# Presentation: 280170

## A Proposed Model for a VOLUNTARY NATIONAL ACCREDITATION PROGRAM for State and Local Public Health Departments

***Exploring Accreditation ***
***Steering Committee Members: ***
***Georges Benjamin – APHA***
***Janet Olszewski – ASTHO ***
***Bobby Pestronk – NACCHO***
***Harvey Wallace – NALBOH***
***Les Beitsch – Public Health Foundation***
***July 19-20***
***Centers for Disease Control and Prevention***

**Notes:**
Introduce yourself

Comment on the reasons for your involvement in the project

## Today’s Objectives

- Briefly describe the process that led to this proposed model
- Outline the major elements of the proposed model
- Obtain feedback from you on the proposed model and its feasibility

**Notes:**
In August 2005, the Exploring Accreditation was launched.

The work has addressed how a national accreditation program should be governed, how standards and measures should be developed, and how it could be financed.  It has also addressed the evaluation and research needs surrounding accreditation and evidence-based public health.

In presenting this model today, we are seeking your input:
Is this model feasible and desirable to implement?
Is there anything missing from this proposed model that is essential to its success?

What else should the Steering Committee consider in making its final recommendations? 

## Project Goal

**	**Design a model voluntary national accreditation program for state and local (governmental) public health departments and determine whether it is feasible and desirable to implement

**Notes:**
Share the goal of the project with the audience.  

Comment on seeking their input in determining feasibility and desirability.

## A Rising Tide...

**CDC’s Futures Initiative**
**“****Future of the Public’s Health in the 21st Century” (IOM)**
**RWJF Key Stakeholder Meeting 2004****	**
**Statewide Accreditation Programs**
**Multi-state Learning Collaborative**

**Notes:**
In 2003, the CDC identified accreditation as a key strategy for strengthening the public health infrastructure.

The 2003 Institute of Medicine (IOM) report, “The Future of the Public’s Health,” called for examination the benefits of accreditation of governmental public health departments.  

In 2004, the Robert Wood Johnson Foundation convened stakeholders in response to the IOM report to determine whether a national accreditation system for state and local health departments should be explored further, and the consensus was to proceed.

Several states currently manage statewide accreditation or related initiatives for local health departments. 

In 2005, the Robert Wood Johnson Foundation funded the Multi-state Learning Collaborative among these states.  All of these efforts have help informed the Steering Committee as they developed the model we are presenting today.  

Begun in 2005, Exploring Accreditation received funded from the CDC and the Robert Wood Johnson Foundation. 

## Key Players

**Notes:**
Planning Committee provides executive oversight and appointed the Steering Committee.  The members are the executive directors of APHA, ASTHO, NACCHO, NALBOH.

Steering Committee consists of people representing  public health practice at all three levels of government and academia.  The philosophy of the SC is to “Leave no stone unturned.”

Work groups also consists of people representing public health practice at all three levels of government AND academia.  The four workgroups are Governance and Implementation, Standards Development, Finance and Incentives, Research and Evaluation.  Workgroups were responsible for developing recommendations and rationales/justifications for all decisions made. 

Consultants who were knowledgeable about accreditation from other disciplines and MLC states were used to share their experience with accreditation in other disciplines; MLC states shared their experiences with the SC; Glen Mays and Lee Thielen papers prepared for the RWJF 12/2004 meeting also served as a valuable resource.

Refer people to the Model, Appendix A for a complete listing of members, where they are from, and the position they hold who were involved in this process. 

## A Proposed Model for a Voluntary National Accreditation Program for State and Local Health Departments

***A Proposed Model for a Voluntary National Accreditation Program for State and Local Health Departments***

**Notes:**
This presentation will emphasize the key components of the proposed model.  This “wheel” is a summary of these elements.

So, let’s now look at the proposed model for a Voluntary National Accreditation Program for State and Local Public Health Departments and the Steering Committee’s recommendations under that model. 

We begin by defining the goal of a voluntary national accreditation program, and that is to improve and protect the health of the public by advancing the quality and performance of state and local public health departments.

In trying to graphically capture the essence of the model, we pose four questions:
Why accreditation now? 
What is the value of the program?
How would the program run?
And who pays for the program’s operation?

Over the course of the next few minutes we will discuss the important questions of how the program might operate and how it might be financed.  

## Why accreditation now?

***Why accreditation now?***

**Notes:**
There is wide recognition that public health agencies can improve performance and outcomes with the right tools and resources.

Demonstrating accountability is essential to gaining and maintaining essential resources.

Polls and studies show that the public supports public health, but doesn’t know what it really is.

To meet current public health challenges efficiently and effectively, we need to increase the consistency of public health services nationwide.

We need to continue building the evidence base for high quality public health services and the role that standards and accreditation play in achieving them.

## What is the value of the program?

**Notes:**
As the Steering Committee discussed why such a program should be consider, they also recognized that there are a number of values of such a program.

Refer to slide.

## How would the 

***program run?***

**Notes:**
There are essentially four components of the model that describe how it will be run.

## Accrediting Entity

**New non-profit organization **
**- Manage the accreditation process**
**- Evaluate effectiveness and impact **
**- Provide orientation to the accreditation process**
**- Advocate for technical assistance**
**- Relate to existing state programs**

**Notes:**
The first component of the proposed model examines how the accrediting entity would be governed. 

Key elements addressed in the proposed model related to the governance structure include establishment of a non-profit entity, relationships with state-based accreditation and performance improvement programs, representation of governing body, and eligible applicants.

