The development of the national voluntary public health accreditation concept has occurred systematically over the last decade. In its 2003 report, The Future of the Public's Health in the 21st Century, the Institute of Medicine recommended that a national dialogue occur about exploring public health accreditation as a way to improve performance and accountability for governmental public health departments.1 The following year, the Centers for Disease Control and Prevention identified accreditation as a key strategy for strengthening the public health infrastructure. In 2005, the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention funded the Exploring Accreditation Project. The study, guided by a steering committee, was charged with investigating the desirability and feasibility of public health accreditation. The report of the Exploring Accreditation Project Steering Committee study,2 released in 2006, concluded that it was both desirable and feasible to move forward with establishing a voluntary national accreditation program. The report also contained some recommendations for how such a program should be established. The report recommended that a national voluntary public health accreditation program should include 4 features: (1) promote high performance and continuous quality improvement; (2) recognize high performers that meet nationally accepted standards of quality; (3) clarify the public's expectations of state and local health departments; and (4) increase the visibility and public awareness of governmental public health.
The Public Health Accreditation Board (PHAB) was incorporated in May 2007 as the nonprofit organization to administer the national public health accrediting body. Funding has been provided by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention for development and initial operational support of the accreditation program. More than 400 public health practitioners have been involved in the development of the various program aspects as part of PHAB-appointed workgroups and committees from the public health practice and academic communities. Major public health associations also contributed to the development of these elements, including the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County & City Health Officials, the National Association of Local Boards of Health, and the National Indian Health Board.3 In creating the accreditation program, PHAB has also sought to learn from other accreditation specialties. Starting with the Exploring Accreditation Project, when white papers were commissioned to study quality improvement and accreditation programs in health care, social service, education, and other sectors,4,5 there has been a deliberate effort to apply to public health accreditation lessons from more established accreditation programs.
The Standards Development Workgroup-composed of public health professionals, experts, and researchers-was convened to develop the standards against which health departments' performance would be assessed. The workgroup built upon state-based public health accreditation programs, the National Public Health Performance Standards Program,6 and the Operational Definition of a Functional Local Health Department.7 The draft standards and measures were assessed through a desk review by 8 health departments (the alpha test) and a public vetting period that yielded approximately 3690 comments from the public health community. In 2010, a total of 30 local, state, and tribal health departments participated in a beta test of the standards and accreditation process to inform the launch of the accreditation system in 2011. A formal evaluation of the beta test was conducted by NORC at the University of Chicago.8 PHAB used these evaluation findings to modify the accreditation process and the standards and measures.
In July 2011, PHAB released version 1.0 of the standards and measures.9 The standards and measures are organized into 12 domains, the first 10 of which address the 10 Essential Public Health Services.10 Domain 11 focuses on management and administration, whereas Domain 12 addresses governance. Each domain comprises 2 or more standards, which reflect "the required level of achievement that a health department is expected to meet."9(p2) In turn, each standard has measures for which the health department must show documentation. While the domains and standards are the same for tribal, state, and local health departments, in limited instances, there is variation in the measures. In total, there are 99 measures for tribal health departments, 105 measures for state health departments, and 97 measures for local health departments. For each measure, PHAB provides a description of the purpose, significance, required documentation, and additional guidance about the documentation.
The standards and measures address the broad array of functions and capacities encompassed in the 10 Essential Public Health Services. Although PHAB standards are not specific to any particular public health program, many of the functions and capacities that they address are appropriate for all program areas (eg, planning, community engagement, evaluation). In addition, there are many links between PHAB standards and standards developed for specific program areas (eg, maternal and child health, environmental health, emergency preparedness11) and many natural connections between the accreditation standards and program areas (eg, community health, chronic disease). In accrediting the overall infrastructure upon which public health programs are operated, PHAB intends to assist health departments in demonstrating their capacity to manage any public health program. Because health departments vary in terms of scope of activity, size, governance, and many other factors, the standards and measures are not meant to be prescriptive about how a health department meets a particular measure. Instead, the measures describe what the health department does or what it collaborates with others to do.
In July 2011, PHAB also released a guide describing the 7 steps of the accreditation process.12 First, health departments engage in preapplication activities, which include assessing their readiness to apply, learning more about the accreditation program, and submitting a "statement of intent." Second, health departments submit an application. In addition to providing descriptive information about their organizations, health departments must provide 3 prerequisite documents: a community health assessment, a community health improvement plan, and a department strategic plan. Recognizing the importance of engaging the health department's governing entity, PHAB also requires a letter of support from the individual who has the authority to appoint the health official. When the application has been accepted, the health department staff member designated as the accreditation coordinator attends a training session provided by PHAB. Third, health departments engage in document selection and submission. During this stage, health departments select examples to demonstrate conformity with each of the measures and upload them into e-PHAB, the electronic system PHAB developed to allow for a paperless accreditation process. Fourth, a team of public health professionals reviews the documents in e-PHAB and conducts a site visit. Drawing on the training they receive from PHAB, these volunteers assess the extent to which the health departments demonstrate conformity with the measures and summarize their findings in the Site Visit Report. Fifth, the PHAB Accreditation Committee reviews the Site Visit Report and makes an accreditation decision about whether to accredit the health department for a 5-year period or to require the health department to develop and implement an action plan. Sixth, accredited health departments must submit annual reports to outline the steps they are taking to address areas for improvement that were identified through the process. Finally, health departments apply for reaccreditation after 5 years.
In developing and refining this process, PHAB has engaged, and will continue to engage, the public health community. In addition to involving public health professionals in the board of directors, committees, and workgroups, PHAB has adopted the think tank/expert panel approach to holding conversations with thought leaders on identified public health topics and issues related to accreditation.13 As part of its commitment to being a consensus organization, PHAB has gathered feedback from the field by providing opportunities to vet the standards and measures; creating discussion forums at national and regional meetings; and soliciting input from site visitors and applicant health departments. PHAB has also worked with its key national partners where planning for health department readiness for accreditation and communications regarding accreditation are the primary topics. The PHAB 5 group (composed of PHAB, Association of State and Territorial Health Officials, National Association of County & City Health Officials, National Association of Local Boards of Health, and National Indian Health Board) meet throughout the year to discuss technical assistance needed in order to ensure an adequate number of health department applicants over time. PHAB has also provided training to these partners as well as to the Public Health Foundation and the National Network of Public Health Institutes about how they can provide technical assistance to health departments seeking accreditation.
On September 14, 2011, national public health department accreditation officially launched during an event held at the National Press Club in Washington, District of Columbia. Almost 200 participants were in attendance, including board members, national partner representatives, health department staff, and various stakeholders. After 18 months of implementation, PHAB awarded 5-year accreditation to 11 public health departments on February 28, 2013 (Table). As a growing number of health departments embark on the accreditation process, PHAB processes and standards will continue to evolve to reflect the field's consensus view on how accreditation can best advance public health performance.
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