Public health accreditation: rubber stamp or roadmap for improvement

Maintaining a Competent Public Health Workforce: Lessons Learned From Experiences With Public Health Accreditation Domain 8 Standards and Measures

CONTEXT

Public health accreditation is an ongoing national movement to improve the quality of public health departments and the public health system in the United States; however, calls have been made for more evidence regarding best practices in the accreditation process.

OBJECTIVE

The purpose of this work is to provide evidence about best practices in the accreditation process, specifically within the workforce development domain. It is the first in-depth investigation into workforce development using data collected by Public Health Accreditation Board (PHAB).

DESIGN

Using deidentified accreditation application data from PHAB, this study employs a mixed-methods approach to examining practices, lessons learned, challenges, and strategies pertaining to workforce development planning for Domain 8.

SETTING

United States.

PARTICIPANTS

US state (n = 19) and local health departments (n = 115).

MAIN OUTCOME MEASURES

Public Health Accreditation Board assessment scores for the workforce measures and the relationship between the health department's approach to meeting a PHAB measure criteria and the PHAB assessment score.

RESULTS

Of the 9 different approaches identified as ways of encouraging the development of a sufficient number of qualified public health workers (version 1, measure 8.1.1), only 1 approach (local health department internship programs with schools of public health; B = 0.25, P < .03) was significantly related to higher scores. An opportunity for improvement identified for measure 8.2.1 was that plans missing a clear identification of the gap between current staff competencies and staff needs were associated with a 0.88-point decrease in the 4-point score (P < .001).

CONCLUSIONS

Findings suggest that there are approaches adopted for meeting PHAB domain 8 measures that will impact the overall conformance assessment and score of a health department pursuing accreditation. There are several opportunities for improvement that health departments might consider when planning for accreditation or assessing their activities.

Association Between Accreditation Engagement and Using The Community Guide for Preventive Services by Local Health Departments

BACKGROUND

Accreditation is one of the macro trends shaping the future of public health practice, and The Community Guide to Preventive Services is a decision-making tool used to select evidence-based interventions. Although local health departments (LHDs) seeking accreditation use The Community Guide, the relationship between the two remains unknown. The purpose of this study was to determine whether accreditation engagement is associated with the extent to which LHDs use The Community Guide.

METHODS

Data from the National Association of County and City Health Officials' 2016 Profile of LHDs were examined for associations between accreditation engagement and the use of The Community Guide.

RESULTS

Whereas 52.8% of LHDs used The Community Guide sometimes or consistently, only 21.5% were engaged in the accreditation process. Engaged LHDs were more likely to use The Community Guide consistently (adjusted odds ratios: 8.2; 95% confidence interval, 4.0-16.4) or sometimes (adjusted odds ratios: 3.6; 95% confidence interval, 2.4-5.3) than those not engaged at all. Local health departments serving a population of more than 50 000, organized with a county or mixed level of jurisdiction, and those having a top executive with a masters' or a doctoral degree, were more likely to report some use of The Community Guide.

CONCLUSIONS

The extent that LHDs utilize The Community Guide is positively associated with the level of their accreditation engagement. Capacity building and policy measures could encourage LHDs to seek accreditation thereby increasing the use of The Community Guide for evidence-informed practice. Future studies should identify causal factors predicting the use of The Community Guide.

Impact of Local Boards of Health on Local Health Department Accreditation, Community Health Assessment, Community Health Improvement Planning, and Strategic Planning

INTRODUCTION

Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs' engagement in activities to meet these standards.

OBJECTIVES

To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program.

METHODS

Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey.

RESULTS

Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent).

CONCLUSIONS

LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs' participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

Pursuing Public Health Accreditation: A Focus on HOW

INTRODUCTION

Balancing competing imperatives of conserving scarce resources while improving organizational performance and community health, many local health departments (LHDs) have decided to pursue national, voluntary public health accreditation as a guide to improvement, but how to do so in the most efficient way possible remains a question for many.

METHODS

This study employed a participatory action research approach in which LHD directors and accreditation coordinators from 7 accredited and 3 late-stage accreditation ready Kentucky LHD jurisdictions participated. Participants organized a set of accreditation deliverables into a chronological sequencing of each site's accreditation readiness process, which was then coded by researchers to identify similarities and differences.

RESULTS

All participating jurisdictions had all-hazards emergency operations plans and public health emergency operations plans while none had workforce development plans, quality improvement plans, or performance management plans before launching accreditation readiness activities. Also identified were the number of accreditation deliverables attempted, simultaneously, by each site and the importance of specific deliverables having a singular focus. Sequences of work on specific deliverables by the majority of participants included completing work on the quality improvement plan immediately, followed by the performance management plan, the Community Health Assessment before the Community Health Improvement Plan, and a strategic plan, followed by a workforce development plan. Factors influencing accreditation readiness processes, elements for sustaining processes, and lessons learned throughout the pursuit of accreditation were also provided by participants.

CONCLUSIONS

Recognizing the impact of staff availability, staff skill sets, training, and available financial resources on the pursuit of accreditation, participants determined that aggregating lessons learned into a flowchart highlighting the interconnectedness of accreditation deliverables could produce a road map for LHDs. Accreditation deliverables could be attempted in a logical, efficient order particularly valuable to small LHDs with limited resources and yet adaptable for those jurisdictions able to devote more resources to the process.

Current challenges and opportunities to providing sexually transmitted disease services in STD clinics: A public health leadership perspective

OBJECTIVE

To assess leaders' perceptions of challenges and opportunities to providing sexually transmitted disease (STD) services in public health departments.

DESIGN AND SAMPLE

Semi-structured interviews were conducted in 2017 with health directors and other designated leaders in 19 public health departments who have an STD clinic. Purposive sampling accounted for geographical differences, providing balanced representation of urban, suburban, and rural agencies in North Carolina.

