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Final Recommendations for a

VOLUNTARY NATIONALACCREDITATION PROGRAM

State & LocalPublic HealthDepartments

for

SUMMARY DOCUMENTSEPTEMBER 12, 2006

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Patrick M. LibbeyExecutive DirectorNational Association of County and CityHealth Officials

The following individuals serve on the Planning Committee

of the Exploring Accreditation project:

This project was made possible with funding fromthe Centers for Disease Control and Prevention (U50/CCU313903-8-1)

and the Robert Wood Johnson Foundation Grant # 053182.

*This position was held by George E.Hardy, Jr., MD, MPH, former ASTHOExecutive Director, until July 1, 2006.

The time and effort contributed by the Planning Committee has been instrumentalto this process, and their support is greatly appreciated.

Georges Benjamin, MD, FACPExecutive DirectorAmerican Public HealthAssociation

Marie Fallon, MHSAExecutive DirectorNational Association of LocalBoards of Health

Paul E. Jarris, MD, MBA*Executive DirectorAssociation of State and TerritorialHealth Officials

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EXECUTIVE SUMMARY ………………………………………………....................................... 4

INTRODUCTION

Message from the Steering Committee………………………………………………......... 6

How the Model was Developed…………………………………………………………....... 7

MODEL

Governance ……………………………………………………………………………........... 8

Eligible Applicants ……………………………………………………………………............ 9

Principles to Guide Standards Development ……………………………………....……… 10

Conformity Assessment Process ………………………………........………………………. 12

Financing ………………………………………………………………………………........... 13

Incentives ………………………………………………………………………….........…….. 15

Program Evaluation …………………………………………………………………….......... 16

Implementation ……………………………………………………………………….......…. 17

NEXT STEPS ………………………………………………………………………………........….. 17

APPENDICES

A – Steering Committee, Workgroup Members, Project Staff, Consultants,

and Funding Organization Representatives ……................................................... 19

B – Examples of Standards and Measures .………………………………………..........… 24

C – Logic Model …………………………………………………………………….............. 26

D – Glossary ………………………………………………………………………..............… 29

TABLE OF CONTENTS

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EXECUTIVE SUMMARYEvery day in communities and states across the country,public health departments help millions of people leadhealthier lives. The Exploring Accreditation project hasbeen an opportunity to consider whether and how avoluntary national accreditation program could lead toeven better health for their constituencies. The ExploringAccreditation Steering Committee and its workgroupsdeveloped a draft model for such a program. Afterreceiving extensive and thoughtful comments throughpresentations, Web-based feedback, and formal surveys,the Steering Committee revised the model. The SteeringCommittee concluded that it is desirable and feasible tomove forward with establishing the recommendedmodel program as it is presented here.

This voluntary national accreditation program should:

• Promote high performance and continuousquality improvement.

• Recognize high performers that meet nationallyaccepted standards of quality.

• Clarify the public’s expectations of state andlocal health departments.

• Increase the visibility and public awareness ofgovernmental public health, leading to greaterpublic trust, increased health departmentcredibility and accountability, and ultimately astronger constituency for public health fundingand infrastructure.

A full description of the Steering Committee’srecommended model follows this brief summary.

GovernanceA new non-profit organization should be formed by thePlanning Committee organizations to oversee thevoluntary accreditation of state, territorial, tribal andlocal governmental public health departments. ThePlanning Committee should appoint the initial governingboard of the new organization. Under its governingboard, the organization would direct the establishmentof accreditation standards; develop and manage theaccreditation process; and determine whether applicanthealth departments meet accreditation standards. Theorganization would maintain the needed administrativeand fiscal capacity and would evaluate the effectivenessof the program and its impact on health departments’performance. The governing board and the organizationwould advocate for available training and technicalassistance for public health departments seeking to meetthe standards and to develop a culture of continuousquality improvement.

Eligible ApplicantsAny governmental entity with primary legal responsibilityfor public health in a state, territory, tribe, or at the locallevel would be eligible for accreditation. Eligibility toapply for accreditation would be determined in a flexiblemanner, given the variety of jurisdictions andgovernmental organizations responsible for publichealth.

Principles to Guide Standards DevelopmentStandards should be developed to promote the pursuitof excellence among public health departments,continuous quality improvement, and accountability forthe public’s health. The process for establishingstandards should consider performance improvementexperience among state and local public healthdepartments.

The Steering Committee created 11 domains for whichstate, territorial, tribal and local health departmentsshould be held accountable. Standards should beestablished for each domain. Measures of compliancemay differ but standards should be complementary andmutually reinforcing to promote the sharedaccountability of public health departments at all levelsof government.

The goal of a voluntary national

accreditation program is to improve and

protect the health of the public by advancing

the quality and performance of state and

local public health departments.

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ImplementationThe details of implementation will be developed by theleaders who take on the challenge of developing the neworganization. Implementation will be a multi-yearprocess requiring substantial external support in thedevelopment years. Implementation should includerigorous evaluation and process improvements in theaccreditation program to make it more successful andcost-effective.

Conformity Assessment ProcessHealth departments seeking accreditation wouldundergo an assessment process. It should include areview to determine readiness, a self-assessment, and asite visit, resulting in a recommendation on accreditationstatus. The final decision on accreditation would bemade by the governing board. A public healthdepartment would be fully accredited, conditionallyaccredited, or not accredited. An appeals process wouldbe established to resolve disputes.

FinancingThe new organization should seek initial start-up fundingfrom interested grant-makers, government agencies, andorganizations of state and local health departments,some of which may be in-kind support. Subsidies forinitial operations will be required, but this phase shouldbe funded in part by applicant fees and other revenues.It is important to attract the full spectrum of local andstate public health departments to the accreditationprogram. As the new organization approaches self-sufficiency, subsidies should be directed more towardapplicant fees and costs.

IncentivesIncentives should be uniformly positive, supportingpublic health departments in seeking accreditation andachieving high standards. Incentives should support thegoal of improving and protecting the health of thepublic by advancing quality and performance of publichealth departments. Credibility with governing bodiesand the public, as well as access to resources forperformance improvement, should encourageparticipation by health departments.

Program EvaluationEvaluation is critical in every stage of the developmentand implementation of an accreditation program. Theaccrediting entity should encourage research andevaluation to develop the science base for accreditationand systems change in public health.

Evaluation is critical in

every stage of the development

and implementation of an

accreditation program.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

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MESSAGE FROM THE STEERINGCOMMITTEEThe 2003 Institute of Medicine (IOM) report, “TheFuture of the Public’s Health,” called for theestablishment of a national Steering Committee toexamine the benefits of accrediting governmental publichealth departments. Within its Futures Initiative, theCenters for Disease Control and Prevention (CDC) hasidentified accreditation as a key strategy forstrengthening the public health infrastructure. Severalstates currently manage statewide accreditation orrelated initiatives for local health departments. Withinthis context, in 2004, the Robert Wood JohnsonFoundation convened public health stakeholders todetermine whether a voluntary national accreditationprogram for state and local public health departmentsshould be explored further. The consensus was toproceed, and the Exploring Accreditation project waslaunched.

