiency for theapplicants and accrediting entity. The principal start-upactivities should include securing leadership, negotiatingcontracts with vendors and consultants, developing thestandards, creating the assessment process, developinginformation systems, and conducting beta tests or pilotprograms. Other start-up activities, such as marketing toapplicants and potential funding sources, managing anapplication process, recruiting and training site visitors,and managing the assessment process through an initialround can be tailored to the number of applicantsexpected.

The incorporators should finance the initial legal work toestablish the non-profit corporation, provide in-kindservices to refine the business plan, and work with aconsortium of grant-makers, government agencies, andorganizations of state and local health departments tofinance the start-up of the voluntary nationalaccreditation program.

Potential private sector funders include grant-makingorganizations promoting health care qualityimprovement, public health performance improvement,

and general government improvement. Within thegovernment sphere, the U.S. Department of Health andHuman Services agencies (Agency for HealthcareResearch and Quality, Food and Drug Administration,and Centers for Medicare and Medicaid Services as wellas CDC and Health Resources and ServicesAdministration) are most important, but theEnvironmental Protection Agency (environmental health,toxicology), the Department of Agriculture (food safetyand WIC), and the Department of Homeland Security(bioterrorism response and emergency managementresponse) should be interested in promoting continuousquality improvement through accreditation. Thefinancing plan should recognize that sponsoringorganizations and health departments could be willing toprovide in-kind contributions and volunteer services.Examples include providing space and equipment,volunteers serving on committees, assisting in therecruitment of funders, and/or assisting in training andpeer review.

Financing the On-going Operations of theAccreditation ProgramOn-going operations costs include those related tomaintaining the standards, training and supervising thesite visit teams, administering and evaluating theprogram, maintaining the supporting informationsystems, and promoting research.

Operations should be funded in part by the applicants,with other funding sources to decrease the burden onthem. Having applicants help pay for the accreditationoperation increases the connection between the costsand the value to the target market. Additionally,applicant fees for a voluntary program build in costcontrol signals for the operation and help keep costcontainment a high priority.

The application fee should be designed to offset theaccrediting entity’s costs. Working with states and federalagencies, the accrediting entity could support plans fortreating fees as allowable costs or indirect costs in grantsand contracts, subsidizing fees of health departments,etc. The accrediting entity also should work withapplicant health departments to support budget requestsfor funding accreditation applications by providing dataon the cost-effectiveness and value of accreditation.

• 31


Other funding sources may include organizations at thenational, state and local level that seek to promoteperformance improvement and continuous qualityimprovement in public health services, and organizationsthat use information about performance and quality indecision-making. The accrediting entity should work withfederal agencies to consider application fees and healthdepartment accreditation costs (self-assessment, site visit,training, and other direct costs) as allowable costs ingrants, reimbursement fees for services, contracts andcooperative agreements.

Controlling the Cost of the Accreditation ProgramAffordability of fees is critical to success, particularlywhen the value of a voluntary national accreditationprogram is being established. Affordability should bemeasured by the actual fees charged, by the cost of theprocess to the applicant, and by the perceived costeffectiveness of the operation.

The fees and the costs of becoming accredited should becommensurate with the value of accreditation to theapplicants. The costs of the accreditation program’soperation should be commensurate with the value ofaccreditation to the public’s health and to the sponsoringagencies.

The accrediting entity should design:• A streamlined accreditation process making

maximum use of electronic data exchange.

• Standardized formats that can also meet theneeds of funding agencies and other oversightbodies.

• Goal-directed self-assessment and site visitassessment procedures.

• An orientation to the accreditation process forapplicants.

Benchmarks and best practices for completing theapplication and conducting the self-assessment shouldbe made available in the pre-application orientation,providing guidance on cost-effective ways to completethe processes and assisting applicants in controllingcosts. Providing sample policies from high performingagencies, setting guidelines on the maximum length ofdocumentation, and providing for the use of existingdata formats to submit information are other techniquesto control applicant costs.

The accrediting entity should establish its architecture tocontrol costs. Volunteer committees should be used todevelop and maintain the standards, with significantparticipation by accredited state and local public healthdepartments and academics. The standards andbenchmarks used in accreditation should be simple, notcomplex. The accreditation cycle should be reasonablylong, using interim data submissions and targetedfollow-up on improvement plans to assure on-goingattention to transforming public health departments intohigh performing, continuously improving organizations.

In the initial development and operation phases,in-kind contributions, volunteer services, and contractualservices should be highly valued by the accreditingentity, but there also should be sufficient investment intraining and supporting site review teams to assurestandardized assessments and efficient administration.As the program develops and the number of accreditedpublic health departments grows, the accrediting entityshould reassess the balance of volunteer, in-kind, andcontractual services to assure continuing costeffectiveness.

The accrediting entity should provide services toencourage cost controls in accreditation processes at theapplicant level. It also should work with state and localpublic health departments, designing its assessmentprocesses to streamline the applicant’s work whilemaximizing the value of the self-assessment, datacollection, site visit, and feedback activities. Moreover,the accrediting entity should collect and aggregate dataon the costs of the accreditation process, including coststo applicants. These data should be available toapplicants for benchmarking their costs and identifyingpotential cost controls. Finally, making use of arecognition/approval process through which existingstate-based programs could demonstrate conformity withnational standards is another way to keep costs down.

32 •

FINANCING DISCUSSIONThe Finance and Incentives Workgroup was charged withexamining the possible ways in which a voluntarynational accreditation program could be financed.Working closely with consultant Michael Hamm, theWorkgroup examined the ways existing accreditationprograms were funded. The Workgroup analyzed thisinformation in light of their own public healthadministrative and business experiences. Within theWorkgroup, consensus emerged around several keypoints on starting an accreditation program:

• Financing the start-up of an accreditationprogram should be considered separately fromfinancing its on-going operations.

• Those who finance the accreditation programhave strong influence over the content and theoperation of the program.

• An accreditation program for publicly-fundedagencies needs to consider cost control forapplicants as a priority in demonstrating itsvalue.

Financing the Initial Development and Operationsof the Accreditation ProgramFinancing start-up through a consortium of funders wasidentified as a key strategy. A consortium of fundersimproves the stability of the new program financially andsignals the breadth of interest in accreditation in thefield. The support of legislators and chief executives hasbeen very important to the development of state publichealth accreditation and improvement programs.Attention to their interests and concerns will beimportant in developing a consortium of funders.

Similarly, demonstrating in-kind and volunteer supportby public health organizations and leadership is crucial insignaling interest in the program and in controllingcosts. Where this support has been weak, accreditationand certification programs have withered, for examplethe recent physician office certification program at theAmerican Medical Association.

Transparency in financing the start up is very important.The potential for a voluntary accreditation program tosucceed will be influenced by the “company it keeps” in

the very beginning. Other accrediting organizationsdepend heavily on applicant fees to support theprogram, but that is not how they started. Mostprograms examined had been financed by tradeorganizations in their start up periods. Commentary inthe public comment periods and discussion within theSteering Committee reflected concerns about capture ofan accreditation program by single interests, howeverbenign their intentions.

Cost containment in the start-up phase is an importantsignal to the field. However, an open, highlyparticipatory process of developing the standards, themeasures and the conformity determination process iscritical. The business case developed for the SteeringCommittee’s consideration placed significant emphasison the need to support extra cost in time and resourcesinvested in full participation in developing theseelements of the accreditation program.

In the start-up phase, attention to operational efficiencyand to standardizing data and procedures for the futureapplicants will be interpreted positively. Complaintsagainst accrediting programs seem to focus heavily onthese issues. The Finance and Incentives Workgroup’srecommendations and the business case developed forthe Steering Committee’s consideration included optionsto enhance efficiency from the outset of operations.

The Finance and Incentives Workgroup examined thepool of potential major funders of the start-up: it is notlarge. As the business case (see Appendix G) wasdeveloped for the recommended model, the Workgrouprecognized the long lead time before the program couldbecome self-sustaining. Potential funders will need to bewilling to wait for results. At the same time, theWorkgroup and the Steering Committee recognized thecritical need for the accreditation program to be fundedby its beneficiaries, even though many healthdepartments will need assistance in paying fees andachieving conformance. (See the discussion of Financingthe On-going Operations of the Accreditation Program,and Incentives, below.)

Looking at the experience in other accreditationprograms, the Workgroup noted that interest ininfluencing the quality of the services being accreditedhas been important in attracting supporters.

• 33


Alternatively, input from the public health fielddemonstrates that there is great concern about captureof the accreditation program by one or two parties. TheWorkgroup and the Steering Committee have identifieda long list of potentially interested parties, few of whichhave the capacity to be major funders. Reaching out tomany partners in forming an in-kind-funding consortiumis an alternate strategy for sustaining a balancedaccreditation program. In its final recommendations, theSteering Committee included both concepts: aconsortium of financial backers and a broadly-basedcadre of in-kind supporters.

Financing the On-going Operations of theAccreditation ProgramAfter examining a number of national accreditationprograms’ finance structures the Workgrouprecommended that on-going operations be fundedprimarily by the applicants and accredited agenciesthrough fees.

The Steering Committee discussed this approachextensively in order to reconcile it with the resourceconstraints within public health. The finalrecommendation is that on-going operations be fundedprimarily by the applicants and accredited departmentsthrough fees, with other funding sources to decrease theburden on applicants.

The Workgroup emphasized the important role thatpaying fees plays in assuring that the customers, theaccredited health departments, have a strong voice inthe operation of the accreditation program. TheSteering Committee understood that applicants’willingness to pay fees help keep the resources focusedon public health outcomes and continuous qualityimprovement as the final product of accreditation. Bybringing other funding sources into the on-goingoperations, the application fees needed to sustainoperations can be kept low enough to attract a widerrange of health departments to seek accreditation.

The Workgroup explored alternatives that wouldincorporate accreditation and performance improvementcosts into indirect cost agreements, incorporate thesecosts as allowable costs in fees for services, and create“scholarships” for under-resourced health departments.These alternatives assure that funding for operations at

least partly flows through the applicants, not directly tothe accrediting program. The final recommendations ofthe Steering Committee state that “the accrediting entityshould work with federal agencies to consider applicationfees and health department accreditation costs asallowable costs ….” These issues are discussed furtherbelow (see discussion on Incentives).

Controlling the Cost of the Accreditation ProgramThe Workgroup explored the sources of costs in theaccreditation program from the perspective of programoperation. One key step was to identify fully thecomponents of operating costs. At the urging of publiccommenters and the Steering Committee, theWorkgroup exploration also included the costs to theapplicants. This is not commonly done, and theinformation from other programs was largely anecdotal.The costs centers identified included such items astraining, data collection, analysis, and staff time, butattaching dollar costs to these centers exceeded theWorkgroup’s capacity. As governmental agencies onstrict resource diets, health departments are especiallysensitive: their concerns center on priority-setting forquality performance and health improvement. Thereforecost containment for both the program and theapplicants could be considered in the business strategy,but placing dollar values on the applicant componenthad too many variables to be practical. The finalrecommendations by the Steering Committee reflectmany cost control decisions. Formally recognizingapplicant costs plays an important part in establishingcredibility, as does having an efficient operation. To be“marketable,” the costs have to be commensurate withthe perceived value of accreditation.

