Public Health Accreditation Board Standards Research Articles

Association Between Local Boards of Health Authority Over Budgets and PHAB Accreditation Standard Score

This study examined the relationship between local board of health authority and local health departments' budget-related activities and performance scores in the Public Health Accreditation Board standards while considering the governance structure under which the local health agencies operate. Data from 250 local health departments were obtained from the Public Health Accreditation Board and were combined with data from the 2016 National Association of County and City Officials Profile Survey. Multilevel regression analysis was used to examine the relationship between local board of health authority on local health departments' budget-related activities, using the governance structure as the group-level variable. Analyses identified positive associations between local board of health authority on local health departments' budget-related activities and local health departments' aggregate average performance scores in Public Health Accreditation Board accreditation. No apparent association was found between the type of governance structure under which a local health department operates and performance scores in Public Health Accreditation Board accreditation standards, perhaps attributable to variation in the characteristics and roles of their governing bodies. The analyses suggest that local boards of health with authority related to local health departments' budgets appear to have an influential role in budget-related activities and may improve local health departments' performance scores in Public Health Accreditation Board accreditation standards. However, vast variations in more specific local boards of health roles and characteristics exist across local health departments and for which there are no national data. More research is thus needed to control for or examine the influences of specific local boards of health characteristics before the benefits of expanded local boards of health authority over local health departments' budgetary decision making on local health departments' performance can be fully understood.

Associations Between Local Health Department Expenditures on Foundational Capabilities and PHAB Accreditation Standards Scores.

ContextFoundational Capabilities (FC) are the public health (PH) infrastructure areas that are essential for local health departments (LHDs) to support a “minimum package” of programs and services that promote population health. Despite being a critical component of LHD programs, FC are chronically underfunded, and studies specific to the relationship between LHD FC expenditures and their performance—the LHDs' ability to provide essential PH programs and services to their community—have not been previously reported. Public Health Accreditation Board (PHAB) accreditation is a nationally recognized accreditation program for PH agencies. PHAB accreditation assesses LHDs' performance against sets of standards that are based on the 10 essential PH services. Alignment between FC and the PHAB standards presents a means for assessing LHD FC expenditures relative to their performance in PHAB accreditation standards.ObjectivesWe examined the association between LHD total FC expenditures, as well as FC funding allocation patterns, and performance score on selected PHAB accreditation standards.MethodsWe used Bayesian regression methods to estimate the coefficients for the aggregate performance score, and performance scores on individual PHAB standards.ResultsAnalyses showed that a dollar increase in total FC expenditures is associated with a 0.2% increase in the aggregate performance score in selected PHAB standards as well as the performance score on most of the standards examined. LHDs that allocated FC budgets more evenly across FC programs were found to be more likely to have higher scores.ConclusionsInvestment in FC could improve LHD performance scores in PHAB accreditation standards and support LHDs' capability for improving community health outcomes. Allocating available FC resources across the various FC programs could support better LHD performance, as indicated by accreditation scores. This study contributes to advancing the understanding of public health finances in relation to performance and could help guide effective LHD resource allocation.

Local Health Department Accreditation Is Associated With Organizational Supports for Evidence-Based Decision Making.

Introduction: Recent studies show that health department accreditation from the U.S. Public Health Accreditation Board (PHAB) drives performance management and quality improvement. PHAB standards call for agencies to use evidence in decision making. It is unknown whether accreditation is associated with organizational supports for evidence-based decision making (EBDM). Self-report data from a 2017 survey of U.S. local health departments were analyzed to test relationships of accreditation status with organizational supports for EBDM.Methods: A cross-sectional survey was conducted in this observational study. A total of 579 local health departments were invited to complete an online survey; 350 (60.4%) provided complete data for the present study. The dependent variables were six factors of organizational supports for EBDM previously validated through confirmatory factor analyses. Accreditation status (PHAB-accredited, preparing, not preparing) was the independent variable of interest. Logistic regression analyses controlled for governance (presence of a local board of health; state, local, or shared state and local governance) and jurisdiction population size.Results: PHAB-accredited health departments were more likely to report higher capacity for EBDM, resource availability for EBDM, and evaluation capacity than health departments that reported not yet preparing for accreditation. Health departments that reported preparing for PHAB accreditation showed a non-significant pattern of higher perceived supports for EBDM compared to departments not preparing for accreditation.Conclusion: PHAB standards and the accreditation process may help stimulate health department organizational supports for EBDM.

