In light of the significant interest in national accreditation for state and local public health agencies, questions have emerged regarding the role current and previous assessment and improvement initiatives can play in such an effort. Articles in this special issue on accreditation have highlighted opportunities represented by several state-established accreditation and standards programs. In this commentary, we discuss the role of another important building block-the National Public Health Performance Standards Program (NPHPSP).

The Institute of Medicine, in its 2003 report, The Future of the Public's Health in the 21st Century,1^(p158) catalyzed renewed interest in accreditation, with its recommendation for the establishment of a national commission to explore agency accreditation. Action toward this recommendation was ultimately taken in 2005-2006 through the Exploring Accreditation Project (EAP), cofunded by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation and jointly coordinated by the Association of State and Territorial Health Officials and the National Association of County and City Health Officials.

Within its recommendation, the Institute of Medicine further stated the need to build on current initiatives, and particularly noted the promise of the NPHPSP. The institute noted, "This [accreditation] commission should focus on the development of a system that will further the efforts of NPHPSP."1 Subsequent policy documents and articles2-5 have reinforced the perspective that the NPHPSP can and should play a valuable role. Turnock commented in a 2006 editorial that a "national voluntary program should [horizontal ellipsis] promote rather than preempt widespread use of tools like NPHPSP and MAPP for self-assessment and improvement[horizontal ellipsis]."6 The following perspectives are offered to demonstrate just how this relationship can be accomplished most effectively.

The NPHPSP

Initiated in early 1998, the NPHPSP is a collaborative effort of 7 national public health organizations coordinated and funded by the Centers for Disease Control and Prevention. Partners, which represent key public health constituencies, include the American Public Health Association, Association of State and Territorial Health Officials, National Association of County and City Health Officials, National Association of Local Boards of Health, National Network of Public Health Institutes, and Public Health Foundation.

The NPHPSP represents a groundbreaking effort to define public health practice standards for state and local public health systems and local governing entities. After extensive development and testing between 1998 and 2002,7-9 the three assessment instruments were finalized and released. Since August 2002, the State Public Health System Performance Assessment has been used in 19 states, the Local Public Health System Performance Assessment has been used in more than 500 jurisdictions, and more than 200 boards of health have used the Local Governance Performance Assessment. The standards are framed around the nationally recognized Essential Public Health Services10 and are set at the optimal level, thus heavily driving performance improvement efforts. The standards focus on the activities of the state and local public health system as a whole, rather than the agency, thus recognizing the important contributions that many organizations play in providing public health services.

The NPHPSP, given its use of optimal-level standards and the focus on the public health system, cannot serve as the standards for agency accreditation. However, the NPHPSP can provide a sound platform and some important tools for the development of a national agency accreditation program. Also, the program can offer much in preparing the state and local levels for participation in a future voluntary accreditation system.

Opportunity #1: Build From the NPHPSP Standards in Developing Agency Standards

As recommended within the EAP's model for a voluntary national accreditation program, the NPHPSP instruments offer a starting point in the development of measurable agency standards.11 This would require amending some of the current optimal and systems-oriented standards to focus on a measurable level of achievement specific to the governmental agency role. It is also notable that the EAP model recommends the use of 11 domains for accreditation standards, based largely upon the Essential Services framework. Therefore, the use of the NPHPSP and its Essential Services-based standards as a platform in developing agency standards is consistent with the future domains for accreditation.

The breadth and detail addressed within the NPHPSP instruments have already led to their use as a key platform in the development of the National Association of County and City Health Officials Operational Definition of a Functional Local Health Department12 (another tool highlighted in the EAP model) and in the work of several state-established standards and accreditation programs (eg, North Carolina, Missouri, and Iowa). Although much of this work has focused on the local level, the NPHPSP offers a much needed tool for the state level as well. As an example, North Carolina adapted the NPHPSP State Assessment Instrument to address its need for a state-level accountability process that complements local accreditation standards. They maintained much of the same content but refocused the standards and questions from the system to the agency.13