The Workgroup also noted the important role that“products sales,” such as training programs, technicalassistance, consultations, and proprietary systems, haveplayed in supporting other accreditation programs.Most have firewalls to assure that the conformity processremains uncompromised. The Steering Committeediscussed this issue extensively, concluding that the risksof product sales outweighed their value. The finalrecommendations limit such activities to training in theapplication process and explication of the standards andmeasures. Product sales are an extremely limitedrevenue source for public health departmentaccreditation.

34 •

Reliance on volunteer expertise, in contrast, is highlyvalued, and does help control costs. The incorporationof volunteers into standards development andmeasurement development committee work and the useof volunteers in the site reviews for the conformityassessment process are two very importantrecommendations for accreditation program operation.At the same time, the Workgroup noted that having apaid team leader is an alternative model that providesstability and quality control in the conformity process.

The role of state-level accreditation and performanceimprovement programs in the future of a voluntarynational accreditation program was considered from acost and financing perspective by the Workgroup. Fromthis perspective, doing accreditation through anestablished vendor or franchisee can enhance credibility,expand the “market,” increase coordination at local andstate levels, and has a number of other attractions.However, while the actual cost to the vendor forconducting conformance reviews is lower, the full cost ofaccreditation to the applicant may well be higher. Theaccrediting program has to assure that the assessmentsby the vendor or franchisee are consistent with all otherdecisions and that the same standards, measures andinterpretations are used. The Governing Board of thenational accreditation program makes the final decisions.These administrative and training requirements aresignificant costs. The applicant still pays theaccreditation application fee and the cost of the sitereview, as well as the costs of oversight of the vendor orfranchisee.

The final recommendations from the Steering Committeeinclude developing agreements with existing stateaccreditation programs where these are interested andsufficiently consistent with the national entity. This is awell-reasoned consensus based on rigorous and intenseengagement with the available data and experiences.

• 35


INCENTIVESWhen surveyed, public health leaders identified qualityand performance improvement, consistency amonghealth departments, and recognition by peers as themost important benefits of accreditation. In thedevelopmental phases of the voluntary nationalaccreditation program, incentives should be uniformlypositive. Incentives should include the following:

High Performance and Quality ImprovementAmong state and local public health departments there isa high value placed on performance improvement andcontinuous quality improvement. A successfulaccreditation program should provide a transformingprocess that supports these goals.

Recognition and Validation of the Public HealthDepartment’s WorkA successful accreditation program should be credibleamong governing bodies and recognized by the generalpublic, providing accountability to the public, fundersand governing bodies (legislatures and governors at thestate/territorial level; tribal governments; and boards ofhealth, county commissions, city councils, and officials atthe local level). The accrediting entity should establish aninformation program which promotes the value ofaccreditation to the public and key stakeholders.Accredited public health departments should receiverights to use credentials in promoting their work to theirconstituencies and in seeking access to grants, contracts,and reimbursement preferences. The accrediting entityshould provide documentation, promotional materialsfor customized use, and specialized support to accreditedpublic health departments. In addition, the accreditingentity should maintain an active program promoting thevalue of quality and performance improvement in publichealth and the role of accreditation in encouraging anddocumenting continuous improvement in public healthdepartments.

Access to Resources and Services to Undergo theAccreditation ProcessTo encourage state and local public health departmentsto seek accreditation, the accrediting entity shouldprovide assistance for the application process as detailedunder “Conformity Assessment Process” (page 28). Theaccrediting entity also should work with potential fundersto develop scholarship programs and encourage peer

consulting services for departments needing assistance inspecific domains. There should be no penalty (other thanexpended costs and fees) for terminating the applicationprocess during the pre-qualification process or before anaccreditation decision is reached.

Improved Access to ResourcesThe accrediting entity should partner with public healthorganizations, foundations, and governmental agenciesto promote incentives for accredited public healthdepartments.These can include:

• Access to funding support for quality andperformance improvement.

• Access to funding to address gaps ininfrastructure identified in the accreditationprocess.

• Opportunities to pilot new programs andprocesses based on proven performance levels.

• Streamlined application processes for grants andprograms.

• Acceptance of accreditation in lieu of additionalaccountability processes.

Accreditation also has been shown to enhancerecruitment and retention of a high quality work forcethrough reputation and an enhanced workingenvironment.

Access to Support for Continuous QualityImprovementThe accrediting entity should maintain active support forcontinuous quality improvement among accreditedpublic health departments. The components of thistransformational practice support program may includein-person and Web-based services, best practicesexchange, peer-group data exchange and analysis, andsimilar resources. Leadership awards may be developedas the accreditation program matures.

36 •

INCENTIVES DISCUSSIONAccreditation is a tool for transforming public healthdepartments into higher-performing, quality-orientedorganizations. For those committed to thistransformation, this program is designed to assure thatparticipants and non-participants become higherperforming, more quality-oriented public healthdepartments. The incentives to use this particular toolfall into two categories: benefits from recognition andsupports for transforming (e.g., financial assistance,technical assistance, etc.). The Workgroup and SteeringCommittee both were adamant about including onlypositive incentives in the program. Throughdeliberations, incentives that appeared restrictive orcoercive or significantly shifted resource patterns werediscounted as negative. Incentives that changedrelationships between the accrediting entity and theaccredited departments, such as access to specialtraining or consultative programs, were recognized asconflicts of interest and also discounted. Incentivescannot be punitive to non-participants if the program isto have a “field-wide” impact on performance andoutcomes.

Exploring the options for incentives to becomeaccredited and evaluating the challenges was revealing.Financial incentives for participation, such as betteraccess to grant funds, training programs, contractingopportunities, and enhanced fees, may exacerbateproblems of smaller, more rural or weaker healthdepartments by drawing the available resources awayfrom them. If the goal of accreditation is improvedhealth status for all, this redirection is seen ascounterproductive. Although recognition for highperformance is considered an important benefit, eventhat is viewed with concern as potentially decreasingaccess to resources by others. Hence, in both financingthe program and developing incentives, the SteeringCommittee recommendations are intended not to beexclusive or too closely tied to the accrediting entityitself. The recommendations are intended to promoteefficiency and value.

The Steering Committee’s final recommendations alsorecognize that the accrediting entity itself has limitedcapacity to provide incentives other than recognition andconfirmation. It will need to seek out others –government funders, foundations and payers for health

care and public health services, for example – to provideincentives. The Steering Committee struck a fine balanceamong competing priorities to identify the types ofincentives that will be most useful for implementing avoluntary national accreditation program.

The Workgroup and the Steering Committee alsoarticulated factors that might influence others to provideincentives. Policy-makers such as legislatures, countyand municipal officials, and boards of health may beencouraged to support the start-up and the participationof state and local health departments if they can see:

• Opportunities to measure performance on anappropriate set of services at a consistent levelof quality.

• A connection between state and localcircumstances and national perspectives on keyservices.

• A single process for assuring readiness andability to perform.

• A single process for accountability.

• External validation that health departments areunder-resourced and of the resultant disparitiesin health outcomes in those communities.

• Information for advance planning to shore upinfrastructure capacity.

• A tool for assessing wise investments over thelong term.

Foundations and state and federal government agenciesmay participate in providing incentives in order topromote their agendas for high quality public healthservices and improved health outcomes, if accreditationmakes the case for transformation.

• 37


PROGRAM EVALUATIONA logic model has been developed to serve as theframework for evaluation of a voluntary nationalaccreditation program. Evaluation of the programshould be highly emphasized throughout the process ofplanning, development and implementation. Theassociated costs need to be factored into the program’sbudget.

Furthermore, the accrediting entity should determinefrom the outset and in a transparent way whichevaluation results will be kept confidential and which willbe shared publicly or made available to researchers andothers. The evaluation plans should be flexible enough tobe implemented by many different organizations (i.e.,the national accreditation program doesn’t have themonopoly on data or evaluation). In addition, qualitydata collection is critical, and data should be collected ina standardized way that allows it to be integrated withdata from other systems.

Aspects of the program to evaluate include thosedescribed as follows.

Effectiveness of the Accrediting Entity• Is the accrediting entity appropriately staffed

and are staff members performing well?

• Does the accrediting entity use results ofevaluation to improve the accreditationprogram?

• Is the financial performance meeting the goalsset by the Governing Board?

Accreditation Process• How much staff time (from both applicant and

accrediting entity) is required to complete theaccreditation process?

• Are the required activities for each step of theaccreditation process clear and understandableto all participants?

• How useful are the various types of training andtechnical assistance?

Marketing and Customer Satisfaction• How many agencies are participating in the

accreditation process and what are theircharacteristics?

• How satisfied are participating agencies with theaccreditation program?

Accreditation Standards and Measures• Are the standards appropriate? Do they need to

be changed?

• Are the standards and measures reliable andvalid?

Improved Performance of Accredited Agencies• What improvements in agency performance

have resulted from participation in theaccreditation program?

Contribution to Evidence Base• Is the accreditation process capturing data to

support key research questions?

• Does the accreditation program have policiesand processes in place to support the use ofaccreditation data by researchers?

Credibility of Accreditation Program• Is the accreditation program perceived as

credible by potential applicants and decisionmakers?

PROGRAM EVALUATION DISCUSSIONThe logic model (see Appendix F) is intended to linkaccreditation activities and outputs to both short-termoutcomes (e.g., changes in health department capacityand practices) and long-term outcomes (e.g., changes inhealth indicators). However, the importance of notsuggesting an automatic link between the short-termand long-term outcomes was noted by the SteeringCommittee. Improving the capacity, programs and/oroperations of a public health agency has not beenproven to lead to improvements in health indicators(such as infant mortality or water quality). Conversely,these outcomes can improve for reasons that have onlylimited relationship with health departmentperformance. Many other contextual variables(independent of the work of health departments) affectthese long-term outcomes. Currently, the evidence baseto support the linkage between specific standards forpublic health (such as those specified in the NationalPublic Health Performance Standards Program) andimproved public health outcomes is very limited. With

38 •

these caveats, the Steering Committee embraced thelogic model as a framework to guide evaluation of thevoluntary national accreditation program. The SteeringCommittee also noted that the accreditation entity hasan obligation to participate in developing and facilitatinga research agenda around the short- and long-termoutcomes of accreditation, and thus to contribute to theevidence base. (See a more detailed discussion aboutresearch below.)

A central responsibility of the accrediting entity’sGoverning Board is to ensure ongoing evaluation of boththe processes and outcomes of the national accreditationprogram and to use this information for continuousquality improvement. Evaluation activities must besufficiently funded in all phases (i.e., the developmental,initial operation and full operation phases) of a newprogram. Evaluation will be critical to the success of theprogram for many reasons. Chief among them are theneed to assure that the program is functioning in a waythat achieves the program goal of promoting quality andperformance improvement; to assess and respond toissues around customer satisfaction; to evaluateefficiencies and cost inputs; and to modify marketingstrategies based on information that is collected.

The Steering Committee recommended a robust set ofdomains for program evaluation (page 37). In itsdeliberations, the Research and Evaluation Workgroupnoted that some evaluation questions should have higherpriority in the early phases of the accreditation program,and to that end recommends the following sequencing.

PRE-LAUNCHFormative evaluation

• Which of the implementation processes underconsideration is more likely to supportperformance improvement?

• Are the proposed accreditation standardsconsistent with the principles recommendedby the Steering Committee?

• Is the proposed accreditation processperceived by potential applicants as offeringsufficient benefits?

PHASE 1Evaluation of inputs

• Agencies’ readiness to apply and maintainaccreditation.

• Perceptions of the value of accreditation.

• Agency interest in pursuing accreditation.

Evaluation of strategies• Accreditation & re-accreditation processes

(self-assessment, external review).