Rurality, Quality Improvement Maturity, and Accreditation Readiness: A Comparison Study of Colorado, Kansas, and Nebraska Local Health Departments

To compare local health department (LHD) accreditation readiness (AR) and quality improvement (QI) maturity in 3 states, between LHDs with varying levels of rurality, and across an LHD staffing-level continuum. This was a cross-sectional comparative study that included an online survey administered to LHD directors in Colorado, Kansas, and Nebraska. The survey included 10 questions assessed on a 5-point Likert scale covering 3 QI domains and 13 questions covering 5 AR domains. The median score for both QI maturity and AR was calculated by each state, by the number of full-time equivalent staff employed at the LHD, and by a measure of rurality and population density. A total of 156 LHDs from the states of Colorado, Kansas, and Nebraska. QI maturity and AR scores. A majority (59%) of the surveyed LHDs plan to apply or have already applied for Public Health Accreditation Board (PHAB) accreditation. The overall QI maturity and AR scores were highest in Nebraska, as was the intent to seek PHAB accreditation and current use of PHAB standards. Across levels of rurality and staffing, LHD QI maturity scores were similar; however, AR scores improved as LHD staffing levels increased and rurality decreased. Small LHDs and rural LHDs have QI maturity levels that are comparable to larger, less rural LHDs, but their AR is much lower. As accreditation has been found to have positive benefits, it is important that all LHDs have the capacity and resources to meet the performance standards required of accredited LHDs. Small, rural LHDs may need additional resources and support in order to improve their ability to be accredited and/or certain accreditation requirements may need modification to make accreditation more accessible to small LHDs.

Kent County Health Department: Using an Agency Strategic Plan to Drive Improvement.

The Kent County Health Department (KCHD) was accredited by the Public Health Accreditation Board (PHAB) in September 2014. Although Michigan has had a state-level accreditation process for local health departments since the late 1990s, the PHAB accreditation process presented a unique opportunity for KCHD to build on successes achieved through state accreditation and enhance performance in all areas of KCHD programs, services, and operations. PHAB's standards, measures, and peer-review process provided a standardized and structured way to identify meaningful opportunities for improvement and to plan and implement strategies for enhanced performance and established a platform for being recognized nationally as a high-performing local health department. The current case report highlights the way in which KCHD has developed and implemented its strategic plan to guide efforts aimed at addressing gaps identified through the accreditation process and to drive overall improvement within our agency.

The Role of the Public Health Training Centers in Advancing Public Health Department Accreditation

In the past few years, the drive for public health department accreditation has continued to build momentum. As the Centers for Disease Control and Prevention notes, “Engaging in accreditation catalyzes quality and performance improvement within all public health programs and can help health departments be better prepared to proactively respond to emerging and reemerging health challenges”. Many organizations support accreditation efforts, including the Public Health Training Centers (PHTCs), which have been providing workforce development support since 1999. This article describes how one PHTC, the Midwestern Public Health Training Center, has supported capacity building for accreditation in partnership with other state-based organizations through the development of three major accreditation readiness activities: accreditation workshops, informational videos on Public Health Accreditation Board standards and measures, and competency-based workforce development assessments. Given the current and emerging public health challenges, the need for a well-prepared workforce is more important than ever to strengthen the public health system, and by engaging in activities to meet the accreditation standards, public health departments will be better positioned to respond to these challenges. PHTCs will continue to have a critical role in capacity building for accreditation.

