Yogi Berra is famously credited with saying that when you come to a fork in the road, take it. Although reportedly he was giving directions to his home, unwittingly he may have been referring to the development of public health accreditation and quality improvement (QI). More intentionally, throughout its 25-year history, the Journal of Public Health Management & Practice (JPHMP) steadfastly has been chronicling this transformational journey of public health modernization. The very first editorial promised a forum where developments and innovations in practice would be showcased, allowing guidance for future direction in public health.1 In fact, on the journal Web site are collections of selected published articles on both accreditation and QI for ready access and retrieval, fulfilling the original pledge to highlight new directions for practitioners.2,3 Yet, more than merely curating these landmark seismic shifts in public health practice, JPHMP actively solicited relevant content to facilitate a deeper understanding by its practice readership-preparing them for the forking road ahead. Moreover, JPHMP sponsored 3 regular or supplemental issues dedicated to these topics, as well as articles within regular editions.

Kudos of recognition go to the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation (RWJF) for their catalytic roles stimulating and incentivizing the adoption of accreditation and QI. Theirs was a multifaceted leadership partnership, encompassing numerous strategic milestones supporting shared concepts, even when at times a consensus among the practice field was lacking. Accreditation and QI can trace their immediate modern lineage back to the adoption of national public health systems performance standards (NPHPS) under the banner of CDC cooperative agreements with the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the National Association of Local Boards of Health (NALBOH). These same membership organizations became key stakeholders, alongside the American Public Health Association, in the ultimate design and uptake of our current accreditation model. Concurrently, RWJF sponsored the bold Turning Point initiative, which emphasized multisector collaboration and partnership formation to strengthen the public health system. Among many foci, the Turning Performance Management Collaborative helped instigate the QI movement in public health.

Both NPHPS and Turning Point were the forerunners of many immediate antecedents of accreditation and QI. All were prominently featured in JPHMP as they unfolded and are catalogued ever so briefly here. NACCHO's efforts to define local public health functional roles (Definition of a Functional Local Health Department) attempted to describe what roles health departments were expected to fulfill within the larger public health system.4 Considered together, performance standards and a definition of local health department (LHD) roles set the stage for the accreditation model that followed. Mobilizing for Action through Planning and Partnership outlined a process for community engagement deeply embedded within the accreditation framework.5 Building upon the foundation of the Turning Point Performance Management Collaborative, 3 waves of the Multi-State Learning Collaborative received support and resources from RWJF to explore accreditation type models and QI. Followed by the Exploring Accreditation Project, these collective initiatives (among many others) greatly influenced the decision to move forward, embracing accreditation, while providing models that inspired its content.

Similarly, much has been written in JPHMP about accreditation, QI, and more recently reaccreditation, since the establishment of the Public Health Accreditation Board (PHAB) in 2007. Perhaps, now we are well beyond the mythical mantra of saying when you have seen one health department, you have seen one health department. It is now far more evident that the common DNA linking one health department with its compatriots far exceeds the unmatched base pairs. Growing pains of developing and field testing standards proposed by the actual end users, health departments, were chronicled, as were the evaluations and experiences of those undertaking the accreditation journey.

Not yet 5 years since the launch of accreditation in fall 2014, more than 230 state, local, and tribal health departments have completed the rigorous process, with more than 200 others in the pipeline.6 That translates into 70% of the US population protected under the auspices of an accredited health department-about 219 million Americans.6 The new PHAB reaccreditation model emphasizes sustainable performance and improved health outcomes even more than its accreditation predecessor-with a goal of true transformation.

All barometers point to successful uptake of accreditation and QI by the practice community. According to Rogers7 in his seminal work, Diffusion of Innovations, we are well past the early adopters and there is evidence that standards setting has benefitted public health writ large.8 Yet, it would be ostrich-like to presume the work of instilling quality and consistent standards across public health practice is done. Numerous challenges remain before the ultimate goals are achieved and genuinely coupled with moving the needle on stubborn health outcomes. Among the accredited health departments are relatively few smaller LHDs, defined as serving jurisdictions fewer than 50 000 residents, despite being the majority of health departments in the nation. Achieving accreditation requires resources, much less for PHAB fees than supporting the capacities, processes, and ultimately programs to meet practice standards. Could accreditation inadvertently exacerbate existing resource inequities even as greater health is accessed by those agencies with larger populations and more robust tax bases? Principles of QI have been widely accepted within public health, but in our observation, significant uptake of performance management has lagged in the field.9

What new models can support smaller LHDs so that they can tackle components of accreditation over manageable time increments, with milestones that articulate together in a developmental manner, allowing them to demonstrate their capabilities? Can new incentives from federal, state, and philanthropic partners be devised to avoid worsening the resource chasm between health department haves and have-nots? In the next 25 years, we fully expect JPHMP to recount the struggle of the broader public health community as it grapples with these significant remaining conundrums, just as it reports the narrative of present-day success.

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