The goal of the Exploring Accreditation project was todevelop recommendations regarding whether it isfeasible and desirable to implement a voluntary nationalaccreditation program or some other method forachieving a systematic approach for public healthimprovement. In order to achieve the goal, we (theSteering Committee) designed a proposed modelprogram and vetted it through public health officials. Wealso considered a business case for the proposed model.In August, we made changes in the proposed model basedon the feedback received and concluded that the revisedmodel is feasible and desirable. We recommend movingforward with implementation.

A full report, which will contain more detail, is underdevelopment and will be released in the Fall of 2006.This document summarizes the model program that werecommend for implementation.

We believe that the establishment of a voluntary nationalaccreditation program is desirable for many reasons.Chief among them is the opportunity to advance thequality, accountability and credibility of governmentalpublic health departments, and to do so in a proactivemanner. At least 18 states are involved in performanceand capacity assessment and improvement efforts,lending excellent experience to the design of a nationalprogram. These experiences illustrate the significant

benefits of engaging in accreditation and related efforts— benefits that the national program is designed toachieve (e.g., quality and performance improvement,consistency among public health departments, andrecognition of excellence). The public comment solicitedfrom public health practitioners in the field indicatedsupport for a voluntary national program. This programwill foster the concept of public health as a system, andpromote consistency and high performance nationwide.It also will strengthen the ability to clarify and articulatewhat public health does, and set reasonable andachievable expectations to this end.

We feel that it is feasible to pursue a voluntary nationalaccreditation program because it is building upon themomentum established by state accreditation andperformance improvement programs. By takingadvantage of knowledge gained from standardsdevelopment, performance measurement methods,technical assistance projects and other operationalcomponents of state-based programs, this program canbe flexible, efficient and nimble. The major factors instarting up the new accreditation body and reachingsustainability include the interest of key funding sourcesin supporting interactive developmental and initialoperational phases. We believe that the potential forfunding a voluntary national accreditation programexists, and we plan to help cultivate that potential. Weunderstand that not all health departments are preparedto become accredited, and this has been factored intothe design of a national program (throughrecommendations to promote the availability of technicalassistance and other support for such healthdepartments). We recognize that a national databasecould facilitate research and enhance the evidence-baseregarding best practices and the utility of accreditationas a performance improvement method. Finally, weacknowledge that long-term success will requiremaintaining the credibility of the accreditation programand continuing interest in the quality of public healthdepartments.

A summary of the substantive changes that were madeto the proposed model include the following:

• Guiding principles for the composition of theGoverning Board have been revised (page 8).

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• Principles for relationships with state-basedaccreditation programs have been expanded,such that national accreditation is automaticallyconferred on health departments accredited bya state-based program that has received formalrecognition/approval from the national program(pages 9-10).

• Territorial and tribal public health departmentsare specifically included in the definition of“eligible applicants” (page 9).

• While applicants are expected to demonstratecompliance with all domains for each programoffered, the conformance assessmentmeasurements will be applied on a samplingbasis (page 12).

Additional clarifications have been made throughout thisdocument in response to questions and commentsreceived. Public comment yielded both support andconcerns about a voluntary national accreditationprogram, and this feedback will inform the program’s

structure and operation in an implementation phase. The details regarding public comment will be describedin the full report.

We thank all public health professionals who took thetime to participate in public comment activities. We alsothank the executive directors of the American PublicHealth Association (APHA), Association of State andTerritorial Health Officials (ASTHO), National Associationof County and City Health Officials (NACCHO), andNational Association of Local Boards of Health(NALBOH), who serve as the Planning Committee andprovided executive oversight to this effort (see insidecover for a full listing). Our recommendations have beensubmitted to the Planning Committee, who in turn willshare them with their organizations to determinepotential action. The Planning Committee also will sharethe recommendations with the Robert Wood JohnsonFoundation and the Centers for Disease Control andPrevention, both of whom funded this effort.

HOW THE MODEL WAS DEVELOPEDIn August 2005, the Planning Committee established a25-member Steering Committee with representativesfrom public health practice organizations at the local,state and federal levels. The guiding philosophy of theSteering Committee was to leave no stone unturned,considering all possible alternatives related to the issuesat hand. Its decisions were informed by the work of fourworkgroups in the areas of Governance andImplementation, Finance and Incentives, Research andEvaluation, and Standards Development.

The workgroups also were comprised of public healthpractitioners from all three levels of government andmembers of academia. Throughout the duration of theproject, the workgroups developed reports that includedconsensus recommendations, other alternatives that wereconsidered, and the rationale for each decision. Subjectmatter experts were also consulted for various issues.Discussion papers with information on accreditation inpublic health and in other sectors were developed tostimulate the workgroups’ discussions.

In April 2006, the Steering Committee met to considerall of the information that was gathered in the previousmonths and develop a proposed model. The proposedmodel was distributed for public comment from Maythrough July 2006. During that time, comments weresolicited through several mechanisms:

• Public presentations and feedback formsdistributed at those events.

• Conference calls.

• E-mail messages and an online survey on theproject Web site.

• A satellite broadcast.

• An opinion survey sent to state, territorial, andlocal health officials.

Extensive feedback was received, and the SteeringCommittee met in August to consider all publiccomment as well as a business case developed by theFinance and Incentives Workgroup. As a result of thefeedback, the model was revised, consensus emergedthat the revised model is feasible and desirable toimplement, and the Steering Committee recommendedthat a voluntary national accreditation program beimplemented accordingly.

See Appendix A (page 19) for a full listing of the Steering Committee, workgroup members,staff, consultants, and funding organization representatives.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

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GOVERNANCEA new, not-for-profit entity should be created to overseethe accreditation of state and local governmental publichealth departments by adopting standards and makingfinal conformance decisions. Having a new, independententity would promote impartiality and avoid real orperceived conflict of interest should the process beconducted by an existing organization. The PlanningCommittee should provide an incorporation process(articles of incorporation, bylaws, governing boardnominations process) that establishes the legitimacy andcredibility of the accrediting entity.

Accrediting EntityThe accrediting entity should:

• Be a recognized legal entity and a tax-exemptorganization under Section 501(c)(3) of theInternal Revenue Code.

• Be separate and independent of the influence ofany single organization.

• Provide relevant accreditation services and avoidactivities that could conflict with accreditationactivity.

• Orient applicants to the application andassessment processes.

• Develop and maintain partnerships.

• Assess conformance.

• Train assessors to assure a consistent and fairprocess.

• Work with partners to ensure the availability oftraining and technical assistance.

• Encourage research and evaluation to improvethe accreditation program.

Governing BoardThis new entity should have a governing board thatwould obtain incorporated status, develop bylaws, andhire staff. The responsibilities of the governing boardshould include, but not be limited to, the following:

• Approving standards.

• Awarding and revoking/suspending status.

• Overseeing the appeals process.

• Ensuring adequate representation of keystakeholder interests.

• Including public representation in all decisionmaking.

• Establishing clear and effective controls againstconflict of interest.

