Equity Work Among Accredited Health Departments in the United States, 2015-2021.

OBJECTIVES: Minimal research has examined the number of health departments conducting work related to equity and/or the kind of work, if any, they are conducting. We examined the relationship between public health accreditation and work related to health equity by analyzing accredited health departments' responses to a prompt in the Public Health Accreditation Board's (PHAB's) annual report. METHODS: We analyzed self-reported responses from accredited health departments to questions about emerging public health issues and innovations in PHAB's annual report. We identified themes using a priori and inductive coding. RESULTS: A total of 316 health departments submitted an annual report from January 2015 through December 2021. Of those health departments, 283 (89.6%) stated in their annual report that they engaged in work related to health equity, 50 (17.7%) of which provided a narrative about this work. Of those 50 health departments, the most common theme reported was community partnership, described by 23 (46.0%) health departments. The next most reported themes were COVID-19 vaccine access for racially or socioeconomically marginalized communities (n = 17, 34.0%) and programs related to health equity (n = 16, 32.0%). CONCLUSIONS: We found that most accredited health departments conduct work related to health equity. Further research is needed to examine characteristics that influence a health department's likelihood of conducting equity work. Models and resources on how health departments, particularly small health departments, can begin equity work would be valuable.

What Are Public Health Agencies Planning for Workforce Development? A Content Analysis of Workforce Development Plans of Accredited Public Health Departments.

OBJECTIVE: Recruiting and retaining public health employees and ensuring they have the skills necessary to respond are vital for meeting public health needs. As the first study examining health department (HD) workforce development plans (WDPs), this study presents gaps and strategies identified in WDPs across 201 accredited HDs (168 initial/33 reaccreditation plans). DESIGN: This cross-sectional study employed qualitative review and content analysis of WDPs submitted to the Public Health Accreditation Board (PHAB) between March 2016 and November 2021. MAIN OUTCOME MEASURES: Eight overarching workforce themes were examined: planning/coordination, leadership, organizational culture, workplace supports/retention, recruitment, planning for departmental training, delivery of departmental training, and partnership/engagement. Within each theme, related subthemes were identified. Coders indicated whether the WDP (1) identified the subtheme as a gap; (2) stated an intent to address the subtheme; and/or (3) identified a strategy for addressing the subtheme. RESULTS: The most common gaps identified included prepare workforce for community engagement/partnership (34.3%, n = 69), followed by resource/fund training (24.9%, n = 50). The subtheme that had the most instances of an identified strategy to address it was assess training needs (84.1%, n = 169), followed by foster quality improvement (QI) culture/provide QI training (63.2%, n = 127). While both of these strategies were common among the majority of HDs, those subthemes were rarely identified as a gap. Secondary findings indicate that increase recruitment diversity/recruit from a more diverse applicant pool was rarely identified as a gap (6.0%, n = 12) and rarely had an identified strategy for addressing the subtheme (9.0%, n = 18). CONCLUSION: While HDs recognized many workforce gaps, HDs did not always propose a strategy for addressing them within the WDP. Conversely, some WDPs proposed strategies for subthemes that did not reflect recognized gaps. Such discrepancies between identified gaps and strategies in WDPs may suggest areas where HDs could use additional support and guidance.

Public Health Department Accreditation and Innovation: A Brief Report of the Approaches Used to Promote Innovation.

To examine the relationship between public health accreditation and innovation, we analyzed accredited health departments' self-reported responses to a prompt within the Public Health Accreditation Board's (PHAB's) Annual Report regarding any approaches to pursuing innovation within their health department. We found that of the 205 health departments examined, 75 (37%) described elements of the health department's approach to fostering innovation. The most common approaches to innovation included partnerships (59% of those health departments that described their innovation approaches) and leadership (27%). Other common elements, mentioned by at least 20% of health departments that provided their innovation approach, include funding, internal collaboration, training, and devoting time to innovation. Both larger health departments and state health departments were more likely than smaller health departments and local health departments to describe elements of their approach in fostering innovation, suggesting that those types of health departments may have access to resources and flexibility in staffing, both integral elements for promoting innovation.

Application for Public Health Accreditation Among US Local Health Departments in 2013 to 2019: Impact of Service and Activity Mix.

Objectives. To examine correlates of applying for accreditation among small local health departments (LHDs) in the United States through 2019.Methods. We used administrative data from the Public Health Accreditation Board (PHAB) and 2013, 2016, and 2019 Profile data from the National Association of County and City Health Officials to examine correlates of applying for PHAB accreditation. We fit a latent class analysis (LCA) to characterize LHDs by service mix and size. We made bivariate comparisons using the t test and Pearson χ2.Results. By the end of 2019, 126 small LHDs had applied for accreditation (8%). When we compared reasons for not pursuing accreditation, we observed a difference by size for perceptions that standards exceeded LHD capacity (47% for small vs 22% for midsized [P < .001] and 0% for large [P < .001]).Conclusions. Greater funding support, considering differing standards by LHD size, and recognition that service mix might affect practicality of accreditation are all relevant considerations in attempting to increase uptake of accreditation for small LHDs.Public Health Implications. Overall, small LHDs represented about 60% of all LHDs that had not yet applied to PHAB.