Utilizing Performance Management to Harness the Power of Quality Improvement in Public Health

Widespread adoption of quality improvement activities in public health trails other U.S. sectors. Launching the national public health accreditation program of the Public Health Accreditation Board (PHAB) has propelled health department momentum around quality improvement uptake. Domain 9 of the PHAB standards focuses on evaluation and improvement of performance, and is acting as a strong driver for quality improvement and performance management implementation within health departments. Several performance management models have received broad acceptance, including among government and nonprofits, and have direct public health application. Turning Point is a model designed specifically for public health users. All models in current use reinforce customer centricity; streamlined, value added processes; and strategic alignment. Importantly, all are structured to steer quality improvement efforts toward organizational priorities, ensuring that quality improvement complements performance management.

Preparing for State Health Department Accreditation: Pivotal Roles for Public Health Surveillance

Many State Health Departments (SHDs) are considering or preparing for voluntary accreditation through the Public Health Accreditation Board (PHAB). With the 2014 release of PHAB's Standards & Measures Version 1.5, health departments must adhere to specific documentation criteria regarding measures for public health surveillance. This presentation will provide one SHD's approach to identifying appropriate documents to meet the public health surveillance measures from a public health informatics perspective. A document selection matrix may be helpful to other SHDs considering accreditation.

Marshaling the evidence: the prioritized public health accreditation research agenda.

A national public health department accreditation program was recently developed and implemented by the Public Health Accreditation Board (PHAB) to improve the quality and performance of public health departments. Because of its potential to transform public health, it is critical that the evidence base around accreditation be strong. With input from public health practitioners and researchers, PHAB developed a research agenda that highlights priority questions related to barriers and facilitators to seeking and obtaining accreditation, the PHAB standards and review process, metrics to determine the impact of accreditation, and benefits and outcomes associated with accreditation for the departments that undergo the process. We present that agenda, discuss the potential challenges of conducting accreditation research, and call on researchers to build a greater base of evidence related to accreditation.

Health department accreditation as a catalyst to foster the development of a future public health workforce.

The relatively new Public Health Accreditation Board (PHAB) proffers a new force to bring attention to the need for undergraduate, graduate, and continuing education for those working in public health. The workforce of federal, state, and local health departments in the United States comprises more than 450,000 individuals representing a wide variety of disciplines, from nurses to sanitary engineers to health educators (1). Despite the many professionals with graduate training in clinical and other disciplines, the majority of those working in local public health departments have baccalaureate-level or less education (2) – making undergraduate college a key focus for public health workforce training. A projected shortage in the future raises concerns about the capacity and capabilities of those working to promote public health (2). This Opinion reveals how PHAB standards reinforce the need to ensure the pipeline for trained public health department workers. In addition, early evidence suggests that accredited health departments have the capacity to partner with schools to strengthen the workforce. As more health departments pursue accreditation, it will likely provide opportunities to foster partnerships between public health agencies and undergraduate institutions that are preparing individuals to address the practical needs of twenty-first century public health.

Deciphering the imperative: translating public health quality improvement into organizational performance management gains.

With the launching of the national public health accreditation program under the auspices of the Public Health Accreditation Board (PHAB), health department momentum around quality improvement adoption has accelerated. Domain 9 of the PHAB standards (one of 12 domains) focuses on evaluation and improvement of performance and is acting as a strong driver for quality improvement and performance management implementation within health departments. Widespread adoption of quality improvement activities in public health trails that in other US sectors. Several performance management models have received broad acceptance, including models among government and nonprofits. A model specifically for public health has been developed and is presented herein. All models in current use reinforce customer focus; streamlined, value-added processes; and strategic alignment. All are structured to steer quality improvement efforts toward organizational priorities, ensuring that quality improvement complements performance management. High-performing health departments harness the synergy of quality improvement and performance management, providing powerful tools to achieve public health strategic imperatives.