• Ensuring ongoing evaluation and continuousquality improvement of the accreditationprogram.

• Overseeing the development and maintenanceof a national database for performanceimprovement and research purposes.

• Promoting research that would improve theaccreditation program.

• Maintaining the administrative and fiscalcapabilities to successfully operate a nationalaccreditation effort.

• Working actively with partners to promote theirdevelopment of positive incentives.

• Working with partners to advocate for andpromote training and technical assistance andassure that they are accessible and available toapplicants.

The Planning Committee should appoint the GoverningBoard. Membership of the governing board shouldinclude both organizational representatives andindividuals with relevant experience and expertise. Whilespecific slots are not being recommended, the followingprinciples should be applied in determining thecomposition:

• Members with recent experience in state orlocal public health should comprise themajority.

• Members should include those with recentexperience on public health governing boards.

• Diversity of ethnicity, experience, andgeographic location is important.

• Terms and term limits should be specified.

• Members should include academics, state andlocal elected officials, health care providers,representatives from federal agencies, andothers with a public health background.

• One or more public members should beappointed.

• Members should include representatives of thefounding organizations and other key publichealth organizations.

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A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

Relationships with State-Based Accreditation andPerformance Improvement ProgramsThe goal of the voluntary national accreditation programis to establish quality and consistency that is recognizedat federal, state, and local levels. Existing state-basedaccreditation and performance improvement programsare providing a laboratory for a national program andnational standards. It is important that state andnational programs continue to learn from, and maintaingood relationships with, each other.

A national program should complement state-basedefforts to establish performance standards for publichealth departments. This may be accomplished by arecognition/approval process through which stateaccreditation programs could demonstrate conformitywith national accreditation standards and processes.Such a process should not preclude states from havingadditional requirements over and above those in thenational program. If a state accreditation program is notso recognized, it may seek to act as an agent.

Agents/contractorsThe accrediting entity may use agents (such as state-based accreditation programs and public healthinstitutes) to provide training, preparatory services, sitevisits, and other services. The accrediting entity isresponsible for developing policies and proceduresregarding relationships with agents. The agent mustdemonstrate to the satisfaction of the governing boardthat its services are consistent with those of theaccrediting entity. When agents are used, the governingboard still makes the final accreditation determination.

ConfidentialityConfidentiality of information is important to achievingthe quality improvement and continuous performanceimprovement goals of the voluntary nationalaccreditation program. The accrediting entity maypublicize the accreditation status of applicants, butshould hold all background information from the processas confidential except as required by law.

ELIGIBLE APPLICANTSThe governmental entity that has the primary statutoryor legal responsibility for public health in a state, aterritory, a tribe or at the local level is eligible foraccreditation. To be eligible, such entities must operatein a manner consistent with applicable federal, state,territorial, tribal, and local statutes. The determination ofeligibility to apply for accreditation should be flexible,recognizing the variety of jurisdictions with local publichealth departments and the variety of state, territorial,tribal and local governmental agencies that may carrythe primary responsibility for public health.

State and Territorial Health DepartmentThe governmental body recognized in the state’sor territory’s constitution, statutes, orregulations or established by Executive Order,which has primary statutory authority to promoteand protect the public’s health and preventdisease in humans, is eligible to apply. Umbrellaorganizations and collaborations among state orterritorial agencies may apply for accreditation ifthe primary entity is a part of the organization orcollaboration. Where the state or territorialhealth department operates local and/or regionalhealth departments, a single applicant or anumber of individual applicants may choose toapply. Compliance with local-level standards mustbe demonstrated for each local/regional unit.

Local Health DepartmentThe governmental body serving a jurisdiction orgroup of jurisdictions geographically smaller than astate, which is recognized in the state’sconstitution, statute, or regulations or establishedby local ordinance or through formal localcooperative agreement or mutual aid, and whichhas primary statutory authority to promote andprotect the public’s health and prevent disease inhumans, is eligible to apply. The entity may be alocally governed health department, a local entityof a centralized state health department, or aregional or district health department. An entitythat meets this definition may apply jointly withother local-level eligible entities for accreditationstatus if some essential services are provided bysharing resources and the manner in which thisoccurs is clearly demonstrated.

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Tribal Health DepartmentThe governmental health department serving arecognized tribe that has primary statutoryauthority to promote and protect the public’shealth and prevent disease in humans is eligible toapply.

Applications should include an opportunity to describesituations where statutes or other legal mechanismsdelegate authority for governmental public healthfunctions to an agency other than the applicant healthdepartment. The applicant health department shoulddemonstrate collaboration with other agencies withrespect to those functions or, in some instances, mayrequest exemptions from those standards that are beingmet in a different governmental agency. Thedesignation of accreditation should note any exemptionsprovided.

Additionally, the applicant health department mayinclude another entity with statutory authority toperform some public health functions in its application,and the other entity may be accredited or recognizedsolely for the standards that it meets.

The purpose of the voluntary accreditation program is toimprove the quality and performance of public healthdepartments without regard to their structure. Healthdepartments may wish to explore cooperativearrangements to help ensure compliance withaccreditation standards.

PRINCIPLES TO GUIDE STANDARDSDEVELOPMENTA voluntary national accreditation program is a tool toadvance the pursuit of excellence, continuous qualityimprovement, and accountability for the public’s health.Standards should be developed in a way that promotesthese attributes.

Standards should address process, capacity, andindicators of outcomes. As the evidence is established,outcome standards that address improved healthindicators could be added; in the shorter term, outcomesshould address achievements such as establishingprograms and implementing new policy. Standardsshould focus on outcomes that can reasonably beinfluenced by health departments, understanding thatpublic health is inextricably linked to many systems andoccurrences that affect health status.

NACCHO’s Operational Definition of a Functional LocalHealth Department should serve as the foundation ofstandards (and associated measures) for local healthdepartments. ASTHO is undertaking a review of statepublic health services that may inform the standardsdevelopment process for state health departments.Existing performance standards for state and local healthdepartments should also be considered.

National Public Health Performance Standards Program(NPHPSP) model standards and measures could be usedin developing health department standards, recognizingthat NPHPSP standards have been developed to assesssystems, not departments.

State, territorial, and local health departments should beheld accountable to the 11 domains listed on thefollowing page, with standards under each domain thatare specific to their respective responsibilities.Additionally, the standards should be complementaryand mutually reinforcing to promote the sharedaccountability between state/territorial and local healthdepartments. The governing board will determine whichset of standards is applicable to tribal health entities.

One or more standards should be associated with eachdomain and at least one criterion should be used tooperationalize each standard. Measures, or the objectivemeans to determine whether, and the extent to which,

The determination of eligibility

to apply for accreditation

should be flexible, recognizing

the variety of ... agencies that

may carry the primary

responsibility for public health.

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CONFORMITY ASSESSMENT PROCESS

each criterion is met would be established for eachcriterion. Measures allow an observer to characterize thelevel of quality achieved for each criterion.