Supporting Increased Local Health Department Accreditation: Qualitative Insights From Accredited Small Local Health Departments.

Accredited health departments now cover 80% of the US population. A relatively modest proportion of these are small local health departments (LHDs), serving fewer than 50 000 people. Despite comprising more than half of all health departments, only 2% of small LHDs are accredited. This brief report is a qualitative inquiry into the enablers of accreditation for small LHDs. We interviewed health department and accreditation leaders from 9 accredited small local LHDs. Interviews were transcribed, verified, and coded by 2 coders. We found that dedicated funding, prework, clear expectations, and peer examples were strong enablers of accreditation for these groups. Additional resources specific to small LHDs may be necessary to expedite application processes and encourage greater uptake from this group.

The Relationship Between Health Department Accreditation and Workforce Satisfaction, Retention, and Training Needs.

BACKGROUND: To improve quality and consistency of health departments, a voluntary accreditation process was developed by the Public Health Accreditation Board. Understanding accreditation's role as a mediator in workforce training needs, satisfaction, and awareness is important for continued improvement for governmental public health. OBJECTIVE: To compare differences in training needs, satisfaction/intent to leave, and awareness of public health concepts for state and local health department staff with regard to their agency's accreditation status. DESIGN: This cross-sectional study considered the association between agency accreditation status and individual perceptions of training needs, satisfaction, intent to leave, and awareness of public health concepts, using 2017 Public Health Workforce Interests and Needs Survey (PH WINS) data. Respondents were categorized on the basis of whether their agencies (at the time of survey) were (1) uninvolved in accreditation, (2) formally involved in accreditation, or (3) accredited. RESULTS: Multivariate logistic regression models found several significant differences, including the following: individuals from involved state agencies were less likely to report having had their training needs assessed; staff from accredited and involved agencies identified more gaps in selected skills; and employees of accredited agencies were more aware of quality improvement. While state employees in accredited and formally involved agencies reported less job satisfaction, there were no significant differences in intent to leave or burnout. Differences were identified concerning awareness of various public health concepts, especially among respondents in state agencies. CONCLUSIONS: While some findings were consistent with past research (eg, link between accreditation and quality improvement), others were not (eg, job satisfaction). Several self-reported skill gaps were unanticipated, given accreditation's emphasis on training. Potentially, as staff are exposed to accreditation topics, they gain more appreciation of skills development needs. Findings suggest opportunities to strengthen workforce development components when revising accreditation measures.

Has Voluntary Public Health Accreditation Impacted Health Department Perceptions and Activities in Quality Improvement and Performance Management?

CONTEXT: The Public Health Accreditation Board (PHAB) is now in its 10th year, making it an ideal time to study the impact of PHAB accreditation on local health departments (LHDs). OBJECTIVE: To examine whether applying for PHAB accreditation affects perceptions and activities regarding quality improvement (QI) and performance management (PM) within LHDs. DESIGN: Data from the National Association of County & City Health Officials' 2010, 2013, and 2016 National Profile of Local Health Departments and associated QI modules were linked to PHAB-applicant data collected in e-PHAB in a cross-sectional and longitudinal approach examining self-reported QI/PM activities. PARTICIPANTS: Local health departments responding to National Association of County & City Health Officials Profile questionnaires and QI modules in 2010, 2013, and 2016. MAIN OUTCOME MEASURES: Implementation of formal QI program within agency, numbers of formal QI projects in the past year, presence of elements indicating formal QI program implementation, and changes over time by accreditation status as of June 2017. RESULTS: Accredited and in-process LHDs showed greater gains over time in all of the outcome measures than LHDs not registered in e-PHAB. Results of logistic regression controlling for population served and governance type found accredited LHDs more likely to report formal QI programs agency-wide (odds ratio: [OR] = 27.0; P < .001) and have implemented 6 to 8 elements of formal QI (OR = 27.0; P < .001) in 2016, compared with nonaccreditation-seeking LHDs. Between 2013 and 2016, LHDs that responded to both survey waves that were registered in e-PHAB or accredited were significantly more likely than nonaccreditation-seeking LHDs to report any increase in overall level of QI implementation (OR = 4.89; P = .006) and increase in number of elements of formal QI (OR = 16.1; P < .001). CONCLUSIONS: Local health departments accredited by June 2017 and those in process reported more formal QI activities and showed greater improvements with QI/PM implementation over time than LHDs not undertaking accreditation. Public Health Accreditation Board accreditation appears to influence QI/PM uptake. As health departments are contemplating whether to apply for accreditation, the potential for developing a more robust QI/PM system should be taken into account.

