In "The 7 Habits of Highly Effective People,"1 Stephen Covey contrasts management and leadership with an example of producers cutting through a jungle. The producers do the actual cutting, while the managers provide support by keeping the equipment sharpened, the work schedules equitable, and the training current. It is the leader, however, who "climbs the tallest tree, surveys the entire situation, and yells 'wrong jungle.'"1^(p101) Visionary leadership engages management, Covey postulates, to effect change that is required for performance improvement. It was visionary leadership on the part of four public health organizations that added fuel to ignite a national discussion about the potential for accrediting public health agencies in the United States. The American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the National Association of Local Boards of Health came together in the summer of 2005 to engage the public health community in a dialogue about improving the health of the nation through a national accreditation effort. It was a conversation that, although painful at times, was embraced, and led to the findings of the Exploring Accreditation Project.2

History

Momentum for these efforts is derived from recent public health history. As far back as the 1970s, model standards for public health were developed.3 Although rudimentary in nature in comparison with the complexities of current public health practice, they fulfilled an early role in acknowledging that governmental public health was no different than other health-related work when it comes to the public's expectations of quality. The trend continued, if slowly, as various approaches to measuring what the public health system does and how it accomplishes its goals evolved. The Assessment Protocol for Excellence in Public Health,4 Mobilizing for Action Through Planning and Partnerships,5 and the National Public Health Performance Standards6 were among the most popular and widespread initiatives aimed at public health system performance improvement.

Moreover, the Institute of Medicine report, "The Future of the Public's Health in the 21st Century," contained a recommendation regarding accreditation of public health agencies. Specifically, the recommendation stated, "The Secretary of the Department of Health and Human Services should appoint a national commission to consider if an accreditation program would be useful for improving and building state and local agency capacities. If such a system is deemed useful, the commission should make recommendations on how it would be governed and develop mechanisms to gain state and local government participation in the accreditation effort."7^(p9) The vision for the Exploring Accreditation Project fulfilled the intent of that recommendation.

The Robert Wood Johnson Foundation funded a stakeholders' meeting in December 2004 to discuss multiple perspectives of accreditation in order to decide whether or not (and how) to continue working on this issue by examining current state and local public health experiences with accreditation and standards setting as well as similar experiences in related fields. The meeting resulted in a national call for action that resulted in the partnership project, Exploring Accreditation.2

At least until this point in the history of public health, no single entity, much less the four leadership organizations in public health, had ever formally asked the question, "Is a voluntary national accreditation program for public health feasible and desirable?" The Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation were ready and willing to fund such a study to seek the answers. The exploratory process was designed so as to be completed within a year. History was once again made as the four "parent" organizations (the Planning Committee) embarked upon a collaboration that valued joint proposal development, project management, and decision making.

Exploring Accreditation Project Process

In August 2005, the Planning Committee established a 25-member Steering Committee with representatives from local, state, federal, and the governance arms of public health organizations. The guiding philosophy of the work was to leave no stone unturned, considering all possible alternatives related to a voluntary national public health accreditation process. Its decisions were informed by the work of four subcommittees: Governance and Implementation, Finance and Incentives, Research and Evaluation, and Standards Development. Exploring every aspect of these four general areas meant involving as many public health practitioners and academicians as possible. More than 40 additional experts in the field of public health worked for a year in an open, consensus-building framework to develop recommendations, considering alternatives and rationale for each. Subject matter experts and consultants were called upon for advice and counsel as appropriate. Discussion papers with information on accreditation in public health and in other sectors were developed to stimulate the workgroup discussions.

In April 2006, the Steering Committee considered all of the information provided to them throughout the previous several months and developed a proposed model. The model was distributed for broader public comment from May through July 2006. Comments were received from more than 650 public health professionals through presentations where public health masses gathered; from conference calls; from e-mail messages and an online survey on the project Web site; from a satellite broadcast; and from opinion surveys sent to local, state, and territorial health officials. In August 2006, the Steering Committee reviewed all of the feedback received and revised the proposed model accordingly. A business case was also developed and adopted. National consensus emerged that a voluntary national public health accreditation program be further developed and implemented.