• Support for accreditation by policy makers(elected and appointed; local, state,national).

• Incentives for participation.

PHASE 2Evaluation of outputs and outcomes

• Ability of accredited agencies to use resourcesmore effectively.

• Willingness of accredited agencies to seek re-accreditation.

• Percentage of population served byaccredited agencies.

PHASE 3Evaluation of outcomes

• Improved outcomes (staff competency, inter-agency collaboration, quality of services) in allpublic health agencies.

• Strengthened organizational capacity ofaccredited agencies.

• Percentage of population served byaccredited agencies.

While Research and Evaluation activities are linked, theSteering Committee listed separate definitions of“research” and “evaluation” in the project glossary(Appendix H). This distinction was important, as it isrecommended that the Governing Board ensure thatprogram evaluation occurs, and also that the GoverningBoard actively promote research conducted by othersthat would benefit the national program. The followingsection discusses principles around research that wouldsupport the national program.

• 39


RESEARCH DISCUSSIONThe accrediting entity and Governing Board arespecifically charged with actively encouraging researchthat would benefit the program. The SteeringCommittee noted that an attendant research agendashould examine issues related to the importance andvalue of a voluntary national accreditation program, aswell as the desired outcomes as listed in the logic model.What constitutes a best practice also should be defined.

Although the Steering Committee did not delve into thislevel of detail, the Research and Evaluation Workgroupgenerated several principles recommending that theaccrediting entity establish a research and evaluationcommittee. The primary responsibilities of thiscommittee would include recommending priorities forevaluation and research as well as identifying which areasare most appropriate for internal evaluation and whichfor external research. Early tasks for this committeeshould include identifying (1) the basic “demographic”data that should be collected from health departmentsmaking inquiries about and applying for accreditationand (2) the data about the accreditation process that areneeded to support evaluation. It would also address themany implications of data needed to support research,e.g., determining what data should be made availablefor research purposes and how they are collected (i.e., tothe degree possible it would be preferable to easilyintegrate them into other available data).

Additional principles regarding research that theWorkgroup identified include the following:

1. The accrediting body should advocate forresources to support relevant research.

2. Research should be conducted by externalparties (i.e., no formal ties to the accreditingentity) to avoid real or perceived conflicts ofinterest.

3. The accrediting body should establish policiesthat allow for the use of data collected throughthe national accreditation program by publichealth systems researchers. These wouldinclude policies on confidentiality and data use,including reasonable fees for use of the data.

4. The accrediting body should coordinate withpublic health organizations that engage inroutine collection of data to encourage them tocollect data that would inform the researchagenda.

5. As the evidence base emerges from research,the accrediting body should use it to improvethe national accreditation program.

40 •

PUBLIC COMMENT DISCUSSIONEstablishing a public comment period for review of thedraft recommendations was viewed by the SteeringCommittee as a very significant component of theirexploration. It was critical to understand how potentialapplicants viewed a voluntary national accreditationprogram for state and local governmental public healthdepartments, and make the recommendations responsiveto the findings. It was also very important to sample theresponse from state and local policymakers and torespond to their interests.

The project consultant, Michael Hamm, fielded anopinion survey to state and local health officials as partof a market research effort. That effort is described onpage 12 of this report. Four additional mechanismswere established to receive public comment:

1. Presentations (in person, conference call, andsatellite broadcast – see Appendix D).

2. Speaker and participant feedback forms(distributed during the in-person meetings).

3. Online survey (accessible throughwww.exploringaccreditation.org).

4. E-mail ([email protected]).

Speaker feedback formsSpeakers from all of the presentations completed aspeaker feedback form. Generally, the in-persondiscussions were followed by a question and answersession, rather than providing a forum in which opinionsare expressed. The most common questions were aboutthe cost of participation, the time required to completethe process, and when implementation will occur.Additionally, concern was expressed that although theprogram is called voluntary, it will become mandatoryover time.

Written responsesA total of 540 individuals responded in written format.See Appendix I, Tables 1, 2, and 3 for the demographicinformation that was collected from the respondents.The respondents were not geographically diverse, withover half coming from U.S. Public Health Service RegionV. In addition, the majority of respondents were fromlocal health departments. The percentage of state andlocal health departments relative to their respective

universes is not available, as more than one individualcould respond from the same health department. It isimportant to note that job title was not requested, andtherefore the responses were not necessarily from thehealth official.

Survey participants were asked to respond to threeclosed-ended statements, indicating the degree to whichthey agreed (strongly agree, agree, neutral, disagree, orstrongly disagree). With respect to “The model isunderstandable” (Appendix I, Table 4), 73 percent (349)of the respondents indicated that they agree or stronglyagree, six percent (27) indicated that they disagree orstrongly disagree, and 21 percent (100) were neutral.With respect to “The model is feasible forimplementation” (Appendix I, Table 5), 46 percent (216)of the survey respondents indicated that they agree orstrongly agree, 28 percent (83) disagree or stronglydisagree, and 35 percent (164) were neutral. In responseto “Our health department would seek accreditationunder this model” (Appendix I, Table 6), 45 percent(195) of the respondents indicated they agree or stronglyagree, 18 percent (80) indicated they disagree orstrongly disagree, and 36 percent (158) were neutral.

These data also were analyzed to see if there was adifference between how individuals from state and localhealth departments responded to these questions. Ingeneral, the responses were similar (Appendix I, Tables 7-9). (Please note that the percentage of respondents wasprovided in order to present a relative picture of theresponses.) Although the percentage of state healthdepartments that rated feasibility for implementationand likelihood of seeking accreditation under this modelappears to be a bit higher than local health departments,a significant difference in the responses from these twogroups cannot be inferred because of the smaller numberof state health department respondents.

Finally, these data were analyzed to evaluate whetherstate and local health departments of varying sizes(defined by size of the jurisdiction served) were more orless likely to seek accreditation under this model(Appendix I, Table 10). For these purposes, small healthdepartments are defined as those serving populations of0-49,999 (n=137); medium serve 50,000 to 999,999(n=204); and large serve 1 million or more (n=51).There is a statistically significant difference between the

http://www.exploringaccreditation.org

• 41


2. What issues or problems are most likely to result inyour deciding against supporting accreditation?

By far, the most frequent responses to this questionwere issues associated with cost and time (Appendix I,Table 12). A predominant perception was thataccreditation is very expensive, and that new fundsare needed or, in order to pay for it, healthdepartments would need to shift money from otherprograms, essentially choosing between accreditationand providing services. Additionally, it was viewed asa time-consuming and complex/difficult process, andmany respondents indicated that they felt they did nothave sufficient staff, and/or that staff time also wouldbe shifted from services to undergoing necessarytraining and then completing the process. Severalrespondents questioned whether the cost justified anybenefits to be derived.

Others voiced concern regarding the applicability orappropriateness of the program to small healthdepartments. There was concern that small and ruralhealth departments would not meet the standards,and that an accreditation program could result in theirelimination or consolidation. Along these same lines,another theme was the need to adjust the program to“fit” different sized health departments/differentinfrastructures, perhaps by establishing categories.

An additional theme that emerged was the difficulty ofobtaining buy-in for accreditation from staff, boards ofhealth and/or elected officials, and the need to marketthe value of accreditation, particularly a voluntaryprogram, to governing boards and elected officials.Along these same lines, several mentioned that theymay not be able to convince those who need tosupport this of its value if it is indeed voluntary.

Still others saw this as unnecessary, and/or nothingmore than a bureaucratic exercise with little to nobenefit or tangible results. A number of respondentsquestioned what the consequences would be of notbecoming accredited (as a result of not passing orsimply choosing not to participate). Potentialconsequences mentioned were loss of funding,negative public opinion, and the notion that thiscould become a political tool.

small and medium health departments, in that thesmallest health departments are less likely to seekaccreditation under this model. There is no statisticallysignificant difference between the responses frommedium and large health departments.

Open-ended questions also were posed, and a summaryof the responses follows.

1. What benefits of accreditation are most important inyour thinking about supporting accreditation?

A number of benefits were cited in response to thisquestion (Appendix I, Table 11), and the terms in boldfont indicate those used on the corresponding tables.Three themes were mentioned frequently (at leasttwice as frequently as any other of the cited benefits).The most frequently mentioned benefits were thoseassociated with increased recognition, which includedincreased public support; increased public awareness;better visibility; credibility to the community,governing bodies and elected officials; and clarity ofexpectations. Other benefits cited very often wereconsistency among health departments (whichincluded the value of having nationally-agreed uponstandards) and improved quality of services providedand improved performance (QPI).

Benefits that were cited less frequently includedaccountability and validation (including objectiveassessment of work), as well as increased funds and tieto funds (i.e., accreditation would be viewed as abenefit if accreditation status were tied to receivingadditional funds). The notion of outcomes –improved community outcomes, and better outcomesof the health department in general – received severalmentions, as did an enhanced evidence base andbenefits to staff (improved morale, collaborationamong staff internally, and improved recruitment andretention efforts). Other items mentioned includedaccreditation as a tool for quality assurance and ameans to identify best practices, and that ease of use,availability of comparison data, streamlined grantsapplication processes and access to technicalassistance and experts would be positive benefits.

Another theme that emerged, however, was that thereare no benefits to be gained.

42 •

Other themes noted included the need to clearlydemonstrate positive outcomes of accreditation beforeestablishing a national program, and concerns thatthis will become a mandatory program. Additionalconcerns were raised that this could be duplicative ofcurrent standards-based efforts. Several respondentsalso directly asked how a national program wouldwork with existing programs, and whether it isacceptable for states to begin or continue to developtheir own accreditation or related programs.

Concerns that accreditation could interfere with localneeds and priorities were also expressed, as was theneed for stronger and better incentives. Finally, ahandful of other potential issues and problems werealso raised in very small numbers, and they deserveattention as well. They include:

• The difficulty and importance in establishingstandards that are clear, measurable, valid,achievable and not political, that are developedusing an inclusive process, and that are neithertoo easy nor too difficult to achieve.

• Concerns regarding a negative effect on staffmorale were also noted.

• A few suggestions to make this a mandatoryprogram.

• The need to modify the composition of thegoverning body, by significantly increasing thenumber of local health department (LHD) slots,including environmental health representation,deliberately including minority representation,and including board of health members.

• The importance of modifying the logic modeland the program to specifically address healthdisparities.

• Advice to learn from the “mistakes” that JCAHOhas made.

These data also were analyzed to determine whetherrespondents were more likely to identify benefits orissues/problems, or whether they identified neither orboth (Appendix I, Table 13). The majority ofrespondents identified both, and more identifiedissues/problems only than benefits only.

The data were also analyzed to compare the numberof benefits cited among those most likely to seek

accreditation under this model (respondents whoanswered “agree” or “strongly agree” to thequestion), least likely (“disagree” or “stronglydisagree”), and uncertain (“neutral”) (Appendix I,Table 14). A similar analysis was done to compare thenumber of issues/problems cited by the three differentgroups (Appendix I, Table 15). Those who are mostlikely to seek accreditation identified the greatestnumber of benefits, possibly suggesting that the clearand compelling benefits may be a key to maximizingparticipation in a national program. In addition, thenumber of issues/problems identified was fairly similarbetween those most likely to participate and thosewho are uncertain, possibly suggesting that attentionto potential issues/problems could encourage moreparticipation by those who are uncertain.