Accredited Health Department Partnerships to Improve Health: An Analysis of Community Health Assessments and Improvement Plans.

CONTEXT: The Public Health Accreditation Board (PHAB) Standards & Measures require the development and updating of collaborative community health assessments (CHAs) and community health improvement plans (CHIPs). OBJECTIVE: The goal of this study was to analyze the CHAs and CHIPs of PHAB-accredited health departments to identify the types of partners engaged, as well as the objectives selected to measure progress toward improving community health. DESIGN: The study team extracted and coded data from documents from 158 CHA/CHIP processes submitted as part of the accreditation process. Extracted data included population size, health department type, data sources, and types of partner organizations. Health outcome objectives were categorized by Healthy People 2020 Leading Health Indicator (LHI), as well as by the 7 broad areas in the PHAB reaccreditation framework for population health outcomes reporting. PARTICIPANTS: Participants included health departments accredited between 2013 and 2016 that submitted CHAs and CHIPs to PHAB, including 138 CHAs/CHIPs from local health departments and 20 from state health departments. RESULTS: All the CHAs/CHIPs documented collaboration with a broad array of partners, with hospitals and health care cited most frequently (99.0%). Other common partners included nonprofit service organizations, education, business, and faith-based organizations. Small health departments more frequently listed many partner types, including law enforcement and education, compared with large health departments. The majority of documents (88.6%) explicitly reference Healthy People 2020 goals, with most addressing the LHIs nutrition/obesity/physical activity and access to health services. The most common broad areas from PHAB's reaccreditation framework were preventive health care and individual behavior. CONCLUSIONS: This study demonstrates the range of partners accredited health departments engage with to collaborate on improving their communities' health as well as the objectives used to measure community health improvement. This illustrates the collaborative nature in which accredited health departments tackle community priorities.

Public Health Employees' Perception of Workplace Environment and Job Satisfaction: The Role of Local Health Departments' Engagement in Accreditation.

OBJECTIVES: To examine the association between local health departments' (LHDs') engagement in accreditation and their staffs' perceptions of workplace environment and the overall satisfaction with their jobs. DESIGN: Data from the 2014 Public Health Workforce Interests and Needs Survey (PH WINS) (local data only) and the 2014 Forces of Change survey were linked using LHDs' unique ID documented by the National Association of County & City Health Officials. The Forces of Change survey assessed LHDs' accreditation status. Local health departments were classified as "formally engaged" in the Public Health Accreditation Board accreditation process if they had achieved accreditation, submitted an application, or submitted a statement of intent. The PH WINS survey measured employees' perception of 3 aspects of workplace environment, including supervisory support, organizational support, and employee engagement. The overall satisfaction was measured using the Job in General Scale (abridged). There are 1884 LHD employees who completed PH WINS and whose agencies responded to the question on the accreditation status of the Forces of Change survey. RESULTS: When compared with employees from LHDs less engaged in accreditation, employees from LHDs that were formally engaged in accreditation gave higher ratings to all 3 aspects of workplace environment and overall job satisfaction. Controlling for employee demographic characteristics and LHD jurisdiction size, the agency's formal engagement in accreditation remained related to a higher score in perceived workplace environment and job satisfaction. After controlling for perceived workplace environment, accreditation status was marginally associated with job satisfaction. CONCLUSION: The findings provide support for previous reports by LHD leaders on the benefits of accreditation related to employee morale and job satisfaction. The results from this study allow us to further catalog the benefits of accreditation in workforce development and identify factors that may moderate the extent of the benefits. Findings from this study show that engagement in public health accreditation is associated with overall job satisfaction. This link may be explained by the hypotheses that meeting accreditation standards could increase staff satisfaction or that having higher job satisfaction could lead to a higher likelihood that a health department would apply for accreditation. Further research to explore this relationship is critical as many health departments are weighing the value of accreditation as they face constrained financial resources.

Evaluating the Impact of National Public Health Department Accreditation - United States, 2016.

In 2011, the nonprofit Public Health Accreditation Board (PHAB) launched the national, voluntary public health accreditation program for state, tribal, local, and territorial public health departments. As of May 2016, 134 health departments have achieved 5-year accreditation through PHAB and 176 more have begun the formal process of pursuing accreditation. In addition, Florida, a centralized state in which the employees of all 67 local health departments are employees of the state, achieved accreditation for the entire integrated local public health department system in the state. PHAB-accredited health departments range in size from a small Indiana health department that serves approximately 17,000 persons to the much larger California Department of Public Health, which serves approximately 38 million persons. Collectively, approximately half the U.S. population, or nearly 167 million persons, is covered by an accredited health department. Forty-two states and the District of Columbia now have at least one nationally accredited health department. In a survey conducted through a contract with a social science research organization during 2013-2016, >90% of health departments that had been accredited for 1 year reported that accreditation has stimulated quality improvement and performance improvement opportunities, increased accountability and transparency, and improved management processes.