Collectively, standards and their associated criteria definethe capacity expected of an accredited department.These criteria should be reflected in the day-to-day workof individual health department programs but are notmeant to be illustrated only through programs since thecapacity of a local health department to meet the needsof its community is represented by its ability to addressnew or emerging situations as well as those associatedwith day-to-day operations.

Program specific standards and criteria exist separatelyand are outside the scope of the national voluntaryaccreditation process since programming varies fromstate to state and locality to locality.

Standards should be designed to assure public healthprotection while improving the public’s health. Allapplicant health departments should be held to the samestandards. However, different measurements may beused to recognize the variety of ways in which thestandards are met by health departments with differentcapacities, governance structures, statutory authorities,other quality improvement processes and health status ofthe population served. The program should promotecontinuous quality improvement, and over time, thelevel of acceptable performance should be increased asthe norm of performance rises.

Selected principles espoused by the American NationalStandards Institute should be applied to developing andupdating standards:

• Consensus on a proposed standard by agroup or “consensus body” that includessubject matter experts and representativesfrom materially affected and interestedparties.

• Broad-based public review and commenton draft standards.

• Consideration of and response tocomments submitted by voting members ofthe relevant consensus body and by publicreview commenters.

• Incorporation of approved changes into adraft standard.

Standards should reflect input from all levels ofgovernment. Further, they should be updated andrefined on a regular basis to reflect the best availableevidence.

Standards need to be sensitive to laws governing state,territorial, tribal and local public health entities, andapplicants should be permitted to request a waiver ormodification of an accreditation standard if compliancecould put them at risk of violating state, territorial, tribalor local law.

In order to promote a common agenda and linkagesamong all levels of government, those involved indeveloping and updating standards and measures in avoluntary national accreditation program should workclosely with entities supporting other national goals,standards and measures for public health.

DomainsDomainsDomainsDomainsDomains*

1. Monitor health status and understandhealth issues.

2. Protect people from health problems andhealth hazards.

3. Give people information they need tomake healthy choices.

4. Engage the community to identify andsolve health problems.

5. Develop public health policies and plans.

6. Enforce public health laws and regulations.

7. Help people receive health services.

8. Maintain a competent public healthworkforce.

9. Use continuous quality improvement toolsto evaluate and improve the quality ofprograms and interventions.

10. Contribute to and apply the evidence baseof public health.

11. Govern and manage health departmentresources (including financial and humanresources, facilities, and informationsystems).

* * * * * See Appendix B (page 24) for examples ofSee Appendix B (page 24) for examples ofSee Appendix B (page 24) for examples ofSee Appendix B (page 24) for examples ofSee Appendix B (page 24) for examples of

standarstandarstandarstandarstandards and measurds and measurds and measurds and measurds and measures.es.es.es.es.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

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Careful consideration should be given to how standardsfor health departments can be applied in an efficient,non-duplicative and non-conflicting manner, and thegoverning board should consider ways to use alternativemeasures of meeting standards, e.g., when a standardessentially has been demonstrated to have been metthrough reporting requirements for contracts, or state orfederal grants.

CONFORMITY ASSESSMENT PROCESSThe conformity assessment process should begin withthe health department undertaking training and areadiness review. If the health department determinesthat it is ready, it secures application materials andcompletes a self assessment. The application shouldinclude confirmation that the applicant’s elected official/governing body supports the application. The applicantsubmits its completed self assessment to theaccreditation staff who review it. When it is accepted ascomplete, a site visit is arranged.

Applicants are expected to be in compliance with alldomains for each program offered. Performanceassessment measurement will be applied on a samplingbasis to determine compliance.

A team conducts the site visit, writes a report, and makesa recommendation based on the findings and the selfassessment. There will be an opportunity for theapplicant to address any deficiencies that are noted.The site visit team includes peers without conflicts ofinterest and other subject matter experts/consultants, allof whom meet training and performance requirements ofthe accrediting entity.

The governing board reviews the recommendation andvotes on whether to award accreditation status. As aresult of the assessment, the applicant may be fullyaccredited, conditionally accredited, or not accredited. Ifthe applicant is conditionally accredited, it should begiven a specific length of time to improve performanceas required to achieve full accreditation status.

If an applicant doesn’t agree with a decision made on awaiver request or during the accreditation process (e.g.,it believes it should have a different status or met acertain standard that the reviewers determined they didnot meet or partially meet), it should be able to appealto an appeals board.

The accrediting entity should offer pre-qualifyingpreparation assistance that includes the orientation ofapplicant staff to the accreditation process, provision ofreadiness review and self-assessment tools that aredevelopmental in design and use, and references foravailable consultation on avenues to meeting andexceeding standards.

If the accrediting entity learns about an applicant notmeeting a standard or requirement after the applicanthas been accredited, the accrediting entity should beresponsible for investigating and determining whether ornot the accreditation status should be revoked. Healthdepartments that lose their status should be permitted tore-apply after a period of time.

CONFORMITY ASSESSMENT PROCESS

Readiness Review

SelfAssessment

AccreditationStaff Review

AccreditationTeam Site Visit

RecommendationsReport

FinalDetermination Appeals Process

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FINANCINGFinancing the development and operation of theaccreditation program can be considered in threephases. In the initial development phase, a consortiumof funders interested in promoting public healthimprovement should be sought to fund the start-uporganization itself. In the initial operating phase,funding should be a mix of direct support from fundersfor operations and revenue from services, such asapplicant fees and training fees. Over time, more of thefunding should come from the applicants, assuring acustomer focus in the accreditation program. In fulloperation, the goal is for the accreditation program to beself-sustaining with reasonable fee revenues from theapplication fees and accredited departments. Supportfor applicant fees could still come from other sources.The accreditation program should advocate for andpromote incentives and capacity building in healthdepartments.

Financing the Initial Development and Operationsof the Accreditation ProgramThe goal of the start-up phase should be to maximizethe credibility of the accrediting entity and its cost-effectiveness. It will be important to simplify processeswherever possible to promote efficiency for theapplicants and accrediting entity. The principal start-upactivities should include securing leadership, negotiatingcontracts with vendors and consultants, developing thestandards, creating the assessment process, developinginformation systems, and conducting beta tests or pilotprograms. Other start-up activities, such as marketing toapplicants and potential funding sources, managing anapplication process, recruiting and training site visitors,and managing the assessment process through an initialround can be tailored to the number of applicantsexpected.

The incorporators should finance the initial legal work toestablish the non-profit corporation, provide in-kindservices to refine the business plan, and work with aconsortium of grant-makers, government agencies, andorganizations of state and local health departments tofinance the start-up of the voluntary nationalaccreditation program.