Finally, the data were analyzed to identify whetherthere were differences in the percentages ofrespondents identifying specific benefits and issues/problems in these three groups (Appendix I, Tables 16and 17). The respondents most likely to participatewere significantly more likely to cite benefits related torecognition (45 percent vs. 19 percent), accountability(12 percent vs. 2 percent), and validation (10 percentvs. 1 percent) than the respondents least likely toparticipate. On the problems/issues side, respondentsin the “uncertain” category were significantly morelikely than those in the most likely category to cite lackof time as a problem (43 percent vs. 27 percent).Cost was cited as a problem more frequently by thoserespondents least likely to participate (69 percent)than those respondents most likely to participate (32percent).

3. Are there design flaws in the proposed model that theSteering Committee should address?

Overall, responses in this category mirrored thethemes above under issues or problems with themodel and as a result have been tabulated with thatquestion. Additionally, 41 respondents noted thateither they would need more information to provide asound response to this question, or more time shouldbe devoted to studying the issue.

Although these data do not include a representativesample of potential applicants, they nevertheless

• 43


provided useful feedback to the Steering Committeeregarding the proposed model and the readiness ofthe field to participate in a national accreditationprogram.

A large majority of respondents (73 percent) agreedthat the model was understandable. Slightly less thanhalf of respondents (47 percent) agreed that themodel was feasible, with a suggestion that a smallerpercentage of local agency respondents than stateagency respondents agreed that the model wasfeasible (44 percent versus 58 percent). Slightly lessthan half of the respondents indicated that they werelikely to seek accreditation (45 percent). For localhealth departments, the likelihood of seekingaccreditation appears strongly related to population ofthe jurisdiction served. Twenty-four percent of localhealth departments serving populations less than50,000 indicated that they were likely to seekaccreditation, versus 57 percent of local healthdepartments serving populations of 50,000 or greater.

Increased recognition, consistency among healthdepartments, and improved agency services were byfar the most frequently cited benefits of a nationalaccreditation program. The cost and time associatedwith the accreditation process were by far the mostfrequently cited problems or issues. Consistent withthe findings of the online survey, likelihood of seekingaccreditation is associated with the degree of benefitsperceived by the health agencies. A wide range ofother benefits and problems were cited byrespondents. Not surprisingly, respondents who weremost likely to participate in a national accreditationprogram were more likely to cite certain benefits(related to recognition, accountability, and validation)and less likely to cite certain problems (time and cost)than those respondents less likely to participate. TheSteering Committee deliberately addressed theseaspects in their final recommendations in order tomaximize participation.

THE BUSINESS CASE FOR ACCREDITATION

Every person in America has a stake in our publichealth system and how well it performs. Most people,when asked, can’t tell you what “public health” is,what it does and what it means to the safety and goodhealth of their community or family. But research tellsus that they sure think it’s important and they wantmore of it, particularly when it comes to protectionfrom broad scale health threats, such as avian flu, oreducation about making healthier lifestyle choices,for example to prevent obesity or tobacco use.

— Risa Lavizzo-Mourey, MD, MBA,President and CEO, RWJF

The business case presented here incorporates theSteering Committee’s decisions, and is matched to thefinal recommendations. The assumptions in the businessmodel and budget provide information on the effects ofdecisions about the major variables that influence thecosts and the credibility of the recommended voluntarynational accreditation program. The findings fromexternal sources have been integrated with therecommendations of the Steering Committee to describethe business environment for a voluntary nationalaccreditation program in the next nine years. Thebusiness case examines the market for the proposedaccreditation program’s product, the volume of work inthe development and initial operation phases, and thepotential revenues generated from services — the basisfor the Steering Committee’s decision that thisrecommended program is feasible.

DemandThe model recommended by the Steering Committeeconsiders all state, territorial, tribal and localgovernmental health departments to be eligible foraccreditation if they apply and meet standards.Presently, there are approximately 2900 local healthdepartments and 57 state and territorial healthdepartments (this number includes Washington, DC).The market among tribal health departments has notbeen assessed at this time, since this task requires its ownparticipatory process. While representatives of tribalinterests have participated in the work to date, thisinformal process is clearly insufficient.

44 •

Feedback from formal presentations and telephoneinterviews supported the view that there will be initialapplicants with enthusiasm. The feedback alsosuggested that early success can build credibility aroundthe standards and the conformance process, attractingan increasing number of applicants. It was also clearthat participant costs are a significant barrier and thatskepticism remains about the best use of limitedresources. The ability to expand to meet demand isgreater than the ability to sustain the effort in the face oflower demand than projected. Therefore, projections ofmarket penetration are very conservative.

A major concern from the field is fear that a nationalprogram will become mandatory despite the project’semphasis on voluntary accreditation. This concernshaped final recommendations on incentives from theSteering Committee: incentives should be positive for theaccredited departments, but not negative for theunaccredited ones. In addition, the emphasis placed onthe voluntary nature of the accreditation program willboth stimulate early adopters to become accredited anddiscourage health departments with significant resourceconstraints from seeking accreditation early. The lattergroup will want to see develop a track record that showsresources to support the application process and achievequality improvement flow to applicants and todemonstrate that accreditation does make economicsense for applicants with resource constraints. Missouri’sexperience with a fully voluntary accreditation programforeshadows limited uptake of the service until incentivesand benefits become clear. The business case is builtupon the expectation of gradual uptake as the newentity demonstrates its value to state and local healthdepartments.

A significant number of states have invested inaccreditation and performance improvement programsalready. The five states in the Multi-state LearningCollaborative funded by Robert Wood JohnsonFoundation have populations between 5 million and 15million. Local public health leadership in these states isvery supportive of the concepts of accreditation. In theinitial years of operation of a national accreditationprogram, participation in a national accreditationprogram may not be seen as adding sufficient value toattract health departments already involved in state levelaccreditation. Issues to be resolved in the process of

determining whether a state program becomes aparticipant will include:

1. What will the fees be and what entity isresponsible for paying the fees?

2. Is national participation voluntary when thestate program is mandated?

3. If a state program declines a partnership, willindividual health departments apply separately?

The answers to these questions will influence thenumbers of accredited health departments in the earlyyears of the program.

Appendix G, Table 1 projects the market andparticipation in accreditation services in the initialoperating period, taking into account local healthdepartments not currently participating in a state-basedprogram.

Competitive landscapeThe greatest competition for a voluntary nationalaccreditation program may be for administrativeresources within health departments with existingprograms and services. Many health departments willmake decisions about whether to seek accreditationbased on the cost benefit ratio for expected healthoutcomes compared with that of existing programs.

We have identified no other national accreditationprogram for health departments under development atthis time.

In contrast, several state-level health departmentprograms exist, but they are not using commonstandards or processes. Accreditation programs for localhealth departments in North Carolina and Michigan andperformance improvement programs for local healthdepartments in Illinois and Washington State (the onlystate that also currently includes the state healthdepartment in its accreditation or performanceimprovement program) are established in statutes.Missouri has a voluntary accreditation program for localhealth departments. As noted above, the modelproposes opportunities for these state programs to bedetermined equivalent and/or to have their accreditationdecisions endorsed by the national program. None ofthese state programs has indicated interest in offering

• 45


their program’s services outside its own state.Accreditation by two different accreditation programs,one state and one national, is unlikely to be attractive tostate or local health departments unless incentives areboth significant and tangible.

Performance improvement efforts using the NationalPublic Health Performance Standards are well-established. These standards are undergoing revisionwith support from some of the same sources that aresupporting Exploring Accreditation. Performanceimprovement models currently result in a similar qualitytransformation method as accreditation.

At least thirteen other state applications were preparedfor the Multi-State Learning Collaborative grant offeringin 2005. Representatives from most of these states(health departments, public health institutes, or both)attended a conference on state performanceimprovement activities in 2006. Their continuedinvolvement has been promoted by the funders ofExploring Accreditation. The national program offerssome support to continued development of state-levelaccreditation. While most states do not haveaccreditation programs under way at this time, there isactive consideration of developing them. State-basedperformance improvement programs have certainadvantages in competing with a national program:

• Responsiveness to state/local variations inpolitical philosophy, demographics andeconomics.

• Direct connection with state and localgovernmental funding sources.

• Established relationship between state and localhealth departments, their leadership, and theirprograms.

• Recognition of geographic variations in publichealth structures and practices.

• History of performance improvement efforts,including Turning Point.

National health accrediting bodies may consider publichealth accreditation a worthwhile business engagementproviding additional competition. The JointCommission on Accreditation of HealthcareOrganizations has developed a line of business incollaboration with the Health Resources and Services

Administration for Community Health Centers, forexample. If the recommended national accreditationprogram is slow in starting, others may step up. Existingnational non-profits with interest in public health,including the sponsors of the Exploring Accreditationproject, could develop an independent program if thecurrent project does not move forward.

Identifying the Financial Factors for the Business CaseThe Workgroup generated a list of the components ofthe model that influence the cost of developing,implementing and operating a voluntary nationalaccreditation program (Appendix G, Table 2). While notexhaustive, the list is intended to capture the principledrivers of cost in the enterprise so that a business casecan be prepared. Using the model, the Workgroup alsogenerated a preliminary list of revenue sources that maybe used to support the new enterprise’s work (AppendixG, Table 3). The Workgroup identified options of designand implementation based on the model and developeda matrix describing three sets of options in order toprovide the Steering Committee with a clearer picture ofthe enterprise and attach cost estimates to the model(Appendix G, Table 4).

The matrix was developed by identifying the range ofoptions for each variable that would fit the model andthe key factors to be considered in selecting an option.The Workgroup included three options for each variablewhenever possible. After options were developed forevery variable, the Workgroup reviewed the matrix toselect the preferred option, based on the criterion thatthe option was the most likely to allow the model tomeet the goals. (Research was identified by the SteeringCommittee as an important component of the finalrecommended model. However, only the evaluation ofthe accreditation program and activities was identified aswork to be done by the new entity. Research is to bestimulated by the accreditation program, rather thanperformed or funded by it.)

Marketing StrategyThe major components of a marketing strategycompatible with the recommended accreditationprogram include the following:

• A vigorously participatory process fordeveloping standards and measures with stronggoverning body involvement.

46 •

• A streamlined conformance assessment processwith emphasis on electronic informationexchange and cost-effectiveness from theapplicant’s perspective.

• A rigorous pilot phase to establish proceduresand show value.

• An investment in tangible incentives forapplicants.

• An investment in outreach to decision makersand users of accreditation information.

The new voluntary national accreditation program willneed to attract and retain applicants/accrediteddepartments in order to demonstrate its value. Thebusiness case for the Final Recommendations reflectsresource needs for cultivating key supporters: publichealth professional membership associations, publichealth institutes, public health department membershipassociations, public health academic organizations,governmental public health agencies at federal, state andlocal levels, and foundations with an interest in healthand in good government. Negotiating volunteerexpertise and in-kind support from existing public healthorganizations will help solidify support and assistoperating efficiency. Securing positive financial andprogrammatic incentives from government and fromprivate foundations will build credibility for theaccreditation program and strengthen the cost-benefitcase for becoming accredited.

The recommended model calls for relying on existingstandard sets and performance measurement systems asthe foundation for accreditation. The preferred optionscontemplate an efficient conformance process tostrengthen the cost-benefit ratio for applicants. Theseprinciples provide a strong basis for marketing to healthdepartments seeking to improve performance and healthoutcomes.

