Everybody doing his best is not the answer. It is first necessary that people know what to do.

W. Edwards Deming

The Centers for Disease Control and Prevention (CDC) mission is to help create the expertise, information, and tools that people and communities need to protect their health-through health promotion; prevention of disease, injury, and disability; and preparedness to promptly address new health threats. It has a long-standing partnership with state, tribal, local, and territorial health departments to help accomplish and further the public health mission. States and localities have the legal responsibility for public health and serve on the front lines as the first to recognize and respond to health threats. The federal government, on the contrary, has resources, expertise, and the responsibility to assess the health of the nation and make recommendations for improvement.1 Given the diversity in size, structure, and activities in health departments, developing standards for governmental public health practice has been a long-standing challenge. Fortunately, the collaborative work necessary to establish accreditation through the Public Health Accreditation Board (PHAB) has forged a national consensus on standards for public health departments.

Where Have We Been?

The Public Health Accreditation Board was established in 2007 to create a national voluntary accreditation program for public health departments. Its vision is to improve and protect the health of the public by advancing the quality and performance of health departments.2 The PHAB program and all of its elements-including the accreditation process, standards, and measures-were developed and tested through an extensive field-driven process. Since the inception of the exploratory work in 2004, the CDC has served as a funder and partner, along with the Robert Wood Johnson Foundation, in the development and establishment of the national accreditation program.

Providing coordinated funding from both a federal public health agency and a major national philanthropic organization has established a valuable and strategic partnership to advance these efforts. Along with its support of PHAB, the CDC has provided support to national partner organizations, including those representing state and local health departments, to help build awareness and capacity for the new national accreditation program.3-6

The CDC supports accreditation as a means to enhance accountability and quality across the public health enterprise. It awarded approximately $5 billion directly to health departments in 2012.7 In addition, the CDC funds national organizations and other entities to provide assistance to health departments in building their capacity to deliver public health services. The CDC provides health departments with workforce resources by placing fellows and CDC staff in health departments to help achieve their missions. Given the size of this investment, it is imperative that health departments use these resources efficiently and effectively. An accreditation system that helps ensure essential capacities and capabilities means that CDC investments are more likely to achieve their intended outcomes.

Where Are We Now?

One of the first decisions Dr Tom Frieden made when he became the director of the CDC in 2009 was to prioritize the CDC commitment to health departments. As part of this commitment, he established the Office for State, Tribal, Local and Territorial Support (OSTLTS). The OSTLTS is a crosscutting office focused on building system capacity through health officer trainings and support, fellowship training for public health advisors, and performance and quality improvement. Its efforts complement the technical support and training provided by the various CDC programs, and it also serves as the CDC lead office for national accreditation efforts. The CDC works closely with the Robert Wood Johnson Foundation and PHAB to provide leadership for accreditation. The CDC unique role and contribution to accreditation is a function of its work to (1) support continuous improvement of the national PHAB program; (2) support accreditation readiness activities in health departments; and (3) advance awareness and build connections with programmatic areas across CDC and sister federal agencies to support accreditation, including establishing incentives.8

As a federal partner, the CDC has played a key role in ensuring the inclusion of PHAB-related objectives in Healthy People 2020, as well as including accreditation-related language and citations within the National Prevention Strategy. CDC policy documents, such as A CDC Framework for Preventing Infectious Disease: Sustaining the Essentials and Innovating for the Future, published in October 2011, also highlight the role of accreditation in strengthening the foundation and performance of public health.9 In 2010, the OSTLTS launched a new cooperative agreement program for state, tribal, local, and territorial agencies, the National Public Health Improvement Initiative, which provides support to health departments in accreditation readiness, performance management, and quality improvement efforts.10

To lend further support to health departments, Director Frieden established the State, Tribal, Local and Territorial Workgroup under the long-standing Advisory Committee to the CDC director. The importance of the State, Tribal, Local and Territorial Workgroup was reflected in its elevation to a permanent subcommittee of the Advisory Committee to the Director in April 2013. The workgroup members are health officers from across the country representing diverse jurisdictions. As the Designated Federal Official for the workgroup, the OSTLTS director serves as a critical bridge between the capacity-building work of health agencies and some of the most important thinkers in public health leadership.

In its initial years, the State, Tribal, Local and Territorial Workgroup provided recommendations to improve the CDC support for health departments, several of which reinforced national accreditation activities. For example, recommendations to improve CDC project officer competencies and technical assistance services, including knowledge of current and best practices in the field, led the OSTLTS to develop the Technical Assistance and Service Improvement Initiative to ensure high-quality services across the board. For the first time in the CDC history, a structured agency-wide approach to supporting project officers was implemented through the Technical Assistance and Service Improvement Initiative. Building on the success of the Project Officer of the Future initiative implemented in the National Center for Chronic Disease Prevention and Health Promotion, the Technical Assistance and Service Improvement Initiative provides the CDC with a platform for increasing the awareness and understanding of PHAB for more than 1400 project officers.