Potential private sector funders include grant-makingorganizations promoting health care qualityimprovement, public health performance improvement,and general government improvement. Within thegovernment sphere, the U.S. Department of Health andHuman Services agencies (Agency for HealthcareResearch and Quality, Food and Drug Administration,and Centers for Medicare and Medicaid Services as wellas CDC and Health Resources and ServicesAdministration) are most important, but theEnvironmental Protection Agency (environmental health,toxicology), the Department of Agriculture (food safetyand WIC), and the Department of Homeland Security(bioterrorism response and emergency managementresponse) should be interested in promoting continuousquality improvement through accreditation. Thefinancing plan should recognize that sponsoringorganizations and health departments could be willing toprovide in-kind contributions and volunteer services.Examples include providing space and equipment,volunteers serving on committees, assisting in therecruitment of funders, and/or assisting in training andpeer review.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

The goal is for theaccreditation program tobe self-sustaining with

reasonable revenues fromthe application fees andaccredited departments.

14 •

Financing the On-going Operations of theAccreditation ProgramOn-going operations costs include those related tomaintaining the standards, training and supervising thesite visit teams, administering and evaluating theprogram, maintaining the supporting informationsystems, and promoting research.

Operations should be funded in part by the applicants,with other funding sources to decrease the burden onthem. Having applicants help pay for the accreditationoperation increases the connection between the costsand the value to the target market. Additionally,applicant fees for a voluntary program build in costcontrol signals for the operation and help keep costcontainment a high priority.

The application fee should be designed to offset theaccrediting entity’s costs. Working with states andfederal agencies, the accrediting entity could supportplans for treating fees as allowable costs or indirect costsin grants and contracts, subsidizing fees of healthdepartments, etc. The accrediting entity also shouldwork with applicant health departments to supportbudget requests for funding accreditation applications byproviding data on the cost-effectiveness and value ofaccreditation.

Other funding sources may include organizations at thenational, state and local level that seek to promoteperformance improvement and continuous qualityimprovement in public health services, and organizationsthat use information about performance and quality indecision-making. The accrediting entity should workwith federal agencies to consider application fees andhealth department accreditation costs (self-assessment,site visit, training, and other direct costs) as allowablecosts in grants, reimbursement fees for services, contractsand cooperative agreements.

Controlling the Cost of the Accreditation ProgramAffordability of fees is critical to success, particularlywhen the value of a voluntary national accreditationprogram is being established. Affordability should bemeasured by the actual fees charged, by the cost of theprocess to the applicant, and by the perceived cost-effectiveness of the operation.

The fees and the costs of becoming accredited should becommensurate with the value of accreditation to theapplicants. The costs of the accreditation program’soperation should be commensurate with the value ofaccreditation to the public’s health and to the sponsoringagencies.

The accrediting entity should design:

• A streamlined accreditation process makingmaximum use of electronic data exchange.

• Standardized formats that can also meet theneeds of funding agencies and other oversightbodies.

• Goal-directed self-assessment and site visitassessment procedures.

• An orientation to the accreditation process forapplicants.

Benchmarks and best practices for completing theapplication and conducting the self-assessment shouldbe made available in the pre-application orientation,providing guidance on cost-effective ways to completethe processes and assisting applicants in controllingcosts. Providing sample policies from high performingagencies, setting guidelines on the maximum length ofdocumentation, and providing for the use of existingdata formats to submit information are other techniquesto control applicant costs.

The accrediting entity should establish its architecture tocontrol costs. Volunteer committees should be used todevelop and maintain the standards, with significantparticipation by accredited state and local public healthdepartments and academics. The standards andbenchmarks used in accreditation should be simple, notcomplex. The accreditation cycle should be reasonablylong, using interim data submissions and targetedfollow-up on improvement plans to assure on-goingattention to transforming public health departments intohigh performing, continuously improving organizations.

In the initial development and operation phases, in-kindcontributions, volunteer services, and contractual servicesshould be highly valued by the accrediting entity, butthere also should be sufficient investment in training andsupporting site review teams to assure standardizedassessments and efficient administration. As the

• 15

program develops and the number of accredited publichealth departments grows, the accrediting entity shouldreassess the balance of volunteer, in-kind, andcontractual services to assure continuing cost-effectiveness.

The accrediting entity should provide services toencourage cost controls in accreditation processes at theapplicant level. It also should work with state and localpublic health departments, designing its assessmentprocesses to streamline the applicant’s work whilemaximizing the value of the self-assessment, datacollection, site visit, and feedback activities. Moreover,the accrediting entity should collect and aggregate dataon the costs of the accreditation process, including coststo applicants. These data should be available toapplicants for benchmarking their costs and identifyingpotential cost controls. Finally, making use of arecognition/approval process through which existingstate-based programs could demonstrate conformity withnational standards is another way to keep costs down.

INCENTIVESWhen surveyed, public health leaders identified qualityand performance improvement, consistency amonghealth departments, and recognition by peers as themost important benefits of accreditation. In thedevelopmental phases of the voluntary nationalaccreditation program, incentives should be uniformlypositive. Incentives should include the following:

High Performance and Quality ImprovementAmong state and local public health departments there isa high value placed on performance improvement andcontinuous quality improvement. A successfulaccreditation program should provide a transformingprocess that supports these goals.

Recognition and Validation of the Public HealthDepartment’s WorkA successful accreditation program should be credibleamong governing bodies and recognized by the generalpublic, providing accountability to the public, fundersand governing bodies (legislatures and governors at thestate/territorial level; tribal governments; and boards ofhealth, county commissions, city councils, and officials atthe local level). The accrediting entity should establish

an information program which promotes the value ofaccreditation to the public and key stakeholders.Accredited public health departments should receiverights to use credentials in promoting their work to theirconstituencies and in seeking access to grants, contracts,and reimbursement preferences. The accrediting entityshould provide documentation, promotional materialsfor customized use, and specialized support to accreditedpublic health departments. In addition, the accreditingentity should maintain an active program promoting thevalue of quality and performance improvement in publichealth and the role of accreditation in encouraging anddocumenting continuous improvement in public healthdepartments.

Access to Resources and Services to Undergo theAccreditation ProcessTo encourage state and local public health departmentsto seek accreditation, the accrediting entity shouldprovide assistance for the application process as detailedunder “Conformity Assessment Process” (page 12). Theaccrediting entity also should work with potential fundersto develop scholarship programs and encourage peer-consulting services for departments needing assistance inspecific domains. There should be no penalty (otherthan expended costs and fees) for terminating theapplication process during the pre-qualification processor before an accreditation decision is reached.

Improved Access to ResourcesThe accrediting entity should partner with public healthorganizations, foundations, and governmental agenciesto promote incentives for accredited public healthdepartments.

These can include:

• Access to funding support for quality andperformance improvement.

• Access to funding to address gaps ininfrastructure identified in the accreditationprocess.

• Opportunities to pilot new programs andprocesses based on proven performance levels.

• Streamlined application processes for grants andprograms.

• Acceptance of accreditation in lieu of additionalaccountability processes.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

16 •

Accreditation also has been shown to enhancerecruitment and retention of a high quality work forcethrough reputation and an enhanced workingenvironment.

Access to Support for Continuous Quality ImprovementThe accrediting entity should maintain active support forcontinuous quality improvement among accreditedpublic health departments. The components of thistransformational practice support program may includein-person and Web-based services, best practicesexchange, peer-group data exchange and analysis, andsimilar resources. Leadership awards may be developedas the accreditation program matures.