Financial FeasibilityThe Steering Committee defined the preferred optionsfor a “reasonable case” operating plan. The revenuesfrom service fees and the operating costs were forecastedfor a nine-year period (see Appendix G, Table 5), and donot take into account the potential fees from theparticipation of state-based programs. The SteeringCommittee concluded that a new national accreditationprogram for public health departments is feasible if key

stakeholders and sponsors are willing to finance adevelopmental phase of up to three years at anestimated cost of approximately $2.1 million dollarsand to cover an anticipated operational deficit ofapproximately $740,000 during the first three years offull operation. (Note: These costs are general estimatesthat were generated by the Finance and IncentivesWorkgroup. Upon further analysis these costs are subjectto change) The Steering Committee also concluded thatlong term success will depend upon support ofapplication fees and compliance activities throughcontinuous quality improvement grants to healthdepartments, indirect cost allowances on grants andcontracts, and adjustments in fees for services toaccredited health departments, just as such sourcesare available to health facilities to cover the costs ofmaintaining high quality performance.

Risk AnalysisThe model may prove more or less acceptable to thepotential applicants than predicted. Fees may beperceived too high, processes too onerous, or standardstoo complex, resulting in fewer applicants and an overlyambitious financial projection. Alternatively, incentivesand benefits could engender more enthusiasm for theprogram than predicted, resulting in a higher number ofapplicants and leaving projections of operations growthtoo conservative. The latter would require tremendousmanagement, but would result in greater financialsuccess than predicted.

Leadership changes at CDC and other major supportingagencies occur frequently. The accrediting entity willneed a strategy for bridging future changes in publichealth leadership. Elements of risk include thewillingness and capacity of federal agencies to supportvoluntary accreditation, escalation of state-basedaccreditation programs that are not interested inparticipating in the national program, and foundationsupport for the developmental phase of the program.

State accreditation programs could proliferate while thedevelopment phase is underway and substantially reduceinterest in a national approach, particularly if strongincentives are not identified for a national program.Maintaining the momentum to implement the proposalfor a voluntary national accreditation program in thenear future will reduce this risk, as will the development

• 47


of sufficient incentives for participation in a nationalprogram.

Major changes in funding of federal, state and localhealth departments could affect the start-up of a newaccreditation program. If the magnitude of change wereas large and rapid as the bioterrorism and emergencypreparedness shifts in the past six years, the generalinstability may complicate development and discourageparticipation. On the other hand, strongly linkingaccreditation to strategic change may encourageparticipation.

Confidentiality of data and political values foraccountability and transparency could collide early in thedevelopment of the program. Policies will need to beenumerated early and widely disseminated to setexpectations before significant data collection begins.A confidentiality dispute or a breach of confidentialitywould set the program back substantially.

A significant performance failure by an accredited healthdepartment could be disastrous for the credibility ofaccreditation as a public accountability system. Thispossibility calls for care in setting expectations at thesame time that the new accreditation program is activelymarketing, a challenging balance.

Research on the value of accreditation is weak. Changein health outcomes is often held out as the “goldstandard,” but research designs to demonstrate effects ofaccreditation on health outcomes are complex, long, andfraught with methodological and policy minefields. Ifquantitative analysis and randomized control trials areover-stressed, studies are more likely to produceequivocal findings, leading to a loss of perceived value.Choosing key research projects wisely will be veryimportant. Developing sustained support throughexpert opinion has worked for the accreditation of directhealth care services, but it is periodically challengeddespite that consensus.

CONCLUSIONThe Steering Committee of the Exploring Accreditationproject determined that this is a reasonable businesscase for the recommended voluntary nationalaccreditation program.

48 •

APPENDIX A

STEERING COMMITTEE, WORKGROUP MEMBERS,PROJECT STAFF, CONSULTANTS, AND

FUNDING ORGANIZATION REPRESENTATIVES

• 49


ChairKaye Bender, RN, PhD, FAANDean, School of NursingUniversity of Mississippi MedicalCenter

Stephanie B. C. Bailey, MD, MSHSADirector of HealthMetro Nashville/DavidsonCounty (TN)NACCHO

Deanna BaumanArea Manager Oneida (WI)Community Health CenterNIHB

Les Beitsch, MD, JDDirector, Center for Medicine/Public HealthFlorida State UniversityPHF

Gordon Belcourt, MPHExecutive DirectorMontana-Wyoming Tribal LeadersCouncilIHS

Eric Blank, DrPHDirectorState Public Health LaboratoryMissouri Dept. of Health and SeniorServicesAt-Large

Joan Brewster, MPADirector, Public Health SystemsPlanning, Washington StateDepartment of HealthAt-Large

Shepard CohenHealth Care Consultant/PrincipalExcellence in Graduate MedicalEducationNALBOH

Harold Cox, MSWChief Public Health OfficerCambridge (MA) Health DepartmentNACCHO

Leah Devlin, DDS, MPHState Health DirectorNC Dept. of Health and HumanServicesASTHO

Colleen Hughes, RN, PhDExecutive DirectorMountain Health Connections, Inc.(NV)APHA

Laura Landrum, MUPPSpecial Projects DirectorIllinois Public Health InstituteNNPHI

Cassie Lauver, LMSW, ACSWDirectorDivision of State and CommunityHealthHRSA

Dennis Lenaway, PhD, MPH*Director, Office of Standards andEmerging Issues in PracticeOffice of Chief of Public HealthPractice, Centers for Disease Controland PreventionEx-Officio

Janet Olszewski, MSWDirectorMichigan Department ofCommunity HealthASTHO

Jan MalcolmChief Executive OfficerCourage Center (MN)At-Large

EXPLORING ACCREDITATIONSTEERING COMMITTEE MEMBERS

Patti Pavey, MSPrincipal Consultant HealthTeknique (UT)NALBOH

Bobby Pestronk, MPHHealth OfficerGenesee County (MI) HealthDepartmentNACCHO

Bruce Pomer, MPAExecutive DirectorHealth Officers Association ofCaliforniaNACCHO

Sandra Shewry, MPH, MSWDirectorCalifornia Department of HealthServicesASTHO

Rachel Stevens, EdD, RNSenior AdvisorNorth Carolina Institute forPublic HealthNALBOH

Robert Stroube, MD, MPHCommissionerVirginia Department of HealthAPHA

Lee Thielen, MPAPublic Health ConsultantThielen Consulting (CO)PHLS

Kathy Vincent, LCSWStaff Assistant to theState Health OfficerAlabama Department ofPublic HealthASTHO

Harvey Wallace, PhDProfessor and Department HeadNorthern Michigan UniversityNALBOH

*This position was initially held by Ed Thompson, MD, MPH,former Chief of Public Health Practice.

50 •

EXPLORING ACCREDITATIONGOVERNANCE AND IMPLEMENTATION WORKGROUP MEMBERSChair

Rachel Stevens, EdD, RNSenior AdvisorNorth Carolina Institute for PublicHealth

Susan Allan, MD, JD, MPHDirectorOregon Department of HealthServices

Scott J. Becker, MSExecutive DirectorAssociation of Public HealthLaboratories

Bobbie Berkowitz, PhD, CNAA, FAANProfessorPsychosocial & Community HealthUniversity of Washington

Claude Earl Fox, MD, MPHResearch ProfessorMiller School of MedicineUniversity of Miami

Paul Halverson, DrPH, MHSA, FACHEDirectorArkansas Department of Health

James G. Hodge, Jr., JD, LLMAssociate Professor, Johns HopkinsBloomberg School of Public HealthExecutive Director, Center for Lawand the Public’s Health

Jerry King, MAExecutive DirectorIndiana Public Health Association

Jeffrey R. Taylor, PhDExecutive DirectorMichigan Public Health Institute

Mary Wellik, MPHPublic Health DirectorOlmsted County (MN) Public HealthServices

Chair

Stephanie B. C. Bailey, MD, MSHSADirector of HealthMetro Nashville/Davidson County(TN) Health Department

Bruce Bragg, MPHDirectorIngham County (MI) HealthDepartment

Liza Corso, MPAPublic Health AdvisorOffice of the Chief of Public HealthPractice, Office of the Director,Centers for Disease Control andPrevention

EXPLORING ACCREDITATIONSTANDARDS DEVELOPMENT WORKGROUP MEMBERS

Ann Drum, DDS, MPHDirector, Division of Research,Training and EducationHealth Resources and ServicesAdministration

Greg Franklin, MHADeputy Director, Health Informationand Strategic Planning DivisionCalifornia Department of HealthServices

Kathy Mason, RN, EdDDean, School of NursingFlorida State University

Glen Mays, PhD, MPHVice Chair and Associate Professor,University of AR for MedicalSciences

Jim Pearsol, MEdAssistant DirectorOhio Department of Health

Joy Reed, EdD, RNHead, PH Nursing & ProfessionalDev. UnitNorth Carolina Department of HHS

Torney Smith, MSAdministratorSpokane (WA) Regional HealthDistrict

Joan Valas, NP, PhD candidateSenior Public Health SpecialistColumbia University School ofNursing

• 51


EXPLORING ACCREDITATIONFINANCE AND INCENTIVES WORKGROUP MEMBERS

Chair

Bruce Pomer, MPAExecutive DirectorHealth Officers Association ofCalifornia

Mark Bertler, CAEExecutive DirectorMichigan Association for LocalPublic Health

Ron Bialek, MPPPresidentPublic Health Foundation

Ed Davidson, MPAPublic Health Administrative OfficerAlabama Department of PublicHealth

Mike Fleenor, MD, MPHHealth OfficerJefferson County (AL) HealthDepartment

Jeffrey Lake, MSDeputy CommissionerVirginia Department of Health

Dennis D. Lenaway, PhD, MPHDirector, Office of Standards andEmerging Issues in PracticeOffice of Chief of Public HealthPractice, Centers for Disease Controland Prevention William Mitchell, MPHDirectorPublic Health ServicesSan Joaquin County (CA)

Gerald R. Solomon, JDPresident and CEOPHFE Management Solutionsaka Public Health FoundationEnterprises, Inc.

