The Birth of National Public Health Department Accreditation

A decade has passed since the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century's report was released with a recommendation related to accreditation for governmental public health departments in this country.1 In that short 10 years, a national public health accreditation program has been developed, tested, and launched and is now officially operational. The first health departments have received accreditation, and as of the writing of this commentary, 148 are in the process along that important journey in the life of public health. What a decade it has been, and what a great experience the last year has been as those initial goals have been realized. Time will tell us what the ultimate outcomes of accreditation will be, but already there are strong signs that it has great potential for changing the landscape of a long-neglected component of our overall public health system, governmental public health departments. The Public Health Accreditation Board's (PHAB's) vision is to accredit all health departments that wish to engage in this work; this would mean that approximately 2000 total accredited health departments for the US population!

As with any new national initiative, there are accomplishments to be celebrated and lessons to be learned. PHAB has developed a strong approach to internal evaluation that is used for regular and ongoing quality improvement and an even more detailed process for external evaluation that will describe observations on complex issues, such as incentives for accreditation, barriers to seeking accreditation, and the impact of the accreditation process on health department operations. PHAB will have robust data upon which concrete observations can be made and conclusions drawn. Already, though, 1 year after the first accreditations have been made, there are many strong observations that can be described. Those are included in this commentary.

The national accreditation process recommended in the Exploring Accreditation Steering Committee report2 and the subsequent work of the original Board of Incorporators (BOI) for PHAB laid outstanding groundwork to get the accreditation movement up and running in a remarkably quick manner. Almost all of the recommendations from that report were used in establishing PHAB's governance and operational frameworks. For example, the structure and composition of the PHAB Board of Directors was completed using those recommendations and remain in place today. The transition from the original BOI to the current governing board representing broad public health perspectives, experiences, and commitment to accreditation has allowed PHAB to develop and manage carefully planned and executed strategies for administering the accreditation program.

The initial approach to the accreditation process, including the standards and measures, has worked remarkably well for the first year of implementation.3 A July 2014 version of the standards and measures will provide some additional clarification and lay the groundwork for emerging public health issues to be addressed. However, Version 1.0 guided the health departments, the site visitors, and all others involved in the overall accreditation process very well. The early success was due primarily to the active, ongoing, and decisive engagement of the public health field. By the time the accreditation program was launched, hundreds of individuals from public health practice, academia, and research had contributed to the development of the work. More than 4000 individuals provided comment during the various vetting and testing stages. Thirty health departments served as beta test sites. By the end of the first year of accepting applications, nearly 100 health departments had declared their intention to apply for accreditation. When PHAB states that it is a national, consensus-based, performance standards setting accreditation organization, it has evidence to show that it was just that. Ownership from the practice community is vital to the long-term success of the accreditation program.

The national partner organizations and their constituent state-level structures, public health institutes, academic institutions, public health training centers, and some local public health foundations had worked hard to provide technical assistance to health departments that were getting ready to apply. This amount of dedicated work toward accreditation readiness has proven to further conversations about the transforming power of accreditation. As new as the concept of public health department accreditation was, the effort of respected public health organizations provided health departments with the tools they needed to successfully manage accreditation readiness.

Support from the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation not only ensured that the national public health accreditation office had the resources it needed to become well established but also provided a myriad of associated opportunities for health departments to engage in cooperative learning about community health needs assessment and planning, performance management, quality improvement, workforce development, and other key areas related to accreditation. Then, when health departments achieve their national accreditation, both organizations developed their own unique and special ways of acknowledging that important milestone in public health department history. Accredited health departments receive a specific letter of congratulations from the director of the Robert Wood Johnson Foundation and from the director of the Office of State, Tribal, Local and Territorial Support. The Robert Wood Johnson Foundation has spotlighted accredited health departments both on its Web site and on http://NewPublicHealth.org. Going forward, linkages with the public health programs that guide many of the services provided by health departments will strengthen the accreditation program and make it even more applicable to the practice community. These linkages emerge from many of PHAB's think tanks where there is a specific focus on how program examples (such as all-hazards communication plans, chronic disease prevention interventions, and communicable disease control efforts, to name a few) can support health department accreditation efforts.

Volunteer site visitors and committee members are the key to PHAB's peer review process. Without their agreement to donate their time to learn more about the standards and measures and to use their professional judgment in applying them to an objective review of a health department, the whole concept of collectively working toward advancing public health practice improvement would not work. Accredited health departments have reported that the conversations with colleagues who understand public health and are willing to provide supportive and constructive feedback have been invaluable to them.

Finally, the health departments that have voluntarily sought and achieved accreditation are truly trendsetters in public health. Leadership and teamwork are required to bravely put the health departments' work out for peer review against national accreditation standards. And, yet, many health departments have done just that. They have reported to PHAB that just going through the process helped them rethink and reorganize their work in better ways to address the complex issues facing them in today's challenging political and economic environments. Others have reported that they learned how to connect with the community they serve based on partnership models that are multifaceted and multidirectional. All of them have celebrated the validation of the fine work they do.

The first year of realizing the goal of accredited health departments has been outstanding, not only from the standpoint of reaching that goal but also from the perspective of experiencing firsthand what the public health community across this country can do when we all work together on a common goal. As the next years unfold and accreditation changes with the inevitable changes in the public health practice environment, these initial days will long be remembered for establishing a sound foundation upon which to build.

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