Accreditation and Emergency Preparedness

Public health officials must frequently demonstrate the quality and value of public health services, especially during challenging fiscal climates. One of the ways that public health quality and accountability have been demonstrated is through the use of accreditation and standard setting initiatives. The objective of this analysis was to identify existing alignment opportunities between standards established by the Public Health Accreditation Board (PHAB) and the Centers for Disease Control and Prevention's (CDC's) public health preparedness (PHP) capabilities in order to optimize and leverage the connections for state and local public health professionals. During March-May 2012, a PHAB/PHP crosswalk was developed by a research team from the CDC's Office for State, Tribal, Local and Territorial Support and Office of Public Health Preparedness and Response's Division of State and Local Readiness to examine the intersection of the PHP capabilities and the PHAB standards. The PHAB/PHP crosswalk used the CDC Public Health Preparedness Capabilities: National Standards for State and Local Planning (PHP Capabilities) and the PHAB Standards and Measures, Version 1.0 (PHAB Standards) as its source documents. To help illustrate the results of the crosswalk, alignment was also depicted through a network graph to transform the results into a visual depiction of the linkages between PHP capabilities and PHAB standards. The most direct links to emergency preparedness were found in PHAB Domains 2 and 5. Opportunities for improved alignment were found throughout the standard documents, particularly in PHAB Domains 3, 8, and 11. The most direct links to accreditation were found in PHP capabilities 1, 2, 3, and 4. The results highlight the synergy between the infrastructure and foundational elements represented by accreditation and targeted programmatic activities supported by preparedness funding.

Guiding the Way to Public Health Improvement

Recent years have seen rising interest in initiatives that focus on public health improvement. This includes support for accreditation of public health departments-administered by the Public Health Accreditation Board (PHAB)-and increasing expectations that health departments should use evidence-based programs, services, and policies (interventions) such as those described in The Guide to Community Preventive Services (The Community Guide). This project was initiated to explore the potential connections between Community Guide interventions and PHAB domains, standards, and measures. The project team focused on developing a Crosswalk tool to assist health departments in identifying evidence-based interventions from The Community Guide whose implementation could help document conformity with PHAB domains, standards, and measures. All Community Preventive Services Task Force-recommended interventions were reviewed to determine whether they reflect the intent and requirements of the PHAB standards and measures. Three types of connections were defined through which Community Guide interventions could be relevant to the required documentation for a PHAB measure. All instances of these connections were identified and included in the Crosswalk. The Crosswalk tool consists of 2 tables. The first table cross-references individual PHAB domains, standards, and measures with interventions from The Community Guide that could help provide documentation for accreditation. The second table can help accreditation preparation staff to engage with program staff. It is searchable by Community Guide topic, identifying the PHAB measures that relate to each Community Guide intervention within that topic. The type, location, and extent of connections between Community Guide interventions and PHAB domains, standards, and measures are presented and discussed. Tools such as the Crosswalk can be instrumental in advancing the use of evidence-based interventions in public health practice.

Improving Public Health Agency and System Performance: Fortification for Promoting Population Health and Wellness

Improving Public Health Agency and System Performance: Fortification for Promoting Population Health and Wellness

Revenue Sources for Essential Services in Florida

The Florida Public Health Practice-Based Research Network conducted the study of Florida county health departments (CHDs) to assess relationships between self-assessed performance on essential services (ESs) and sources of funding. Primary data were collected using an online survey based on Public Health Accreditation Board standards for ES. Bivariate and multivariate analyses were conducted to assess the relationship of sources and amounts of revenue obtained from the Florida Department of Health financial system to responses to the survey of CHD capacity for ESs. Self-assessed CHD performance for each ES varied extensively among the CHDs and across the 10 ESs, ranging from a high of 98% CHDs completely or almost completely meeting the standards for ES 2 (Investigating Problems and Hazards) to a low of 32% completely or almost completely meeting standards for ES 10 (Research/Evidence). Medicaid revenue and fees were positively correlated with some ESs. Per capita revenue support varied extensively among the CHDs. Revenue for ES is decreasing and is heavily reliant on noncategorical (discretionary) revenue. This study has important implications for continued reliance on ES as an organizing construct for public health.