PROGRAM EVALUATIONA logic model has been developed to serve as theframework for evaluation of a voluntary nationalaccreditation program (see Appendix C, page 26).Evaluation of the program should be highly emphasizedthroughout the process of planning, development andimplementation. The associated costs need to befactored into the program’s budget.

Furthermore, the accrediting entity should determinefrom the outset and in a transparent way whichevaluation results will be kept confidential and which willbe shared publicly or made available to researchers andothers. The evaluation plans should be flexible enoughto be implemented by many different organizations(i.e., the national accreditation program doesn’t have themonopoly on data or evaluation). In addition, qualitydata collection is critical, and data should be collected ina standardized way that allows it to be integrated withdata from other systems.

Aspects of the program to evaluate include thosedescribed as follows.

Effectiveness of the Accrediting Entity

• Is the accrediting entity appropriately staffedand are staff members performing well?

• Does the accrediting entity use results ofevaluation to improve the accreditationprogram?

• Is the financial performance meeting the goalsset by the governing board?

Accreditation Process

• How much staff time (from both applicant andaccrediting entity) is required to complete theaccreditation process?

• Are the required activities for each step of theaccreditation process clear andunderstandable to all participants?

• How useful are the various types of trainingand technical assistance?

Marketing and Customer Satisfaction

• How many agencies are participating in theaccreditation process and what are theircharacteristics?

• How satisfied are participating agencies withthe accreditation program?

Accreditation Standards and Measures

• Are the standards appropriate? Do they needto be changed?

• Are the standards and measures reliable andvalid?

Improved Performance of Accredited Agencies

• What improvements in agency performancehave resulted from participation in theaccreditation program?

Contribution to Evidence Base

• Is the accreditation process capturing data tosupport key research questions?

• Does the accreditation program have policiesand processes in place to support the use ofaccreditation data by researchers?

Credibility of Accreditation Program

• Is the accreditation program perceived ascredible by potential applicants and decisionmakers?

• 17

IMPLEMENTATIONThe Steering Committee has developed a recommendedmodel to serve as a framework around which a voluntarynational accreditation program could be built. Thedetails of implementing this program have beenintentionally left to the leaders who take on thechallenge of developing the accrediting entity.Implementation would be a multi-year process, and itwould be important to maintain momentum aroundperformance improvement activities during that time.

Implementation activities would include:

• Establishing a governing board.

• Developing a detailed business plan.

• Setting up an organization and engaging in thestart-up activities.

• Getting “agreed upon” standards in place.

• Undertaking beta testing or pilot testing todevelop the processes.

• Phasing-in accreditation activities in an orderlyfashion.

This multi-year process will allow adjustment of thevoluntary national accreditation program to make itmore successful in promoting public health performanceand improved community health outcomes, and toincrease the cost-effectiveness of the operation.

The details of implementing this

program have been intentionally

left to the leaders who take on the

challenge of developing the

accrediting entity.

A VOLUNTARY NATIONAL ACCREDITATION PROGRAM FORSTATE AND LOCAL PUBLIC HEALTH DEPARTMENTS

18 •

NEXT STEPSThe Planning Committee has received theserecommendations, and will share them with theirorganizations for potential action. The PlanningCommittee will also share these recommendations withthe Robert Wood Johnson Foundation and the Centersfor Disease Control and Prevention, both of whomfunded this effort. In addition, these recommendationsare available to members of all participatingorganizations.

A full report is under development and will be released inthe Fall. The full report will include a detailedmethodology, a description of the business case, aresearch agenda to further support the success of avoluntary national accreditation program as a tool toimprove public health, and a full summary of the publiccomment. The full report will be posted on the projectwebsite, and members of the organizations representedon the Steering Committee will be notified when itbecomes available.

Preliminary outreach efforts have indicated some interestand support from county commissioners, mayors, statelegislators and governors’ health policy advisors. Anothernext step will be to continue to work to engage thesegroups in the establishment of a voluntary nationalaccreditation program.

• 19

APPENDIX A

STEERING COMMITTEE, WORKGROUP MEMBERS,PROJECT STAFF, CONSULTANTS, AND

FUNDING ORGANIZATION REPRESENTATIVES

20 •

ChairKaye Bender, RN, PhD, FAANDean, School of NursingUniversity of Mississippi MedicalCenter

Stephanie B. C. Bailey, MD, MSHSADirector of HealthMetro Nashville/Davidson County(TN)NACCHO

Deanna BaumanArea Manager Oneida (WI)Community Health CenterNIHB

Les Beitsch, MD, JDDirector, Center for Medicine/Public HealthFlorida State UniversityPHF

Gordon Belcourt, MPHExecutive DirectorMontana-Wyoming Tribal LeadersCouncilIHS

Eric Blank, DrPHDirector, State Public HealthLaboratoryMissouri Dept. of Health andSenior ServicesAt-Large

Joan Brewster, MPADirector, Public Health SystemsPlanning, Washington StateDepartment of HealthAt-Large

Shepard CohenHealth Care Consultant/PrincipalExcellence in Graduate MedicalEducationNALBOH

Harold Cox, MSWChief Public Health OfficerCambridge (MA) Health DepartmentNACCHO

Leah Devlin, DDS, MPHState Health DirectorNorth Carolina Dept. of Health andHuman ServicesASTHO

Colleen Hughes, RN, PhDExecutive DirectorMountain Health Connections, Inc.(NV)APHA

Laura Landrum, MUPPSpecial Projects DirectorIllinois Public Health InstituteNNPHI

Cassie Lauver, LMSW, ACSWDirectorDivision of State and CommunityHealthHRSA

Dennis Lenaway, PhD, MPH*Director, Office of Standards andEmerging Issues in PracticeOffice of Chief of Public HealthPractice, Centers for Disease Controland PreventionEx-Officio

Janet Olszewski, MSWDirectorMichigan Department ofCommunity HealthASTHO

Jan MalcolmChief Executive OfficerCourage Center (MN)At-Large

EXPLORING ACCREDITATIONSTEERING COMMITTEE MEMBERS

Patti Pavey, MSPrincipal ConsultantHealth Teknique (UT)NALBOH

Bobby Pestronk, MPHHealth OfficerGenesee County (MI) HealthDepartmentNACCHO

Bruce Pomer, MPAExecutive DirectorHealth Officers Association ofCaliforniaNACCHO

Sandra Shewry, MPH, MSWDirectorCalifornia Department of HealthServicesASTHO

Rachel Stevens, EdD, RNSenior AdvisorNorth Carolina Institute forPublic HealthNALBOH

Robert Stroube, MD, MPHCommissionerVirginia Department of HealthAPHA

Lee Thielen, MPAPublic Health ConsultantThielen Consulting (CO)PHLS

Kathy Vincent, LCSWStaff Assistant to theState Health OfficerAlabama Department ofPublic HealthASTHO

Harvey Wallace, PhDProfessor and Department HeadNorthern Michigan UniversityNALBOH

*This position was initially held by Ed Thompson, MD, MPH,former Chief of Public Health Practice.

