In the decades following the War of Independence, local boards of health were established in major colonial population centers to fight recurrent epidemics of infectious diseases.1 As public health practices evolved with improvements in science and medicine, local boards of health assumed a governance role ensuring a close connection between the health department and the community it served. Today, the legal authority for public health governance is most commonly fulfilled by boards of health but it may also be performed by commissions, councils, individuals, or other legally accountable bodies. Decisions made by these governing entities will drive the process toward accreditation for their public health departments. We will explore how those decisions are best informed.

With the leadership and support of the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation, the concept of accrediting public health departments has gained national support. Public health department accreditation is defined as "the development of a set of standards, a process to measure health department performance against those standards, and reward or recognition for those health departments who meet the standards."2 The first national voluntary public health accreditation program for state, local, territorial, and tribal public health authorities/agencies was launched in September 2011 by the Public Health Accreditation Board (PHAB). The standards and measures against which these health departments are evaluated (the PHAB Standards and Measures, Version 1.0)3 are divided into 12 domains-one domain for each of the 10 essential public health services4 plus domains for public health department administration and public health governance.

The National Association of Local Boards of Health (NALBOH), in an effort to support governing bodies, has developed the Six Functions of Public Health Governance, which include partner engagement, resource stewardship, policy development, legal authority, continuous improvement, and oversight.5 Just as the health department's performance is measured against the current PHAB standards and measures, the Six Functions of Public Health Governance serve as a practice guide for public health governing entities. While the current PHAB standards and measures neither assess nor accredit the performance of governing entities, a fundamental assumption still remains that governing entities play a series of critical roles in public health department accreditation.

Before the first national voluntary public health accreditation program was launched, PHAB employed a series of think tanks to anticipate and consider many of the complexities of the accreditation process.6 One think tank focused on the contributions governing entities could provide to the accreditation process and to the agency being accredited.7 Participants reviewed extensive background materials, heard wide testimony concerning quality improvement in organizational governance, and debated the role of governing entities in accreditation. The think tank resulted in several recommendations specific to the role of governing entities in accreditation. On the basis of these recommendations and other identified needs, the governing entity must do the following:

* Elevate its leadership, support, resource stewardship, and advocacy roles for the health agency;

* Be engaged throughout the accreditation process;

* Ensure the health department's readiness to seek and meet accreditation standards;

* Participate in developing all 3 of the accreditation prerequisites;

* Endorse the agency's decision to seek accreditation;

* Support the agency's efforts to meet or exceed the requirements of the PHAB standards and measures;

* Participate in the planning, preparation, implementation, and follow-up of accreditation events; and,

* Support the continuous quality improvement activities for sustained excellence.

In addition, think tank participants recommended that PHAB not include standards or measures to assess the governing entity. However, the health department should be assessed on how it engages the governing entity, particularly in Domain 12 (maintain capacity to engage the public health governing entity).3 To document conformity with that domain, a public health agency applying for accreditation must demonstrate that it clearly communicates with the governing entity, educates and informs that entity about the needs of the jurisdiction for public health interventions, and receives clear and appropriate direction to implement agency actions to address these needs.

Agency applications to PHAB must be accompanied by a formal letter of support by the entity that appoints the health director. In the first 18 months after PHAB's launch, 69 local public health agencies submitted applications to PHAB.* Of those original 69 agencies, 22 (32%) had letters from local elected officials; 11 (16%) from supervising government officials (eg, from a state public health agency in the case of centralized states or from a representative of a superagency); and 36 (52%) from a board of health (PHAB Staff, Unpublished data, 2013). Of these 36 agencies, 26 (72%) stated that the board played a governing role, 2 agencies said the board played a policy role, and the remaining 8 agencies said that the board plays a combination of governing, policy, and advisory roles (PHAB Staff, Unpublished data, 2013).

To illustrate how a governing entity can play an instrumental role throughout the accreditation process, consider this scenario. A local health department begins with a discussion between the health agency director and the governing entity on the value of becoming an accredited agency, which may be the single most important part of deciding to pursue accreditation. The value of accreditation must be demonstrated to the governing entity because accreditation represents a considerable, long-term investment of both time and money for the agency. In addition, the voluntary nature of accreditation by PHAB may add complexity to these discussions because an unaccredited health department does not face the same consequences (eg, loss of funding) as an unaccredited hospital or university. After these discussions, the governing entity should review the agency's budget to ensure that resources are available both prior to and during the accreditation process. If funding is secure, the governing entity should participate in the community health assessment, use results of the assessment to set health agency priorities, and assist with the development of the community health improvement plan. Following the community health assessment and community health improvement plan, the health director and staff, with input from the governing entity, will prepare an agency strategic plan to address the community's needs. The governing entity completes the requirements of the accreditation preapplication process by writing a letter to PHAB supporting their health department's decision to pursue accreditation. Upon official entrance to the accreditation process, the governing entity should continuously elevate its leadership, support, resource stewardship, and advocacy roles for the health agency.8 There is a demonstrated role for them in all domains with the exception of Domain 2 (investigate health problems and environmental public health hazards to protect the community) and Domain 7 (promote strategies to improve access to health care services).3 However, experience would indicate a role for governing entities may be found in every domain. Finally, the governing entity should also be available during each accreditation site visit.

Participation by governing entities in national voluntary health department accreditation is a key step toward being able to assess governing entity performance. The emerging data from accreditation site visits, particularly regarding Domain 12 on governance, as well as through NALBOH's programmatic efforts, already make it evident that as experience grows, PHAB and NALBOH will provide a rich and important source of data about the nature and functions of these governing entities. In addition, the Six Functions of Public Health Governance are a foundational framework that may, with the public health agency-governing entity interactions demonstrated in PHAB Domain 12, lead to more informed and powerful governing entities that can provide stronger oversight for public health departments nationwide.

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