The Public Health Accreditation Board (PHAB) appreciates the work of Dr Kovach1 in his seminal research in exploring PHAB accreditation's impact on population health status in "Age-Adjusted All-Cause Mortality in Counties Served by PHAB-Accredited Local Health Departments Compared With Counties Served by Nonaccredited Local Health Departments: 1999 to 2020."

Like with many programs and initiatives, PHAB is often asked about the relationship between health outcomes and accreditation. Indeed, PHAB's logic model has always included improvement in community health indicators as an ultimate outcome.2 Although focused mostly on proximate and intermediate outcomes related to performance improvement and organizational and systems change, PHAB's rationale for community health indicators as an ultimate outcome is that a health department that works with its community to develop a solid community health improvement plan, that tracks and monitors its ongoing community/stakeholder relationships, and that bases its work on evidence will positively contribute to improving the health of its jurisdiction. To strengthen this link and gather information, PHAB has recently added the monitoring and reporting of a limited number of health department selected population outcomes to the reaccreditation requirements. Cleaning and analysis of these data will start soon, providing an important addition of information to address this issue.3

At the same time, PHAB has been cautious about correlating accreditation to health outcomes because PHAB believes strongly in a multiple determinants of health model. As outlined in models such as County Health Rankings4 and Public Health 3.0,5 there is a profound impact of social and environmental conditions, including policies and structures that exacerbate health disparities, on health. As such, PHAB continues to think it is important to consider the impact of a program like accreditation in the context of these other factors. In addition, like the author, PHAB is concerned about the lack of formative research on the time needed after a health department engages in a project or initiative, like PHAB accreditation, to move the needle on health outcomes. For instance, are the 4 years of outcomes data postaccreditation used by the author sensitive enough? Could other measures like life expectancy or infant mortality be more sensitive to the impact of accreditation? With these 2 outcome measures specifically, do disparities change as a result of going through PHAB accreditation? We also agree with the author that additional study methods, such as time-series and qualitative methods, to explore the impact of PHAB accreditation on health outcomes is necessary to more fully and appropriately answer this question. For instance, 51% of health departments surveyed by NORC at the University of Chicago 4 years after becoming accredited said that health department activities implemented as a result of being accredited have led to improved health outcomes in the community.6 Although self-reported, this type of information is part of the complement of data to continue to suggest and encourage further research on PHAB accreditation's impact on health outcomes. It may be beneficial to further explore from the perspective of those health departments what changes were made (eg, new partnerships, application of new evidence-based interventions, stronger communications capacities) and how they might influence the health outcomes the health department was specifically focused on.

PHAB is especially encouraged and interested to see the improvement in 2020 between accredited and nonaccredited counties.1 Although 2020's improvement was singular, it was the last year studied, and as noted, potentially related to the COVID-19 pandemic. It is possible that the performance of governmental public health departments might have had a more direct and immediate impact on COVID-19-related mortality, given the multiple mitigation strategies to which health departments contributed. PHAB surveys during and since the pandemic support this hypothesis. PHAB found that 80% of accredited health departments report that accreditation had helped their response to the COVID-19 pandemic.6 One health department stated, "Accreditation has particularly helped us quantify and address health equity issues in our community. It has also helped us establish stronger working relationships with certain partners that have since proved invaluable in our COVID response."6

PHAB encourages further research to explore whether the 2020 results could indeed be the beginning of a trend in health outcomes improvement related to accreditation that needs to be further explored, or whether these findings appear to be related to COVID-19 to better understand the mechanisms through which accreditation could have strengthened response. With reaccreditation data becoming more robust (providing a stronger and longer-term picture for a health department's journey with accreditation) along with renewed focus on PHAB accreditation within the Public Health Infrastructure Grant7 and a resurgence of interest in Public Health Services and Systems Research,8 the time is right to further explore and describe PHAB accreditation's impact on population health status. PHAB is committed to releasing data generated through the accreditation process and encourages researchers to consider this issue and reach out to us at mailto:[email protected] with interest.9

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