Opportunity #2: Complement Agency Accreditation With Attention to the System

As a second opportunity, the focus of the NPHPSP on the public health system can serve as a worthwhile complement for an accreditation program's attention to the public health agency. Significant progress has been made in recent decades toward building awareness and improvement of the public health system as a whole. Users of the state and local NPHPSP instruments and the companion tool, Mobilizing for Action through Planning and Partnerships (MAPP),14 have reported positive outcomes in engaging system partners, building a stronger awareness of the interconnectedness of public health activities, and creating a stronger level of collaboration among organizations in the public health system. Furthermore, these processes have been instrumental in helping organizations pool resources within the system and conduct more coordinated community or state-level decision making (National Association of County and City Health Officials, unpublished data, August 2006).15

As we develop an accreditation system for state and local public health agencies, it will be imperative to sustain attention to the concept of a public health system, as well as the role that agencies should play in fostering system partnerships. Recognizing this, the EAP Standards Development Work Group recommended that "assessment of the public health system using the NPHPSP instruments could be a recommended 'self study' in preparing for or maintaining accreditation. Such attention to the public health system, in a manner that complements health department-specific standards, could serve to emphasize the importance of external relationships and document the role that health departments play in creating such a system."16^(p26) In anticipation of this, the NPHPSP partner organizations have proceeded with planned revisions to the current NPHPSP instruments by incorporating changes that better reflect the role of the agency within the public health system.

Opportunity #3: Develop an Effective Performance Improvement-Oriented Culture

The NPHPSP represents one of the largest and most comprehensive efforts in public health standards setting to date. As such, the NPHPSP offers some valuable lessons learned and tools related to developing a national program that advances performance improvement activities. To optimize success in the field, the NPHPSP partners have attempted to develop a culture of performance improvement through peer support, sharing of resources, and strategic linkages with other programs and resources such as the Turning Point Performance Management Collaborative and MAPP. Those jurisdictions that have engaged in the NPHPSP and have taken action to address their weaknesses should be well positioned to measure themselves against accreditation standards and measures. In addition, as a result of using the NPHPSP or other similar assessment processes, they may have already established a culture of self-appraisal and performance improvement that will prepare agency leaders and staff for successful participation in an accreditation program.

The voluntary accreditation program, which will also be heavily geared toward supporting performance improvement, can build upon the momentum and successes of the NPHPSP as well as learn from its shortcomings. NPHPSP partners have learned that incentives for participation in a voluntary national program as well as technical assistance resources are critical. In a time of tight fiscal constraints, there will likely be few who can participate solely because it is the "right thing to do." And even those who undertake such a process without incentives require significant assistance in translating their results into tangible plans for improving their agency's performance. Proper attention to these elements may be instrumental in achieving the EAP Steering Committee's stated goal of "advancing the quality and performance of state and local health departments."11

Opportunity #4: Draw From the National Model

Finally, there are other connections and lessons that can be drawn from the experiences of the NPHPSP. The NPHPSP partnership represents a collaborative model as well as a practice-driven approach to developing and revising standards that remain current and relevant to the field. The program itself exists within a continuous quality improvement environment, which has supported ongoing attention to developing and adjusting tools for users. The NPHPSP also offers a potential research and monitoring surveillance system from which to learn, as we seek to build an accreditation monitoring system. Last, the experiences of states in adopting the NPHPSP-by some states into legislation, regulation, or administrative rules-provide a precedent and possible pathway for how the legal aspects of a national accreditation system can be accommodated within states.

Conclusion

The EAP Steering Committee has placed considerable value on the work of previous and current efforts. In doing this, they recognize two important points. First, significant investments have been made in these other programs that can be effectively leveraged as building blocks for a national accreditation effort. In the case of the NPHPSP, since its inception 9 years ago, considerable funding and time have been devoted to developing the program and supporting the use of the NPHPSP standards in states and localities. The second-and perhaps more critical-point is that programs and tools such as the NPHPSP, MAPP, and state-established standards and accreditation programs can do much to prepare the field for the successful use of accreditation standards within a performance improvement environment. The use of the NPHPSP, in particular, is consistent with the identified domains of an accreditation program and also allows for recognition of the valuable contributions made by other system partners. The NPHPSP represents one of the most comprehensive outlines of public health system activities, addressing a mix of capacities, processes, and outputs. This establishes an excellent starting point for thinking through governmental agency roles. Consequently, any state or local jurisdiction that uses the NPHPSP may be positioning itself well for the future as we move toward a national accreditation program.

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