EXPLORING ACCREDITATIONRESEARCH & EVALUATION WORKGROUP MEMBERS

ChairLes Beitsch, MD, JDDirector, Center for Medicine/PublicHealthFlorida State University

Stacy Baker, MSEdDirector, Performance ImprovementPublic Health Foundation

Joan Brewster, MPADirector, Public Health SystemsPlanning,Washington State Department ofHealth

Kristine M. Gebbie, DrPH, RNAssociate ProfessorDirector, Center for Health PolicyColumbia University

Karen Hacker, MD, MPHExecutive DirectorInstitute for Community Health

Mary Kushion. MSAHealth OfficerCentral Michigan District HealthDepartment

Charlie Mahan, MDProfessorUniversity of South Florida

F. Douglas Scutchfield, MDPeter P Bosomworth Professor ofHealth Services Research and PolicyUniversity of Kentucky MedicalCenter

Susan R. Snyder, PhD, MBAEconomistLaboratory Practice Eval. &Genomics BranchDiv. of Public Health Partnerships/National Center Health MarketingCenters for Disease Control andPrevention

Beverly Tremain, PhD, CHESEvaluation ConsultantMissouri Institute for CommunityHealth

Bernard J. Turnock, MD, MPHClinical ProfessorDirector, Center for Public HealthPracticeUniversity of Illinois, Chicago

52 •

ASSOCIATION OF STATE ANDTERRITORIAL HEALTH OFFICIALS(ASTHO)

Lindsey Caldwell, MPHDirector, Accreditation andPerformance Standards

Jacalyn Carden, RN, MS, CAEAssociate Executive DirectorPolicy and Programs

Sterling Elliott, MPHSenior AnalystPublic Health Systems

Jennifer Jimenez, MPHSenior AnalystPublic Health Systems

Patricia A. Nolan, MD, MPHASTHO Consultant

Adam ReichardtSenior AnalystPublic Health PerformanceImprovement

Mary Shaffran, MPAPrincipal DirectorPublic Health Systems

EXPLORING ACCREDITATIONCONSULTANTS AND STAFF

NATIONAL ASSOCIATION OFCOUNTY & CITY HEALTHOFFICIALS (NACCHO)

Priscilla Barnes, MPH, CHESProgram ManagerPublic Health Infrastructure andSystem Team

Carol Brown, MSSenior AdvisorPublic Health Infrastructure andSystem Team

Penney Davis, MPHProgram AssociatePublic Health Infrastructure andSystem Team

Grace Gorenflo, RN, MPHSenior AdvisorPublic Health Infrastructure andSystem Team

Carolyn Leep, MPHProgram ManagerPublic Health Infrastructure andSystem Team

Jocelyn RonaldProgram AssistantPublic Health Infrastructure andSystem Team

Jessica Solomon, MCPProgram ManagerPublic Health Infrastructure andSystem Team

CONSULTANTS

Chuck AlexanderBurness Communications

Francie de PeysterBurness Communications

Michael HammMichael Hamm & Associates

Shelley KesslerTCC Group

Jared RaynorTCC Group

EXPLORING ACCREDITATIONFUNDING ORGANIZATION REPRESENTATIVES

CENTERS FOR DISEASE CONTROLAND PREVENTION

Liza Corso, MPATeam LeaderOffice of the Chief of Public HealthPractice, Office of the Director

Dennis Lenaway, PhD, MPH*Director, Office of Standards andEmerging Issues in PracticeOffice of Chief of Public HealthPractice

THE ROBERT WOOD JOHNSONFOUNDATION

Russell Brewer, Dr.P.H., C.H.E.S.Program AssociatePublic Health Team Carol Chang, MPA, MPHProgram OfficerPublic Health Team/Research &Evaluation

Pamela Russo, MD, MPHSenior Program OfficerPublic Health Team Leader

Anthony D. Moulton, PhDActing ChiefOffice of Chief of Public HealthPractice

*This position was initially held by Ed

Thompson, MD, MPH, former Chief of

Public Health Practice

• 53


APPENDIX B

QUESTIONS FOR WORKGROUPS

54 •

OC

TOB

ERJA

NU

AR

Y

MEETING QUESTION GI* SD FI RE1. Is the general direction of an accreditation system: X

a. A single national voluntary program?b. A national umbrella for state and/or regional

programs?c. Some other model?d. A completely open question?

What are the advantages and disadvantages ofeach option?

2. What are we trying to achieve with respect to agency Xperformance and governmental public health systemperformance? What are the advantages anddisadvantages?

3. What should the standards measure (performance, Xoutcome, other aspects)? What are the advantagesand disadvantages of each?

4. What are the benefits and drawbacks of various Xfinancing options?

5. How can costs be minimized and/or confined to those Xthat add value?

6. Who should finance the system? X

7. What are the most appropriate measures of change Xresulting from a voluntary national accreditationprogram?

MEETING QUESTION GI SD FI RE1. Should an existing organization be used for the X

governing entity or should a new one be created?What criteria should be considered to answer thisquestion?a. Who will be the founders and/or incorporators?b. What are the advantages and disadvantages of

various governance options for start-up,implementation and on-going operations?

c. What principles should guide potential funders inorder to avoid a conflict of interest?

2. What are the responsibilities of the governing body, and Xhow will the first body of members be selected?

3. What are the most effective and efficient relationships Xamong federal, state and local levels to sustain anaccreditation system and how can they beaccommodated through the governance structure?

4. What principles would apply to states that already have XLHD accreditation or related programs to be participantsin a new accreditation process? What principles wouldapply to states that already have state accreditation orrelated programs? (Criteria for a migration strategywould be addressed later by a governing body.)

EXPLORING ACCREDITATION WORKGROUP QUESTIONS Revised February 16, 2006

* GI: Governance and Implementation Workgroup. SD: Standards Development Workgroup. FI: Finance and Incentives Workgroup. RE: Research and Evaluation Workgroup

• 55


JAN

UA

RY

MEETING QUESTION GI* SD FI RE

5. What principles for appeals should be considered for Xstate and local health departments?

6. What are the principles governing standards where X Xsome of the core function/essential public health servicesare assigned by state or local statute to othergovernmental agencies? Are the same principles appliedto state and local health departments, and if not, howare they different and why?

7. What are the principles governing standards where X Xthere are varying public health governance structures?a. In states that have a centralized health

department, how are standards applied to thestate health department itself, and how arestandards applied to their local branches? Whatare the advantages and disadvantages to variousapproaches?

b. How are standards applied within regions ordistricts that comprise a group of local healthdepartments? What are the advantages anddisadvantages of various approaches?

8. What constitutes the potential range of accreditation Xrecognition and what are the advantages anddisadvantages of each approach? Is the desired rangethe same for state and local health departments? If not,what is the distinction and why?

9. What domains should be included in the accreditation Xprogram for future development of standards, and whatare the advantages and disadvantages of each? Are theythe same for state and local health departments, and ifnot, what domains are specific to each?

10. What is the difference between standards and measures Xand how should that difference be reflected in theprinciples?

11. Where should the bar for standards be set? What are Xthe advantages and disadvantages? Is the bar the samefor state and local health departments? If not, whatdistinction needs to be made and why?

12. a. What are acceptable operating costs? Xb. What are the opportunities for controlling costs?

13. What principles should underlie fees? X

14. Where do the SC-identified goals for accreditation fit into Xthe proposed logic model for a national accreditationsystem?

15. What existing standards for state and local health Xdepartments are empirically linked to outcomes?

16. What principles should guide the development of Xmeasures for short-term, intermediate, and long-termoutcomes included in the logic model?


56 •

MA

RC

H

These questions were all posed to the RE WG.See recommended revisions, below.

Change to “What is the best methodology to pick upon unintended consequences of a national accreditationsystem?” and move to the June/July meeting.

Staff to draft a principle regarding thisissue for the Steering Committee toconsider.

Delete.

Move to June/July meeting.


1. How can the accreditation system attract and retain Xleadership and commitment from the accreditedparticipants?

2. Describe the pros and cons of various assessment Xsystems (e.g. self-assessment, peer review, third party,etc.) inherent in most programs for validating agencyperformance against standards?

3. What elements need to be considered in structuring Xgovernance to protect access to preliminaryaccreditation results/findings?

If not addressed in January:4. What principles for appeals should be considered for X

state and local health departments?

5. What consideration should be given to existing work Xsuch as:a. NACCHO’s Operational Definitionb. NPHPSPc. State-developed standardsd. Other standards?

6. What principles should be applied to updating Xstandards (e.g., dynamic, periodic updates) ?

7. How should standards be coordinated among all three Xlevels of government?

8. Can a selection of specific standards lead to specific Xincentives, and if so, should we prioritize incentives?

9. What incentives would most encourage participation Xin the model system?

10. What are the barriers, predictable effects, and possible Xconsequences of incentives to be anticipated and howcan they be addressed?

11. Consider the impact on HDs with less capacity (i.e.,those HDs with greater capacity typically have helpedthose with less; the system should not further decreasethe capacity of those HDs with less capacity)

12. Provide comment on (1) how the lack of evidence mayaffect our current work, (2) ways in which we couldextrapolate anything from the anecdotal evidence thatexists, and/or (3) what proxy measures of outcomewould enable us to establish early in the process someevidence of efficacy.

13. What additional research will result in a strongerevidence base?

14. Evaluate health equity and social justice impactof accreditation.

EXPLORING ACCREDITATION WORKGROUP QUESTIONS Revised February 16, 2006


• 57


1. Is there a good business case for establishing a Xvoluntary national accreditation system?

2. What strategies can enhance the business case? X

3. What constitutes a sufficient evaluation framework? X

4. How can evaluation efforts of current accreditation Xand related programs be enhanced?

5. What constitutes sufficient, ongoing research to Xdevelop the evidence base concerning accreditationas a tool for improving the quality and outcomes ofgovernmental public health services?

JUN

E/JU

LY



58 •

APPENDIX C

EXPLORING ACCREDITATION FEEDBACK FORM

• 59


Exploring AccreditationFEEDBACK FORM

Thank you for taking the time to complete this feedback survey. Your comments will assist the Exploring AccreditationSteering Committee in their final deliberations.

Strongly Disagree Neutral Agree Strongly agree disagree

1. The model is understandable. 1 2 3 4 5

2. The model is feasible for implementation. 1 2 3 4 5

3. Our health department would seekaccreditation under this model. 1 2 3 4 5

OVERALL COMMENTS

4. What benefits of accreditation are most important in your thinking about supporting accreditation?

5. What issues or problems are most likely to result in your deciding against supporting accreditation?

6. Are there design flaws in the proposed model that the Steering Committee should address?

7. Other comments:

Questions continue on the back of this sheet – Please turn this page over.

60 •

DEMOGRAPHIC INFORMATION

Affiliation: � � State Health Department�� Local Health Department�� Public Health Institute�� Academic Institution�� Elected official�� Policy Advisor�� Board of Health�� Other:_______________

US DHHS region: �� Region 1�� Region 2�� Region 3�� Region 4�� Region 5�� Region 6�� Region 7�� Region 8�� Region 9�� Region 10

Size of jurisdiction: �� < 25,000�� 25,000 – 49,999�� 50,000 – 99,999�� 100,000 – 499,999�� 500,000 –999,999�� 1,000,000 to 4,999,999�� >5,000,000

Is your department currently involved in performance improvement, certification or accreditation? � yes ��no

Exploring AccreditationFEEDBACK FORM

• 61


APPENDIX D

LIST OF PRESENTATIONS

62 •

ORGANIZATION TYPE OF FORUM TYPES OF ATTENDEES EST. # DATE

National Network of Public On-site Presentation Public health institutes 75 May 10, 2006Health Institutes

OH Combined Public On-site Presentation Variety of public 350 May 16, 2006Health Conference health professionals

UT Public Health Association On-site Presentation State and local HD employees 70 May 17, 2006

NACCHO Workforce On-site Presentation Local health officials (LHOs) 8 May 25, 2006Development AdvisoryCommittee

California Health Executive On-site Presentation Health administrators 40 June 1, 2006Association

California Conference of On-site Presentation LHOs 75 June 1, 2006Local Health Officers

Council of State and Territorial On-site Presentation State and local 65 June 5, 2006Epidemiologists epidemiologists

CO Association of Local On-site Presentation Mostly LHOs 17 June 7, 2006Public Health

Michigan Association of On-site Presentation LHOs and board of 30 June 12, 2006Local Public Health health members

Local Public Health On-site presentation LHOs and LHD employees 65 June 15, 2006Association of MN

NPHPSP users Conference call State and LHD employees 50 June 20, 2006

KY Health Department On-site presentation LHOs 30 June 20, 2006Association

CT Association of Directors On-site presentation LHOs 30 June 21, 2006of Health

IN Association of Public Health On-site presentation LHOs and public health 30 June 21, 2006Physicians and LHD physiciansOrganizations

KS Association of Local Health On-site presentation LHOs 20 June 21, 2006Departments

LIST OF PRESENTATIONS

• 63


ORGANIZATION TYPE OF FORUM TYPES OF ATTENDEES EST. # DATE

Metro Washington Public On-site presentation Various public health 7 June 21, 2006Health Association professionals

NACCHO Conference call LHOs from rural areas 40 June 22, 2006

NACCHO Conference call LHOs from metro areas 80 June 27, 2006

MA Health Officers Association Conference call LHOs 25 July 11, 2006

VT Department of Health On-site presentation LHOs and state HD 50 July 12, 2006employees

IA Association of Local Public On-site presentation LHOs and senior staff 100 July 13, 2006Health Agencies

ASTHO Senior Deputies On-site presentation SHD senior deputies 50 July 13, 2006

NACo, USCM, NGA, NCSL Conference calls State and local elected 5 July 17, 18, 25,officials and staff and 27, 2006

CDC/ASTHO/NACCHO/ Satellite broadcast Various public health 400 July 20, 2006NALBOH/APHA professionals

Missouri Institute for Conference call Various public health 20 July 21, 2006Community Health professionals

NACCHO/NALBOH Town Hall meeting LHOs and local board of 600 July 26, 2006Annual Conference health members

LIST OF PRESENTATIONS continued

64 •

APPENDIX E

EXAMPLES OF STANDARDS AND MEASURES

• 65


2. Maintain a competent public health workforce

STATE LOCAL

Standard

Measure

Identify the public health workforce (the workforceproviding population-based and personal healthcare services in public and private settings acrossthe state) needs of the state and implementrecruitment and retention policies to fill thoseneeds.