National Voluntary Public Health Accreditation: Are More Local Health Departments Intending to Take Part?

OBJECTIVE: This article examines local health department (LHD) participation and intentions to participate in national voluntary accreditation and reasons for not seeking accreditation. Specifically, it compares the results of national surveys among LHDs in 2010, 2013, and 2014. DESIGN: Longitudinal cohort study. SETTING: United States. PARTICIPANTS: LHDs that responded to the 2014 Forces of Change Survey and the 2010 and 2013 National Association of County and City Health Officials Profile studies. MAIN OUTCOME MEASURES: LHD level of engagement in Public Health Accreditation Board (PHAB) accreditation. RESULTS: Data of 2014 indicated that 1% of LHDs achieved accreditation and 11% had submitted an application or a statement of intent, compared with 6% of LHDs that submitted an application or a statement of intent in 2013. The percent of LHDs that indicated they planned to apply for accreditation but had not submitted a statement of intent declined from 27% in 2013 to 22% in 2014. In multivariate models, controlling for governance category and jurisdiction population size, LHDs in states where the state health department (SHD) participated in e-PHAB had higher odds of being favorably inclined toward accreditation than those located in states where the SHD was not in the e-PHAB system (odds ratio = 2.82, 95% confidence interval: 1.81-4.41). Across 2013 and 2014, and across small and large LHDs, the top 2 reasons for deciding not to apply for accreditation were the time/effort required exceeded the benefits (67%) and fees were too high (46%). CONCLUSIONS: SHDs are powerful mediators of LHDs' perceptions of the PHAB accreditation program. Health department governance structure and jurisdiction population size are associated with LHD accreditation participation decisions. With the launch of PHAB's program, fewer LHDs are undecided about accreditation participation and many have taken affirmative steps to become accredited. The top 2 reasons LHDs indicated for not proceeding with accreditation were time/effort exceed benefit and fees perceived as too high.

Marshaling the evidence: the prioritized public health accreditation research agenda.

A national public health department accreditation program was recently developed and implemented by the Public Health Accreditation Board (PHAB) to improve the quality and performance of public health departments. Because of its potential to transform public health, it is critical that the evidence base around accreditation be strong. With input from public health practitioners and researchers, PHAB developed a research agenda that highlights priority questions related to barriers and facilitators to seeking and obtaining accreditation, the PHAB standards and review process, metrics to determine the impact of accreditation, and benefits and outcomes associated with accreditation for the departments that undergo the process. We present that agenda, discuss the potential challenges of conducting accreditation research, and call on researchers to build a greater base of evidence related to accreditation.

Public health accreditation addresses issues facing the public health workforce.

As the Public Health Accreditation Board (PHAB) launched the nation's only accreditation program for state, local, tribal, and territorial health departments in September 2011, attention to the issues facing the public health workforce in these health departments was included. PHAB developed several measures in the accreditation standards and measures related to public health workforce development. The accreditation process calls upon health departments to focus more intentionally on their current workforce, while also supporting the development of future public health workers. Working with a group of public health workforce thought leaders, PHAB developed a long-range plan for the expectation of accredited health departments in workforce development. Beginning with the development of intentional standardization in workforce development and moving into future challenges and issues, PHAB uses its platform of quality improvement to bring emphasis on the current and future public health workforce. This article describes the development of the workforce components of public health department accreditation as well as future plans to ensure that the momentum continues. Using data from the accredited health departments at the time of article submission, PHAB also describes some of the approaches that governmental public health departments that have completed the accreditation process are using to develop their own workforce and support the development of the future public health workforce. Challenges faced by health departments in these areas are also described.

A consensus-based approach to national public health accreditation.

The Public Health Accreditation Board (PHAB) solicited (and continues to solicit) the input of more than 400 subject matter experts in various areas of public health during the development and ongoing revision of the accreditation standards and measures. This process is designed to ensure that the standards and measures remain relevant and accommodate the various contexts under which public health departments practice in the United States. One way PHAB gathers feedback is convening a series of discussion meetings, or think tanks, with thought leaders in specific areas of public health, that focus on specific programmatic areas of public health, on the broader context of public health practice, or on emerging issues, such as public health informatics. The think tanks complement other mechanisms to assure that standards and measures are relevant, including gathering input from the practice community, receiving recommendations from public health departments that have undergone the accreditation process, and reviewing relevant literature. While this process allows PHAB to demonstrate its commitment to continuous quality improvement by modifying and improving the standards and measures, it also serves as a communication vehicle for PHAB to educate thought leaders and public health practitioners about the national accreditation program.