The articles in this special issue demonstrate a sea change in the national public health community's attitude toward agency accreditation over the past few years. In 2004, momentum around accreditation was being fueled by the Institute of Medicine's recommendation in The Future of the Public's Health1 that a national steering committee be formed to examine potential benefits; the Centers for Disease Control and Prevention's Futures Initiative2 for identification of accreditation as a key strategy; and the demand to increase government accountability for funds invested in public health emergency preparedness. At the same time, the possible negative consequences of an accreditation system were raising deep concerns in the practice community. Proponents saw accreditation as a means to provide accountability and a platform for improving performance. Detractors feared that accreditation would be another bureaucratic exercise without meaningful positive outcomes, would be costly in terms of staff time and resources, and that a remediation process for agencies not meeting standards would not be available.

In December 2004, the Robert Wood Johnson Foundation acted as a neutral convener to bring together stakeholders to examine the issue in depth and reach a consensus on whether, and how, to continue working on agency accreditation. The foundation commissioned two background reports for the meeting. The first article, "Exploring public health experience with standards and accreditation,"3 reviewed positions that major public health organizations had taken on accreditation and comparable performance assessment programs. It also reviewed existing agency accreditation programs in eight states. It became clear from this report that a number of states already had significant experience to share on developing and implementing accreditation processes. A second article, "Can accreditation work in public health? Lessons from other service industries,"4 reviewed the literature on the experiences and outcomes of existing accreditation programs in health and social service industries and identified relevant findings for designing a sustainable accreditation system for public health agencies. Drawing on the lessons from these articles and their previous work, the meeting participants crafted a set of guiding principles for developing an accreditation system that would maximize benefits and minimize risks. In addition, the participants agreed that a committee of stakeholders should be established to develop recommendations regarding the feasibility and desirability of implementing a voluntary national accreditation program model.

This consensus resulted in the Exploring Accreditation Project,5 the design and results of which are well documented in this issue. To provide the committee with empirical information on existing public health accreditation practices, the Robert Wood Johnson Foundation supported the Multi-State Learning Collaborative6 (MLC) to bring five states together to share information and enhance the performance assessment process taking place in each state. The foundation had previous experience with successful collaboratives involving public health practitioners through the Turning Point program.7 The invaluable contributions of the MLC for identifying effective practices and informing the design of a national system are also detailed in this issue.

Expected Potential Benefits of Accreditation

The results of these projects and other work described in this issue provide evidence that accreditation yields not only expected and obvious benefits but also multiple, unanticipated benefits. The most explicit benefit of public health agency accreditation is that it sets a benchmark of consistent standards for public health services that should be met in every community across the country. Prior to the December 2004 meeting, the Robert Wood Johnson Foundation had supported the work of the National Association of County and City Health Officials (NACCHO) to develop the Operational Definition,8 which outlines what communities can expect of local public health departments. NACCHO's work resulted in a comprehensive set of standards that has been adopted as the framework for the national accreditation initiative. In a similar effort, the Association of State and Territorial Health Organizations is now in the process of developing a model to define services expected of state health agencies to generate standards at the state level. North Carolina will soon join Washington as the first states to undergo state agency performance assessment with external review.

A second expected objective for accreditation is to create a platform for quality improvement. In Michigan,9 as part of their MLC work, a survey of nearly 200 local and state public health professionals found that 90 percent believe the purpose of accreditation should be ongoing quality improvement that will increase efficiency and performance, decrease waste, and improve health outcomes. This view is also clearly articulated in Exploring Accreditation's final recommendation. Accreditation standards in some states already include quality improvement activities that will help quality improvement become part of the culture of public health. An increased emphasis on quality improvement will likely raise the bar for accreditation over time, so that agencies achieve more and more quality standards at higher and higher levels of performance.

A third and fairly obvious benefit of accreditation is to provide a means of documenting accountability to the public and to policy makers. Documented outcomes and performance can provide public health leaders and advocates with the increased ability to show positive results of public health fund allocations. Analysis of accreditation in other sectors has shown increased efficiency and cost savings, and there is some preliminary evidence to support this in public health. A corollary of being able to document performance is that if standards can be translated from arcane, process-heavy metrics into readily understandable evidence of superior health services, then accreditation can help to better communicate the role and value of public health to the public and elected officials. Analysis of accreditation in other sectors similarly found that they were able to present a more coherent public image due to the unifying effect of accreditation.10 Washington State's11 public health performance assessment program has placed great emphasis on communicating evidence regarding performance to the community and to policy makers in language that is meaningful to them.

Less Obvious Potential Benefits

In addition to the expected benefits, there are numerous less obvious benefits to be gained if accreditation is implemented in a right way. An example frequently reported in public health, as well as by other sectors, is improved staff morale and better awareness of each other's activities, resulting in greater collaboration and coordination within the agencies that go through accreditation. An important outcome observed in the MLC states is improved local and state health agency relationships, with better alignment of activities resulting from clear definitions of the mutual responsibilities of each agency. In Michigan, for example, the original system of accreditation was a top-down system that emphasized program grant compliance and used state health staff as reviewers. This initial approach has evolved into a collaborative process, yielding a more comprehensive assessment of performance, inclusion of quality improvement, and external review by multiple stakeholders, including peer reviewers.

Analyses in other types of organizations have noted that accreditation also provides an effective way to exchange information and share relevant resources within an industry. This can include more efficiency in staff training, sharing of best practices, and exchange of products. This has already been demonstrated to apply in public health as shown by the active exchange among the states in the MLC, between the MLC and the National Exploring Accreditation group, and with the broader public health community.

A third less obvious benefit of accreditation is as a path to promote regionalization across public health jurisdictions. Many jurisdictions may not be able to meet comprehensive accreditation standards on their own due to limited staff and other resources, particularly in rural areas or in states with very large numbers of small municipal public health departments. Sharing of resources and staff via regional arrangements can increase efficiency and broaden effectiveness without requiring agency mergers or consolidation, which clearly present major political barriers. The Robert Wood Johnson Foundation is supporting NACCHO in working with Kansas and in Massachusetts on strategies for achieving regionalized accreditation that could serve as potential models for the national accreditation system.

Accreditation can also improve public health performance in emergency preparedness, an area that has recently received increased scrutiny. Preparedness is a critical area for the credibility of accreditation, and a national accreditation system has the opportunity to establish a consistent set of emergency preparedness standards for the nation.

Conclusion

The momentum for public health agency accreditation is stronger in 2007 than ever before. The Exploring Accreditation's September 2006 recommendation for a national model for accreditation has been endorsed by NACCHO, the Association of State and Territorial Health Organizations, the National Association of Local Boards of Health, and the American Public Health Association. More than 20 states responded to the call for proposals for the second round of the Multi-State Learning Collaborative on Quality Improvement in the Context of Accreditation. North Carolina successfully achieved a legislative mandate for local and state health agency accreditation that included the appropriation of funds to support accreditation. The rigorous work of the Exploring Accreditation Project, combined with the best practices and collected experience from the MLC, NACCHO's local agency Operational Definition framework for standards, and the current work at the state agency level together yield a comprehensive road map for moving forward with accreditation. This road map incorporates the commitment of the multiple partners that the ultimate goal of accreditation is to strengthen the effectiveness of health agencies to improve the health of the communities they serve, a commitment that the Robert Wood Johnson Foundation shares.

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