Recruit, train, develop, and retain a diverse staff.

Personnel in regulated professions are assessed toassure that they meet prescribed competenciesincluding certifications, licenses, and educationrequired by law or recommended by local, state, orfederal policy guidelines.

Workplace policies promoting diversity and culturalcompetence, describing methods for compensationdecisions, and establishing personnel rules andrecruitment and retention of qualified and diversestaff are in place and available to staff.

The following standards and measures are meant toprovide examples of what might be used in a voluntarynational accreditation program. These examples arebased on NACCHO’s Operational Definition, the NationalPublic Health Performance Standards Program StateInstrument, and the Washington State Public HealthImprovement Plan.

These examples have not been approvedby the Exploring Accreditation SteeringCommittee, and feedback is not beingsought at this time.

STATE LOCAL

Standard

Measure

1. Protect people from health problems and health hazards

STATE LOCAL

Standard

Measure

Collaborate with public and private laboratories,which have the ability to analyze clinical andenvironmental specimens in the event of suspectedexposures and disease outbreaks.

Maintain access to laboratory expertise andcapacity to help monitor community healthstatus and diagnose and investigate publichealth problems and hazards.

Written procedures describe how expanded labcapacity is made readily available when needed foroutbreak response, and there is a current list oflabs having the capacity to analyze specimens.

Has current list of available labs and currentwritten protocols and/or guidelines forhandling clinical and environmentallaboratory samples.

3. Evaluate and improve programs and interventions

Evaluate the effectiveness and quality of allprograms and activities and use the informationto improve performance and health outcomes.

Evaluate the effectiveness and quality of allprograms and activities and use the informationto improve performance and health outcomes.

There is a planned, systematic process in which allprograms and activities, whether provided directlyor contracted, have written goals, objectives, andperformance measures. Program performancemeasures are tracked, the data are analyzed andused to change and improve program activitiesand services and/or revise curricula/materials.

There is a planned, systematic process in which allprograms and activities, whether provided directlyor contracted, have written goals, objectives, andperformance measures. Program performancemeasures are tracked, the data are analyzed andused to change and improve program activitiesand services and/or revise curricula/materials.

66 •

APPENDIX F

LOGIC MODEL

• 67


68 •68 •

• 69


APPENDIX G

BUSINESS CASE

70 •

TABLE 1: The Market for Accreditation Services

Strata Population Served Number of Percentage Estimated Number ofLHDs of Total Uptake Applicants

1 0 - 24,999 1322 46.5% 10% 132

2 25,000 - 49,999 579 20.4% 20% 116

3 50,000 - 74,999 261 9.2% 30% 78

4 75,000 - 99,999 139 4.9% 30% 42

5 100,000 - 199,999 235 8.3% 40% 94

6 200,000 - 499,999 177 6.2% 40% 71

7 500,000 - 999,999 69 2.4% 40% 28

8 1,000,000 + 43 1.5% 25% 11

2825 572

State Health Departments Territories 6 0% 0

Small 500,000 - 4,999,999 31 25% 8

Medium 5,000,000 - 14,999,999 16 25% 4

Large 15,000,000 + 4 25% 1

57 13

TOTAL HEALTH 2882 585 DEPARTMENTS

• 71


TABLE 2: Cost Components

GOVERNANCEBoard compensation

Number of meetings

Committee meetings

Sponsors – number and capital v. operations

Implementation length (development and pilot testing)

Appeals

Geography

ADMINISTRATION/MANAGEMENTMarketing budget

Market size/ penetration over 5 years

Size of staff/growth

Contractors/outsource

Data management

Pre-implementation phasing/ number of pilots

STANDARDS AND MEASUREMENTSNumber and complexity of standards

Development process

• Methods

• Interaction with stakeholders

• Timeline

Revision cycle

CONFORMITY ASSESSMENTCycle length

Site visit team size

Length of visit

Cost and who pays

Training site visitors

Standardizing

Volunteer vs. paid

Technical assistance and training for applicants

Benchmarking applicant activities

Web site development

Data collection

Self assessment process

Vendors

“Surveillance” in between surveys

72 •

TABLE 3: Potential Sources of Revenue

Applicant fees — These provide a significant source of revenue in most accreditation programs. Thisempowers applicants to influence operations, standards, and data requirements. At the same time,government budgeting may not provide additional funding for applying for and preparing foraccreditation. On the other hand, applicants need a revenue source in order to pay fees. Options includedirect grants to applicants, having reimbursements for health department work incorporate the cost ofaccreditation fees as allowable costs, and including application fees as allowable direct or indirect costs ongrants and contracts.

Scholarships/applicant subsidies — These could be direct revenues to the accrediting body or offsets ofapplicant expenses that allow applicant fees to reflect actual costs.

Grants from government sources — These could be directed to support specific start up activities suchas development of standards and conformance processes.

Grants from foundations — These could be directed to support performance improvement strategies ingovernmental public health agencies, for example.

Service charges — These would underwrite access to data, training services, possibly marketing services,for example.

Capital from traditional sources

Endowments

In-kind/sponsorships — These can offset fixed and capital costs in development and operations, forexample and they provide strong messages to the target market about the value of the enterprise.

• 73


TABLE 4: The Business Matrix

COST VARIABLE PREFERRED OPTION CONSIDERATION

Board composition Expenses for board Stipends send wrong messages.meetings only Recruitment of good members likely without

them. Not paying expenses increases the reachof the sponsors.

# of board meetings Initially meet bi-monthly, move Initially more expensive but allows the Boardto quarterly, with teleconferencing itself to do more of the standards and

marketing work.Committee meetings Few committees

Less delegation

Sponsors # of Contributions Seek capitalization of startup Major concern is finding enough sponsors thatCapitalOperations and transition. The pool of capture is not seen as a risk by the potential(model said no seats) capital sources is small, and will applicants.

require showing a plan forsustainability $$/sponsor

Implementation period to 4 years Should push efficiency and give best chance ofdevelop accreditation finding sponsors. Allows adequate pilot testing.program (develop corporation, Affects when revenues flow from applicants.standards and processes andconduct one pilot round)

Appeals mechanism Internal system more control and Probably needs to be tested among the potentialprobably fewer costs applicants. Cost are not the only considerations

Geography of headquarters Seek a balance of costs, access topersonnel and academic associations

Marketing budget >5% of operating costs, includes In start up, requires maximum effortdeveloping incentives & subsidies, from board and staffgetting states on board and findingsponsors, TA etc.

Market size/ penetration in 8-9 (15%) states & 250-400 locals Signal that this is voluntary, and build credibility5 years of program operation(beyond implementationperiod)

Size/growth of staff Exec. Dir.,Admin. Asst., 2-3 staff withyearly growth to 50% or > ofoperation costs

Contract/outsource Professional consultants, data Conservative but building a crediblemanagement and organization, not a shell.operational functions

74 •

TABLE 4: The Business Matrix continued


In-kind Operational functions, furniture, Balance is maintaining independence fromFixed Capitalizing equipment and space, loaned staff, fostering organization.

housed within another organization

Data management Outsourced initially, move to in-house More expertise needed at front end whenin operational phase resources are thin

Pre-implementation 12 months Assume that accreditation is awarded, but nophasing, # of pilots 3 state pilots charge in the pilot cycle

20 local pilots1 pilot cycle

Number and complexity 110 (10 standards per domain) The number of standards affects many costs.There is a multiplier effect for an accrediting entityand for applicants.

Methods for developing Committee process to integrate Balancing broad participation and recognizingstandards and measures existing models and seek input existing innovations

Interactions and Timeline Active input process: 12 - 18 months Balancing full input and stakeholder buy-inwith time

Revision cycle Every 5 years, with triggers for Credibility of standardsis crucial. interim changes

Cycle length 4 years Balancing frequency with costs, especially inearly years.

Site visit team size 3 – 5, varying with size and Use more days instead of more people, but trycomplexity of applicant to keep to <2 days

Length of visit 1 day The composition of teams and length of visitsare determined by the scope and complexity ofthe standards

Costs/payers Fee + site visit expenses using a mix Stable and predictable assessment processof volunteer & paid surveyors

Applicant pays, accreditation payspaid surveyors

Training volunteer site visitors In-person training (1 day) with Stable and predictable assessment processweb back-up

• 75


TABLE 4: The Business Matrix continued


Standardizing site visitor work Training site visit, group discussions, Stable and predictable assessment processlook back, or matched scoring

Volunteer/paid Team leader only paid, Stable and predictable assessment processothers volunteer

Technical assistance for Offer on-line and telephone TA Stable and predictable assessment processapplicants

Benchmarking of compliance Offer on-line information andstrategies written materials

Web site development All on-line, electronic exchange Important trade off of agency costs with applicantefficiency

Maintenance

Data collection Needed for decisions and accreditedbody programs operations evaluation

Self-assessment process More detailed internally Learn efficiencies from current assessment-onsite validation programs-selective

Vendors Existing state programs only Manageable-negotiation-controls-risk management

Surveillance between Annual report Consider moving to selective audits or revisits assite visits -update program matures

-compliance-changes

76 •

TABLE 5

YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 YEAR 8Development Development Development Operations Operations Operations Operations Operations

Total Salary $270,000 $283,500 $297,675 $320,892 $402,938 $456,785 $479,473 $494,950and Fringe

Total Direct $564,000 $383,000 $459,200 $696,400 $765,200 $789,520 $894,150 $904,600Expenses

TOTAL $834,000 $666,500 $756,875 $1,017,292 $1,168,138 $1,246,305 $1,373,623 $1,399,550EXPENSES

Total $0 $80,000 $120,000 $565,000 $905,000 $940,000 $1,505,000 $1,505,000Revenues

NET -$834,000 -$586,500 -$636,875 -$452,292 -$263,138 -$306,305 $131,377 $105,450INCOME

*Red font distinguishes the development period from the operational period.