MEASUREMENT

Audiotaped interviews were transcribed verbatim. All transcripts were independently coded, with cross comparison and agreement between researchers. Rigorous thematic and content analyses were performed.

RESULTS

Perceived stigma, funding constraints, and client-centered issues were identified as the greatest challenges to providing services. Opportunities to improve these services were offering comprehensive screening methods, quality improvement, and public health accreditation. Focused training on revenue and billing practices for staff was acknowledged as the most needed technical assistance. A "culture of free services", perceived by clients and staff, was revealed throughout several themes.

CONCLUSIONS

Leaders in publicly funded STD clinics face many challenges and opportunities to providing clinical services. Health directors often serve as change agents and improving the sexual health of communities remains a priority. Results of this study will assist in crafting future policy and practice for STD clinics in the public health sector.

Framing Bias in the Interpretation of Quality Improvement Data: Evidence From an Experiment

Background: A growing body of public management literature sheds light on potential shortcomings to quality improvement (QI) and performance management efforts. These challenges stem from heuristics individuals use when interpreting data. Evidence from studies of citizens suggests that individuals’ evaluation of data is influenced by the linguistic framing or context of that information and may bias the way they use such information for decision-making. This study extends prospect theory into the field of public health QI by utilizing an experimental design to test for equivalency framing effects on how public health professionals interpret common QI indicators.

Methods: An experimental design utilizing randomly assigned survey vignettes is used to test for the influence of framing effects in the interpretation of QI data. The web-based survey assigned a national sample of 286 city and county health officers to a "positive frame" group or a "negative frame" group and measured perceptions of organizational performance. The majority of respondents self-report as organizational leadership.

Results: Public health managers are indeed susceptible to these framing effects and to a similar degree as citizens. Specifically, they tend to interpret QI information presented in a "positive frame" as indicating a higher level of performance as the same underlying data presenting in a "negative frame." These results are statistically significant and pass robustness checks when regressed against control variables and alternative sources of information.

Conclusion: This study helps identify potential areas of reform within the reporting aspects of QI systems. Specifically, there is a need to fully contextualize data when presenting even to subject matter experts to reduce the existence of bias when making decisions and introduce training in data presentation and basic numeracy prior to fully engaging in QI initiatives.

Drivers and Barriers for Adopting Accreditation at Local Health Departments for Their Performance Improvement Effort

CONTEXT

A national system of voluntary public health accreditation for state, local, and tribal health departments (local health departments [LHDs]) is part of a movement that aims to improve public health performance with ultimate impact on population health outcomes. Indiana is a good setting for the study of LHD accreditation adoption because several LHDs reported de-adopting accreditation in a recent statewide survey and because 71% of Indiana counties serve populations of 50 000 or less.

DESIGN

A systematic method of analyzing qualitative data based on the Performance Improvement Model framework to expand our understanding of de-adoption of public health accreditation.

SETTING/PARTICIPANTS

In 2015, we conducted a key informant interview study of the 3 LHDs that decided to delay their engagement in the accreditation based on findings from an Indiana survey on LHD accreditation adoption. The study is an exploration of LHD accreditation de-adoption and of the contributions made to its understanding by the Performance Improvement Model.

RESULT

The study found that top management team members are those who champion accreditation adoption, and that organizational structure and culture facilitate the staff's embracing of the change. The Performance Improvement Model was found to enhance the elucidation of the inner domain elements of Consolidated Framework for Implementation Research in the context of de-adoption of public health accreditation.

CONCLUSION

Governing entities' policies and priorities appear to mediate whether the LHDs are able to continue accreditation pursuit. Lacking any of these driving forces appears to be associated with decisions to de-adoption of accreditation. Further work is necessary to discern specific elements mediating decisions to pursue accreditation. This study demonstrates the added knowledge of Performance Improvement Model (PIM) to the CFIR framework. A large scale study is called to further clarify and discern supports of specific to the needs of individual LHDs for their performance improvement effort.

Prevalence and correlates of local health department activities to address mental health in the United States

Mental health has been recognized as a public health priority for nearly a century. Little is known, however, about what local health departments (LHDs) do to address the mental health needs of the populations they serve. Using data from the 2013 National Profile of Local Health Departments - a nationally representative survey of LHDs in the United States (N=505) - we characterized LHDs' engagement in eight mental health activities, factors associated with engagement, and estimated the proportion of the U.S. population residing in jurisdictions where these activities were performed. We used Handler's framework of the measurement of public health systems to select variables and examined associations between LHD characteristics and engagement in mental health activities using bivariate analyses and multilevel, multivariate logistic regression. Assessing gaps in access to mental healthcare services (39.3%) and implementing strategies to improve access to mental healthcare services (32.8%) were the most common mental health activities performed. LHDs that provided mental healthcare services were significantly more likely to perform population-based mental illness prevention activities (adjusted odds ratio: 7.1; 95% CI: 5.1, 10.0) and engage in policy/advocacy activities to address mental health (AOR: 3.9; 95% CI: 2.7, 5.6). Our study suggests that many LHDs are engaged in activities to address mental health, ranging from healthcare services to population-based interventions, and that LHDs that provide healthcare services are more likely than others to perform mental health activities. These findings have implications as LHDs reconsider their roles in the era of the Patient Protection and Affordable Care Act and LHD accreditation.

The Journey toward Voluntary Public Health Accreditation Readiness in Local Health Departments: Leadership and Followership Theories in Action

Local health department directors’ intent on getting their organizations ready for accreditation must embrace the blurring of leader/follower lines and create an accreditation readiness team fueled not by traditional leader or follower roles but by teamship.