• 21

EXPLORING ACCREDITATIONGOVERNANCE AND IMPLEMENTATION WORKGROUP MEMBERSChair

Rachel Stevens, EdD, RNSenior AdvisorNorth Carolina Institute for PublicHealth

Susan Allan, MD, JD, MPHDirectorOregon Department of HealthServices

Scott J. Becker, MSExecutive DirectorAssociation of Public HealthLaboratories

Bobbie Berkowitz, PhD, CNAA, FAANProfessorPsychosocial & Community HealthUniversity of Washington

Claude Earl Fox, MD, MPHResearch ProfessorMiller School of MedicineUniversity of Miami

Paul Halverson, DrPH, MHSA, FACHEDirectorArkansas Department of Health

James G. Hodge, Jr., JD, LLMAssociate Professor, Johns HopkinsBloomberg School of Public HealthExecutive Director, Center for Lawand the Public’s Health

Jerry King, MAExecutive DirectorIndiana Public Health Institute

Jeffrey R. Taylor, PhDExecutive DirectorMichigan Public Health Institute

Mary Wellik, MPHPublic Health DirectorOlmsted County (MN) PublicHealth Services

Chair

Stephanie B. C. Bailey, MD, MSHSADirector of HealthMetro Nashville/Davidson County(TN) Health Department

Bruce Bragg, MPHDirectorIngham County (MI) HealthDepartment

Liza Corso, MPATeam LeaderOffice of the Chief of Public HealthPractice, Office of the DirectorCenters for Disease Control andPrevention

EXPLORING ACCREDITATIONSTANDARDS DEVELOPMENT WORKGROUP MEMBERS

Ann Drum, DDS, MPHDirector, Division of Research,Training and EducationHealth Resources and ServicesAdministration

Greg Franklin, MHADeputy Director, Health Informationand Strategic Planning DivisionCalifornia Department of HealthServices

Kathy Mason, RN, EdDDean, School of NursingFlorida State University

Glen Mays, PhD, MPHVice Chair and Associate ProfessorUniversity of Arkansas for MedicalSciences

Jim Pearsol, MEdAssistant DirectorOhio Department of Health

Joy Reed, EdD, RNHead, Public Health Nursing &Professional Development UnitNorth Carolina Department ofHealth and Human Services

Torney Smith, MSAdministratorSpokane (WA) Regional HealthDistrict

Joan Valas, NP, PhD candidateSenior Public Health SpecialistColumbia University School OfNursing

22 •

Chair

Bruce Pomer, MPAExecutive DirectorHealth Officers Association ofCalifornia

Mark Bertler, CAEExecutive DirectorMichigan Association for LocalPublic Health

Ron Bialek, MPPPresidentPublic Health Foundation

EXPLORING ACCREDITATIONFINANCE AND INCENTIVES WORKGROUP MEMBERS

Ed Davidson, MPAPublic Health Administrative OfficerAlabama Department of PublicHealth

Mike Fleenor, MD, MPHHealth OfficerJefferson County (AL) HealthDepartment

Jeffrey Lake, MSDeputy CommissionerVirginia Department of Health

Dennis D. Lenaway, PhD, MPHDirector, Office of Standards andEmerging Issues in PracticeOffice of Chief of Public HealthPractice, Centers for Disease Controland Prevention William Mitchell, MPHDirectorPublic Health ServicesSan Joaquin County (CA)

Gerald R. Solomon, JDPresident and CEOPHFE Management Solutionsaka Public Health FoundationEnterprises, Inc.

EXPLORING ACCREDITATIONRESEARCH & EVALUATION WORKGROUP MEMBERS

ChairLes Beitsch, MD, JDDirector, Center for Medicine/Public HealthFlorida State University

Stacy Baker, MSEdDirector, Performance ImprovementPublic Health Foundation

Joan Brewster, MPADirector, Public HealthSystems PlanningWashington State Departmentof Health

Kristine M. Gebbie, DrPH, RNElizabeth Standish Gill AssociateProfessorDirector, Center for Health PolicyColumbia University

Karen Hacker, MD, MPHExecutive DirectorInstitute for Community Health

Mary Kushion. MSAHealth OfficerCentral Michigan District Health Department

Charlie Mahan, MDProfessorUniversity of South Florida

F. Douglas Scutchfield, MDPeter P. Bosomworth Professorof Health Services Researchand PolicyUniversity of KentuckyMedical Center

Susan R. Snyder, PhD, MBAEconomistLaboratory Practice Evaluation &Genomics BranchDiv. of Public Health Partnerships/National Center Health MarketingCenters for Disease Controland Prevention

Beverly Tremain, PhD, CHESEvaluation ConsultantMissouri Institute forCommunity Health

Bernard J. Turnock, MD, MPHClinical ProfessorDirector, Center for Public HealthPracticeUniversity of Illinois, Chicago

• 23

ASSOCIATION OF STATE ANDTERRITORIAL HEALTH OFFICIALS(ASTHO)

Jacalyn Carden, RN, MS, CAEAssociate Executive DirectorPolicy and Programs

Sterling Elliott, MPHAnalystPublic Health Systems

Jennifer Jimenez, MPHSenior AnalystPublic Health Systems

Patricia A. Nolan, MD, MPHASTHO Consultant

Adam ReichardtSenior AnalystPublic Health PerformanceImprovement

Mary Shaffran, MPAPrincipal DirectorPublic Health Systems

EXPLORING ACCREDITATIONCONSULTANTS AND STAFF

NATIONAL ASSOCIATION OFCOUNTY & CITY HEALTHOFFICIALS (NACCHO)

Priscilla Barnes, MPH, CHESProgram ManagerPublic Health Infrastructure andSystem Team

Carol Brown, MSSenior AdvisorPublic Health Infrastructure andSystem Team

Grace Gorenflo, RN, MPHSenior AdvisorPublic Health Infrastructure andSystem Team

Carolyn Leep, MPHProgram ManagerPublic Health Infrastructure andSystem Team

Jocelyn RonaldProgram AssistantPublic Health Infrastructure andSystem Team

Jessica Solomon, MCPProgram ManagerPublic Health Infrastructure andSystem Team

CONSULTANTS

Chuck AlexanderBurness Communications

Francie de PeysterBurness Communications

Michael HammMichael Hamm & Associates

Shelley KesslerTCC Group

Jared RaynorTCC Group

EXPLORING ACCREDITATIONFUNDING ORGANIZATION REPRESENTATIVES

CENTERS FOR DISEASE CONTROLAND PREVENTION

Liza Corso, MPATeam LeaderOffice of the Chief of Public HealthPractice, Office of the Director

Dennis Lenaway, PhD, MPHDirector, Office of Standards andEmerging Issues in PracticeOffice of Chief of PublicHealth Practice

THE ROBERT WOOD JOHNSONFOUNDATION

Russell Brewer, DrPH, CHESProgram AssociatePublic Health Team Carol Chang, MPA, MPHProgram OfficerPublic Health Team/Researchand Evaluation

Pamela Russo, MD, MPHSenior Program OfficerPublic Health Team Leader

Anthony D. Moulton, PhDActing ChiefOffice of Chief of PublicHealth Practice

24 •

APPENDIX B

EXAMPLES OF STANDARDS AND MEASURES

• 25

2. Maintain a competent public health workforce

STATE LOCAL

Standard

Measure

Identify the public health workforce (the workforceproviding population-based and personal healthcare services in public and private settings acrossthe state) needs of the state and implementrecruitment and retention policies to fill thoseneeds.