• 77


APPENDIX H

GLOSSARY

78 •

GLOSSARY

Accreditation – (1) the development of a set ofstandards, a process to measure health departmentperformance against those standards, and some form ofreward or recognition for those agencies meeting thestandards. (2) the periodic issuance of credentials orendorsements to organizations that meet a specified setof performance standards. (3) A voluntary conformityassessment process where an organization or agencyuses experts in a particular field of interest or disciplineto define standards of acceptable operation/performancefor organizations and measure compliance with them.This recognition is time-limited and usually granted bynongovernmental organizations.

1 – EA project definition2 – Lee Thielen

3 – Michael Hamm

Accountability – the principle that individuals,organizations and the community are responsible fortheir actions and may be required to explain them toothers.

Benchmark – a standard established for anticipatedresults, often reflecting an aim to improve over currentlevels.

Beta testing (pilot testing) – allowing organizations touse a new product before it is officially launched.

Capacity – resources and relationships necessary to carryout the core functions and essential services of publichealth; these include human resources, informationresources, fiscal and physical resources, and appropriaterelationships among the system components.

– Bernard Turnock, Public Health:What It Is and How It Works

Conformity assessment – the determination of whethera product, process, or service conforms to particularstandards or specifications. Activities associated withconformity assessment may include testing, certification,accreditation, and quality assurance system regulation.

– Michael Hamm

Conditional accreditation – a rating that anorganization receives when a number of standards werescored ‘not compliant’ at the time of the onsite survey.

– Joint Commission on Accreditation ofHealthcare Organizations (JCAHO)

Continuous quality improvement – an ongoing effortto increase an agency’s approach to manageperformance, motivate improvement, and capturelessons learned in areas that may or may not bemeasured as part of accreditation. – Public Health Foundation (PHF)

Core standards – the fundamental activities or group ofactivities, so critical to an organization’s success thatfailure to perform them in an exemplary manner willresult in deterioration of the organization’s mission.

Customer – the person or group that establishes therequirement of a process and receives or uses theoutputs of that process, or the person or entity directlyserved by the organization.

– Serving the American Public: Best Practicesin Performance Measurement

Domain – a broad area having some commoncharacteristics and for which criteria and standards arespecified for assessing performance in that domain.

–Michael Hamm

Evaluation - Systematic approach to determine whetherstated objectives are being met.

-Brownson, RC, Baker EA, and Novick, LF. Community-based Prevention: Programs That Work. Gaithersburg,

MD: Aspen Publishers, Inc. 1999

Impact – the total, direct and indirect, effects of aprogram, service or institution on a health status andoverall health and socio-economic development.

Measure – a statement of quantification/qualification/action to reach a desired condition/state of affairs; themeans of determining compliance with a standard.

Example: The number of trained epidemiologistsavailable to investigate outbreaks (capacity measure).

Example: The percentage of notifiable diseases reportssubmitted within the required time lines (processmeasure).

Example: Percentage of disease outbreaks that arecontrolled and contained before deaths or disablingconditions occur (outcome measure).

• 79


Outcome – (1) the desired result of a service or program;(2) indicator of health status, risk reduction, and quality-of-life enhancement. For the purposes of the ExploringAccreditation project, short-term outcomes are definedas results that are achieved in 1 year; results ofintermediate outcomes are achieved between 2-5 years;and results of long-term outcomes are achieved between5-10 years.

– (2) Bernard Turnock, Public Health:What It Is and How It Works

Performance standard – a generally accepted, objectiveform of measurement that serves as a rule or guidelineagainst which an organization’s level of performance canbe compared.

– Guidebook for Performance MeasuresTurning Point Program

Performance improvement/Quality improvement – Systematic processes ofdesigning and developing cost-effective and ethically-justifiable methods to address performance gaps orimprove products; implementing processes, procedures,and/or interventions in order to obtain better results;and/or evaluate financial and non-financial findings inorder to improve efficiency in obtaining results. Qualityimprovement contains the element of “doing the rightthing” while performance improvement is focused ondoing what we are doing “better.”

– From Silos to Systems Turning Point Program

Research - A systematic investigation, including researchdevelopment, testing, and evaluation, designed todevelop or contribute to generalized knowledge.

-United States Department of Health and HumanServices. Healthy People 2010. Washington, DC: US

Department of Health and Human Services, 2000

Standard – a desired condition/state of affairs, and mustbe actionable, attainable, and measurable.

80 •

APPENDIX I

PUBLIC COMMENT TABLES

• 81


11111 22222 33333 44444 55555 66666 77777 88888 99999 1010101010

250

200

150

100

50

0

TABLE 1. Number of Respondents by Affiliation

TABLE 2. Number of Respondents by U.S. Public Health Service Region

400

350

300

250

200

150

100

50

0

Num

ber

of R

espo

nden

ts

State

HD

State

HD

State

HD

State

HD

State

HD

Local H

D

Local H

D

Local H

D

Local H

D

Local H

DPHIPHIPHIPHIPHI

Academ

ic

Academ

ic

Academ

ic

Academ

ic

Academ

ic

Elected

Elected

Elected

Elected

Elected

Policy

Policy

Policy

Policy

Policy

BOHBOHBOHBOHBOH

Other

Other

Other

Other

Other

55

368

3 925

19 16

AFFILIATION

Num

ber

of R

espo

nden

ts

U.S. PUBLIC HEALTH SERVICE REGION

82 •

350

300

250

200

150

100

50

0

TABLE 3. Number of Respondents by Size of Jurisdiction

100

90

80

70

60

50

40

30

20

10

0

NUMBER OF POPULATION SERVED IN JURISDICTION

<25,000

<25,000

<25,000

<25,000

<25,000

25,000-49,999

25,000-49,999

25,000-49,999

25,000-49,999

25,000-49,999

50,000-99,999

50,000-99,999

50,000-99,999

50,000-99,999

50,000-99,999

100,000-499,999

100,000-499,999

100,000-499,999

100,000-499,999

100,000-499,999

500,000-1 mill

ion

500,000-1 mill

ion

500,000-1 mill

ion

500,000-1 mill

ion

500,000-1 mill

ion

1 mill

ion-5 mill

ion

1 mill

ion-5 mill

ion

1 mill

ion-5 mill

ion

1 mill

ion-5 mill

ion

1 mill

ion-5 mill

ion

>5 mill

ion

>5 mill

ion

>5 mill

ion

>5 mill

ion

>5 mill

ion

Num

ber

of R

espo

nden

tsN

umbe

r of

Res

pond

ents

TABLE 4. The Model is Understandable (All Responses)

RESPONSES

StronglyStronglyStronglyStronglyStronglyAgreeAgreeAgreeAgreeAgree

AgreeAgreeAgreeAgreeAgree NeutralNeutralNeutralNeutralNeutral DisagreeDisagreeDisagreeDisagreeDisagree StronglyStronglyStronglyStronglyStronglyDisagreeDisagreeDisagreeDisagreeDisagree

• 83


TABLE 5. The Model is Feasible for Implementation (All Responses)

350

300

250

200

150

100

50

0

RESPONSES

TABLE 6. Our Health Department Would Seek Accreditation Under this Model (All Responses)

350

300

250

200

150

100

50

0

RESPONSES

Num

ber

of R

espo

nden

tsN

umbe

r of

Res

pond

ents





84 •

TABLE 7. The Model is Understandable (State and Local Health Department Responses)

70

60

50

40

30

20

10

0

RESPONSES

Perc

enta

ge o

f Re

spon

dent

s

State Health Departments

Local Health Departments

TABLE 8. The Model is Feasible for Implementation (State and Local Health Department Responses)

70

60

50

40

30

20

10

0

RESPONSES

Perc

enta

ge o

f Re

spon

dent

s







• 85


TABLE 9. Our Health Department Would Seek Accreditation Under this Model(State and Local Health Department Responses)

70

60

50

40

30

20

10

0

RESPONSES

Perc

enta

ge o

f Re

spon

dent

s



TABLE 10. Our Health Department Would Seek Accreditation Under this Model(By Size of Health Department)



70

60

50

40

30

20

10

0

RESPONSES

Perc

enta

ge o

f Re

spon

dent

s

Small Health Departments

Large Health Departments

Medium Health Departments



86 •

Mandatory

Cost

Time

Small HDs

Buy-In

No Benefit

Categories

Consequences

Outcomes

Duplication

Incentives

Local Needs

Staff

TABLE 11. What Benefits of Accreditation are Most Important inYour Thinking About Accreditation (All Responses)

0 50 100 150 200 250 300

Ben

efit

s

NUMBER OF RESPONDENTS

Recognition

Consistency

QPI

Accountability

Validation

Increased Funds

Outcomes

Tie to Funds

No Benefits

Evidence Base

TABLE 12. What Issues or Problems are Most Likely to Result in YourDeciding Against Supporting Accreditation (All Responses)

0 50 100 150 200 250 300

Issu

es o

r Pr

oble

ms

NUMBER OF RESPONDENTS

• 87


Least Likely

Uncertain

Most Likely

350

300

250

200

150

100

50

0

TABLE 13. Number of Responses Regarding Benefits and Issues/Problems

TYPES OF RESPONSES

NoNoNoNoNoCommentsCommentsCommentsCommentsComments

BenefitsBenefitsBenefitsBenefitsBenefitsOnlyOnlyOnlyOnlyOnly

Issues/Issues/Issues/Issues/Issues/ProblemsProblemsProblemsProblemsProblems

OnlyOnlyOnlyOnlyOnly

BothBothBothBothBoth

Num

ber

of R

espo

nden

ts

TABLE 14. Number of Benefits Cited(By Likelihood of Seeking Accreditation Under This Model)

00000 11111 2+2+2+2+2+

70

60

50

40

30

20

10

0

NUMBER OF BENEFITS CITED

Perc

enta

ge o

f Re

spon

dent

s

88 •

Recognition

Consistency

QPI

Accountability

Validation

Increased Funds

Outcomes

TABLE 16. What Benefits of Accreditation are Most Important inYour Thinking About Supporting Accreditation

(By Likelihood of Seeking Accreditation Under This Model)

0% 20% 40% 60% 80%

Ben

efit

s

Least Likely

Uncertain

Most Likely

Least Likely

Uncertain

Most Likely

TABLE 15. Number of Issues/Problems Cited(By Likelihood of Seeking Accreditation Under This Model)

70

60

50

40

30

20

10

0

NUMBER OF ISSUES/PROBLEMS CITED

00000 11111 2+2+2+2+2+

Perc

enta

ge o

f Re

spon

dent

s

PERCENTAGE OF RESPONDENTS

• 89


Cost

Time

Small HDs

No Benefit

Buy-In

Categories

Outcomes

0% 20% 40% 60% 80%

Issu

es/P

robl

ems

Least Likely

Uncertain

Most Likely

TABLE 17. What Issues or Problems are Most Likely to Result in YourDeciding Against Supporting Accreditation

(By Likelihood of Seeking Accreditation Under This Model)

PERCENTAGE OF RESPONDENTS

90 •

WWW.EXPLORINGACCREDITATION.ORG

1100 17TH STREET, NW, 2ND FLOORWASHINGTON, DC 20036(202) 783-5550(202) 783-1583 FAXWWW.NACCHO.ORG

NATIONALASSOCIATION OFCOUNTY & CITY

HEALTH OFFICIALS

http://www.exploringaccreditation.org

http://www.astho.org

http://www.naccho.org

final recommendations for a · 2018-12-11 · final recommendations for a voluntary national...

Documents