ACCREDITATION AND ACCOUNTABILITY: IS THE CART BEFORE THE HORSE?

Abstract

As the authors of “Accountability: The Fast Lane on the Highway to Change”1 point out, public health accreditation appears to be similar to a train with a strong head of steam. The train's destination of improving population health by improving public health management is laudable. The arguments behind holding local public health departments accountable with accreditation are that it will improve population health, that marginal benefits outweigh marginal costs, and that undesirable unintended consequences can be mitigated. The causal mechanism is that accountability will result in better performance of the essential health services, which will result in improved population health.2,3 Because the accreditation standards focus on the essential services functions rather than on content, such as Healthy People 2010, the accreditation effect presumably occurs in 2 ways: (1) accreditation makes resource acquisition for population health improvement easier because it legitimizes local health departments,1 and (2) accreditation leads to better management, which improves population health. Adel Hanna of Framingham (left) and Herman Cohen of Boston (right) join a group of protestors outside of the statehouse in Boston, Massachusetts, on October 3, 1989. The noon rally was a protest against the proposed repeal of the state's Universal Health Plan. Photograph by Julia Malakie. Printed with permission of AP Photo. Although anecdotal evidence of improvement suggests that accreditation can work, is it sufficient as an evidence-based approach? As the anecdote of food safety in Mississippi County, Missouri, suggests, public health is improved by implementing programs in specific content areas such as food safety. In contrast to the anecdotal evidence, the accreditation standards have an emphasis on functions rather than content; it is reasonable to argue that this emphasis may be harmful to achieving accreditation goals. While the difficulty with specifying accreditation standards in terms of content is understandable,4 has the pendulum swung too far toward functions? There are at least 6 reasons why the current approach to accreditation may be more harmful than helpful: (1) functionality is emphasized over content; (2) accreditation does not have a strong evidence base; (3) accreditation costs outweigh its benefits; (4) accreditation may have unintended consequences; (5) accreditation weakly acknowledges the contribution of related health professionals; and (6) accreditation may not fit local health department economics. (The e-note at http://www.ajph.org/cgi/eletters/99/9/1545 more fully develops these arguments.) Because of the potential harmful effects of accreditation, it may be wise to approach it in a more deliberate fashion that addresses potential difficulties. We hope this letter will help spark a broader debate about accreditation that will result in an improved accreditation process, one that has a greater promise for improving population health.