Public Health Accreditation and Metrics for Ethics

As public health departments around the country undergo accreditation using the Public Health Accreditation Board standards, the process provides a new opportunity to integrate ethics metrics into day-to-day public health practice. While the accreditation standards do not explicitly address ethics, ethical tools and considerations can enrich the accreditation process by helping health departments and their communities understand what ethical principles underlie the accreditation standards and how to use metrics based on these ethical principles to support decision making in public health practice. We provide a crosswalk between a public health essential service, Public Health Accreditation Board community engagement domain standards, and the relevant ethical principles in the Public Health Code of Ethics (Code). A case study illustrates how the accreditation standards and the ethical principles in the Code together can enhance the practice of engaging the community in decision making in the local health department.

Improving Knowledge of Public Health Accreditation Through a Group Vetting Session of a Practice-Based Research Network

This article describes efforts to improve knowledge of and acceptance of the proposed voluntary health department accreditation program, put forth by Public Health Accreditation Board (PHAB), by conducting a group vetting session. The vetting session closely followed the PHAB guidelines, and participants received pre- and postvetting surveys to gauge their knowledge of the accreditation standards and related items and their perception of the utility of the standards and the ability of their agencies to meet the standards. Respondents reported that the vetting session did improve their knowledge and understanding of the standards (increase in mean score from 3.6 to 4.4). In addition, respondents had overwhelmingly favorable responses to the draft standards (28 of 31 received positive responses from more than 85% of participants). This suggests that conducting group vetting sessions may be an effective way to increase awareness of the PHAB standards and may help prepare local health agencies for the accreditation process.

BEITSCH AND CORSO RESPOND

In “Accountability: The Fast Lane on the Highway to Change,”1 we recommended a suite of strategies that act synergistically to improve public health performance at multiple levels. Besides accreditation for state, local, and tribal health departments, we suggest improvement efforts directed at the public health system as well as quality improvement for defined processes and programs. From our perspective, the attainment of desirable public health goals (the ultimate aim being improved community health) is less likely without such a comprehensive approach. We agree that the pathway to accreditation should be approached thoughtfully and deliberately. In fact, the journey toward accreditation has not been a hasty one. Even when narrowly defining the history to the start of Exploring Accreditation in 2005,2 this program represents a longer timeline than many other accreditation programs undertook before their launch.3 But most importantly, the work of the Public Health Accreditation Board (PHAB) is building heavily on numerous predecessor and concurrent public health efforts,4–9 diligently considering how benefits can outweigh costs, and engaging hundreds of public health professionals through workgroups, testing, and public input.10 Moreover, at least 10 state accreditation or standards programs have informed the draft PHAB standards and measures, thus indirectly drawing from an even wider range of consensus building and testing. We likewise agree that accreditation should be evidence-based, but contend that the launch of accreditation can best accomplish this very aim. The assertion—that accreditation programs can facilitate progress toward evidence-based practice—is derived from experiences from other accreditation programs.11 PHAB's Research and Evaluation Committee has been established to ensure attention to this purpose. Further, PHAB will sample health department programs in accreditation reviews and also require health assessments and health improvement plans. This approach is designed to drive action toward improving health outcomes and will not neglect the critical need to focus public health attention on the public's health in a data-driven manner. We should remind ourselves of the long-term evolution experienced by other accrediting bodies and the considerable time required to move from process measures to greater emphasis on outcome measures. Nevertheless, we can be inspired by the findings of newer accreditation programs, which are likewise largely comprised of process measures, and the positive impacts they report.1,12 Therefore, we seek to learn what public health can do to improve accreditation; but as we move boldly ahead, we also look forward to what accreditation can do for public health.