A number of workgroup recommendations were also addressed through the development of a standardized Funding Opportunity Announcement (FOA) template. Led by the Office of the Associate Director for Program, in partnership with the OSTLTS and the Procurement and Grants Office, a new standardized FOA template and guidance was released for CDC use in October 2012. All CDC programs are required to use the new template; however, the decision to allow funding for accreditation is a program decision. The template provides the opportunity to incorporate PHAB accreditation into program planning by offering

applicants from state, tribal, local, or territorial government the ability to use funds to seek or maintain national public health accreditation standards. The use of funds for such purpose must align with the underlying statutory authorities cited in the FOA and be in furtherance of the underlying activities of the FOA.

In addition, the budget template narrative and guidance describe how funds may be used to meet national standards and/or seek health department accreditation if consistent with the statutory authority. To further institutionalize accreditation, applicants may describe their current status in applying for accreditation in the background section of their application.

Efforts to support accreditation across the CDC and within programs have picked up momentum as national accreditation became a reality on September 14, 2011. In early 2012, a cross-CDC seminar featuring PHAB leadership drew attendance from more than 300 CDC staff members. Programmatic connections have been built or initiated across the CDC as evidenced by articles in this issue (Koo, Singleton, Mercer, and Thomas) and other journals.11 CDC staff partnered to conduct webinars and develop crosswalks tying PHAB standards to programmatic metrics such as Public Health Emergency Preparedness capabilities. PHAB standards have also been tied to evidence-based recommendations from The Community Guide and to FOA priorities such as those found in immunization and occupational health programs. Such efforts are leading the way in demonstrating how PHAB standards reinforce the priorities of different components of the agency. Both CDC leadership and staff have also participated in PHAB "think tanks" on topics as diverse as workforce, emergency preparedness, laboratory, environmental health, ethics, health equity, and informatics. The CDC is eager to collaborate with PHAB on future topics, including chronic disease and the integration of public health and health care.

Where Are We Going?

To achieve health impact, the CDC is currently focused on 3 priorities: (1) improving health security at home and abroad; (2) preventing the leading causes of illness, injury, disability, and premature death; and (3) strengthening the interface and collaboration of public health and health care.

These priorities require a high-performing governmental public health system at the federal, state, tribal, and local levels, and accreditation contributes directly to achieving this vision. To improve health security, we need to continue to sustain, upgrade, and modernize public health systems at home and abroad and equip them with state-of-the-art information and laboratory technologies so that we can more quickly and accurately detect and respond to health threats. To better prevent the leading causes of illness, injury, disability, and death, health departments are expected to use evidence-based programs, services, and policies. The articles by both Singleton et al12 and Mercer et al13 show that PHAB accreditation already has great synergy with these priorities. As work continues to evolve, connections should be reinforced and strengthened.

To achieve greater improvements in health outcomes at lower cost, public health and health care need to work together as interactive parts of a single, cohesive health system. The Patient Protection and Affordable Care Act (aka, "Affordable Care Act" or "ACA") is expanding insurance coverage and creating integrated systems through Accountable Care Organizations. This is a tremendous opportunity for public health and clinical sectors to work together to improve health. To fully realize this opportunity will require the focus and engagement of national, state, and local partners. PHAB is playing an important role by convening a think tank to explore how the accreditation standards and measures can support and promote the linkages between public health and health care.

As we move toward the full implementation of the Patient Protection and Affordable Care Act, with more Americans with health insurance, greater access to clinical preventive services, and payment reform that creates the incentives for a healthier population, health departments face challenges and opportunities. They can facilitate the enrollment in health insurance exchanges, enhance their role in health data through the adoption of health information technology, collaborate with nonprofit hospitals to conduct community health needs assessments, and be active members of the emerging Accountable Care Organizations.

In this new landscape of health system reform, PHAB has a critical role and obligation to ensure that the standards and measures are supporting the current and future roles of health departments. Evolving partnerships with health care and stronger attention to health information technology and informatics represent just 2 examples of important areas for PHAB's ongoing attention.

Accreditation is an affirmation that a health department has the capacity to provide services the general public has a right to expect. The CDC will continue to support the evolution of PHAB and explore incentives for all stages of accreditation including readiness, implementation, and maintenance. As Deming noted, health departments must do their best, but they first must know what to do, and PHAB standards provide the roadmap.

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