Recruit, train, develop, and retain a diverse staff.

Personnel in regulated professions are assessed toassure that they meet prescribed competenciesincluding certifications, licenses, and educationrequired by law or recommended by local, state, orfederal policy guidelines.

Workplace policies promoting diversity and culturalcompetence, describing methods for compensationdecisions, and establishing personnel rules andrecruitment and retention of qualified and diversestaff are in place and available to staff.

The following standards and measures are meant toprovide examples of what might be used in a voluntarynational accreditation program. These examples arebased on NACCHO’s Operational Definition, the NationalPublic Health Performance Standards Program StateInstrument, and the Washington State Public HealthImprovement Plan.

These examples have not been approvedby the Exploring Accreditation SteeringCommittee, and feedback is not beingsought at this time.

STATE LOCAL

Standard

Measure

1. Protect people from health problems and health hazards

STATE LOCAL

Standard

Measure

Collaborate with public and private laboratories,which have the ability to analyze clinical andenvironmental specimens in the event of suspectedexposures and disease outbreaks.

Maintain access to laboratory expertise andcapacity to help monitor community healthstatus and diagnose and investigate publichealth problems and hazards.

Written procedures describe how expanded labcapacity is made readily available when needed foroutbreak response, and there is a current list oflabs having the capacity to analyze specimens.

Has current list of available labs and currentwritten protocols and/or guidelines forhandling clinical and environmentallaboratory samples.

3. Evaluate and improve programs and interventions

Evaluate the effectiveness and quality of allprograms and activities and use the informationto improve performance and health outcomes.

Evaluate the effectiveness and quality of allprograms and activities and use the informationto improve performance and health outcomes.

There is a planned, systematic process in which allprograms and activities, whether provided directlyor contracted, have written goals, objectives, andperformance measures. Program performancemeasures are tracked, the data are analyzed andused to change and improve program activitiesand services and/or revise curricula/materials.

There is a planned, systematic process in which allprograms and activities, whether provided directlyor contracted, have written goals, objectives, andperformance measures. Program performancemeasures are tracked, the data are analyzed andused to change and improve program activitiesand services and/or revise curricula/materials.

26 •

APPENDIX C

LOGIC MODEL

• 27• 27

• 29

APPENDIX D

GLOSSARY

30 •

GLOSSARY

Accreditation – (1) the development of a set ofstandards, a process to measure health departmentperformance against those standards, and some form ofreward or recognition for those agencies meeting thestandards. (2) the periodic issuance of credentials orendorsements to organizations that meet a specified setof performance standards. (3) A voluntary conformityassessment process where an organization or agencyuses experts in a particular field of interest or disciplineto define standards of acceptable operation/performancefor organizations and measure compliance with them.This recognition is time-limited and usually granted bynongovernmental organizations.

1 – EA project definition2 – Lee Thielen

3 – Michael Hamm

Accountability – the principle that individuals,organizations and the community are responsible fortheir actions and may be required to explain them toothers.

Benchmark – a standard established for anticipatedresults, often reflecting an aim to improve over currentlevels.

Beta testing (pilot testing) – allowing organizations touse a new product before it is officially launched.

Capacity – resources and relationships necessary to carryout the core functions and essential services of publichealth; these include human resources, informationresources, fiscal and physical resources, and appropriaterelationships among the system components.

– Bernard Turnock, Public Health:What It Is and How It Works

Conformity assessment – the determination of whethera product, process, or service conforms to particularstandards or specifications. Activities associated withconformity assessment may include testing, certification,accreditation, and quality assurance system regulation.

– Michael Hamm

Conditional accreditation – a rating that anorganization receives when a number of standards werescored ‘not compliant’ at the time of the onsite survey.

– Joint Commission on Accreditation ofHealthcare Organizations (JCAHO)

Continuous quality improvement – an ongoing effortto increase an agency’s approach to manageperformance, motivate improvement, and capturelessons learned in areas that may or may not bemeasured as part of accreditation. – Public Health Foundation (PHF)

Core standards – the fundamental activities or group ofactivities, so critical to an organization’s success thatfailure to perform them in an exemplary manner willresult in deterioration of the organization’s mission.

Customer – the person or group that establishes therequirement of a process and receives or uses theoutputs of that process, or the person or entity directlyserved by the organization.

– Serving the American Public: Best Practicesin Performance Measurement

Domain – a broad area having some commoncharacteristics and for which criteria and standards arespecified for assessing performance in that domain.

–Michael Hamm

Evaluation - Systematic approach to determine whetherstated objectives are being met.

-Brownson, RC, Baker EA, and Novick, LF. Community-based Prevention: Programs That Work. Gaithersburg,

MD: Aspen Publishers, Inc. 1999

Impact – the total, direct and indirect, effects of aprogram, service or institution on a health status andoverall health and socio-economic development.

Measure – a statement of quantification/qualification/action to reach a desired condition/state of affairs; themeans of determining compliance with a standard.

Example: The number of trained epidemiologistsavailable to investigate outbreaks (capacity measure).

Example: The percentage of notifiable diseases reportssubmitted within the required time lines (processmeasure).

Example: Percentage of disease outbreaks that arecontrolled and contained before deaths or disablingconditions occur (outcome measure).

• 31

Outcome – (1) the desired result of a service or program;(2) indicator of health status, risk reduction, and quality-of-life enhancement. For the purposes of the ExploringAccreditation project, short-term outcomes are definedas results that are achieved in 1 year; results ofintermediate outcomes are achieved between 2-5 years;and results of long-term outcomes are achieved between5-10 years.

– (2) Bernard Turnock, Public Health:What It Is and How It Works

Performance standard – a generally accepted, objectiveform of measurement that serves as a rule or guidelineagainst which an organization’s level of performance canbe compared.

– Guidebook for Performance MeasuresTurning Point Program

Performance improvement/Quality improvement – Systematic processes ofdesigning and developing cost-effective and ethically-justifiable methods to address performance gaps orimprove products; implementing processes, procedures,and/or interventions in order to obtain better results;and/or evaluate financial and non-financial findings inorder to improve efficiency in obtaining results. Qualityimprovement contains the element of “doing the rightthing” while performance improvement is focused ondoing what we are doing “better.”

– From Silos to Systems Turning Point Program

Research - A systematic investigation, including researchdevelopment, testing, and evaluation, designed todevelop or contribute to generalized knowledge.

-United States Department of Health and HumanServices. Healthy People 2010. Washington, DC: US

Department of Health and Human Services, 2000

Standard – a desired condition/state of affairs, and mustbe actionable, attainable, and measurable.

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