What was the intended outcome of the Exploring Accreditation Project? Was consensus difficult to achieve throughout the process? Have the four organizations maintained consensus on moving forward with the accreditation notion? The questions are perhaps best answered by reviewing policy statements on the topic of performance improvement from these organizations prior to and since the initiation of this study. All four organizations, joined by the Centers for Disease Control and Prevention, the National Network of Public Health Institutes, and the Public Health Foundation initiated the pilot study to develop the National Public Health Performance Standards in June 2002. The American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the National Association of Local Boards of Health all have policy statements supporting the idea of assisting public health systems across the country in their efforts to deliver services to their states, communities, and territories.8

In July 2005, the National Association of County and City Health Officials adopted a resolution in support of voluntary national accreditation programs for public health agencies provided that local public health departments are actively involved in the development of the process; that community health status improvement is a focus; that financial barriers are minimized; and that standards are developed by consensus and updated regularly. Since then, the National Association of County and City Health Officials Executive Committee has endorsed the work of the project.9 The Association of State and Territorial Health Officials Executive Committee, in a policy statement in October 2005, unanimously expressed pleasure with the initiation of the Exploring Accreditation Project, indicating its interest in and anticipation of receiving the recommendations of the Steering Committee for that project. This statement, according to the Association of State and Territorial Health Officials leadership, reaffirmed a previous position in support of effective quality improvement efforts for governmental public health agencies.10 In November 2004, the National Association of Local Boards of Health adopted a statement on voluntary accreditation of public health agencies. Recognizing the important role of governance in ensuring the quality and effectiveness of the delivery of essential local public health services, the National Association of Local Boards of Health described accreditation as one way in which continuous quality improvement in public health services could be defined, measured, and evaluated. The National Association of Local Boards of Health called accreditation "a critical factor for accountability and advocacy." Through the conditions set forth in the policy statement, the National Association of Local Boards of Health affirmed its willingness to be an accountable leader in planning and implementing such efforts.11 At its November 2006 Board meeting, the American Public Health Association reaffirmed its previous position that public health agency focus on performance improvement has the potential to improve its capacity to serve the public and has made supporting accreditation part of its strategic plan (G. Benjamin, personal communication, November 4, 2006).

Conclusion

The four organizations have worked diligently to achieve and maintain consensus on the forward movement of the project. Doing so has not always been an easy endeavor. Survey results during the project's development indicated perceived drawbacks such as variations in health department structure/operation; skepticism about potential standards and the accreditation review process; loss of credibility for nonaccredited agencies; challenges of achieving accreditation with limited public health capacity; political issues, such as securing approval for accreditation from legislatures or defending departments that are not accredited (or their budgets) from opponents; potential role of accreditation in influencing how money is spent in public health; concern about potential federal mandates/requirements for accreditation; time and money needed to apply for and achieve accreditation; and public health officials already having too much on their plates. Many of these themes are the same as those stated earlier. Accreditation as a concept is painful, as most change is. Clearly, an accreditation entity will need to consider all of these historical reservations as marketing plans are developed.12

The goal of a voluntary national public health accreditation program is to improve and protect the health of the public by advancing the quality and performance of state and local health departments. In reaching this goal, the partners anticipated that such a program would clarify the public's expectations of health departments; recognize performance improvement in meeting nationally accepted standards of quality; and increase the visibility and public awareness of governmental public health, leading to greater public trust, increasing health department credibility, and ultimately resulting in a stronger constituency. The vision for a strengthened public health enterprise continues.

If the model program accomplishes what the developers intended, it will ultimately result in a national system that will ensure consistency in public health department activities regardless of location. The ultimate success of the model in doing so, however, will depend on financial and constituent support. Tremendous progress has been made, and implementation has begun with incorporation activities and staff selection in progress at the time of this writing.

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