A new non-profit organization should be established and needs to be new in order to avoid conflict of interest within any existing programs.

The entity would provide training to applicants on the accreditation process.  It also would advocate (not provide) for the availability of technical assistance for health departments seeking to meet the standards. 

The SC also recommends that the national program relates to existing programs.  States may choose to align their accreditation programs with the core standards in the national program.  In addition, state-based programs may or may not choose to be vendors.  The accrediting entity would also have a mechanism to solicit feedback regarding how well the relationships with state-based programs are working. 

## 	“A voluntary national accreditation program “should reinforce rather than replace efforts that establish performance standards for [health departments], promote rather than pre-empt widespread use of tools like NPHPSP and MAPP for self-assessment and improvement, and ultimately unify rather than unlink organizational performance and human resource management activities within public health [departments].”

**Bernard J. Turnock**
***Journal of Public Health Management and Practice***
**May-June 2006**

**Notes:**
Professor Turnock at the University of Illinois at Chicago’s School of Public Health, has captured the delicate balance of establishing a national accreditation program at this time. 

The Steering Committee recognizes that a number of states are using various tools and methods to address performance improvement.  

A national program should reinforce rather than replace state-based efforts to establish performance standards for health departments.  

Consistency is the intent of the program, not control.  

The Steering Committee developed the principles of governance, standards development, and operations in this model with this balance firmly in mind. 

## Governing Body

**	****18 members selected for expertise and to represent key stakeholders**
**Establishes accreditation standards**
**Determines if departments meet standards**
**Manages vendors**

**Notes:**
The proposed composition of the governing body includes both members representing local, state and federal agencies and members with expertise in various aspects of public health.  Basically, there would be 5 local officials, 4 state officials, 2 federal officials, and 7 other members.

The governing board establishes the organization and volunteer structures needed, approves the standards and makes final determinations about whether health departments meet them

Vendors may be used to do performance assessments, but not to make final determinations.  Vendors may be those entities that currently are doing performance assessments in various states (e.g., public health institutes) to go through the process of accreditation (conformity assessment process).  The vendor does not make the final decision if the health department is accredited.

## Eligible Accreditation Applicants

**	****Governmental state or local entities with legal responsibility for public health**

**Notes:**
Any governmental entity with primary legal responsibility for public health in a state or at the local level would be eligible for accreditation.

Eligibility to apply for accreditation should be determined in a flexible manner, given the variety of jurisdictions and governmental organizations responsible for public health, and given the variety in how public health responsibilities are statutorily delegated

## Standards Development

- 	Promote pursuit of excellence, improve performance, and strengthen accountability
-  Consider existing and developing performance improvement work
-  Create specific standards around 11 domains based on essential services

**Notes:**
The second component describes the development of standards of a national program.

The charge of the Steering Committee was to create principles that guide standards development, but not the standards itself.  In developing these guiding principles, the Steering Committee realized that there is a built-in tension regarding how standards might be developed.  It was agreed that the bar should be set at a level that assures public health protection – above the minimum – AND the program needs to encourage quality improvement, regardless of where a health department is performing.

This is not a regulatory program. Standards would be designed to promote quality improvement. Standards would be based on existing work, specifically citing NACCHO’s Operational Definition, the National Public Health Performance Standards Program, and standards already in use in statewide accreditation or related efforts.  

The Steering Committee also identified 11 domains for which both state and local health departments should be held accountable based on 10 essential services, plus one for governance and management.  Standards that are specific to state and local responsibilities should be established under each domain. 

## Who pays for the 

***Who pays for the ***
***program’s operation?***

**Notes:**
Financing and incentives was the third element examined by the Steering Committee.  

This slide illustrates key stakeholders who are needed to support a national program from a monetary sense.  

Refer to contents on the slide.

## Financing

**Start-Up**
- Grant-makers
- Government agencies
- Health department associations
**Operations**
- Applicant fees
- Other sources

**Controlling Costs**
- Phased development
- Efficient process design
- Prudent use of resources
- Providing benchmarks to applicants
- Building volunteer support

**Notes:**
Specifically, a national program must take into account start-up and operational fees as well as strategies to control costs.

The goal of the start-up phase should maximize the credibility of the accrediting entity.  It is important to make the program affordable to attract the full spectrum of local and state public health departments to the accreditation system. Principal start up activities are described on page 13.  The governing body should seek initial start-up funding from interested grant-makers, government agencies, and organizations of state and local health departments.

On-going operations should be funded in part by applicant fees, with other funding sources to decrease the burden on them (e.g., state and local organizations that promote performance improvement and continuous quality improvement in public health services, and organizations that use information about performance quality in decision-making).

Attention to cost control within the accrediting entity establishes the prudence of the accrediting entity and supports the concept of accountability for outcomes.

Furthermore, attention to the costs of applicants and the public health system supports a cost-effective approach to preparation and to performance improvement.  These are some of the opportunities for prudent cost control.

## Incentives

-  Orientation of the applicant staff to the process
-  Readiness review and self-assessment tools
-  Sources for consultation on ways to meet and exceed standards
-  Recognition of their accomplishments
-  Access to funding support for quality and performance improvement and infrastructure needs identified in the accreditation process
-  Opportunities to pilot new programs and processes based on proven performance levels
-  Streamlined application processes for grants and programs

**Notes:**
During the development phase of the voluntary program, incentives for the foreseeable future should be uniformly positive. Inclusive rather than exclusive preferences for access to resources should be the norm.

Health departments should receive recognition and validation of their work, and in the process demonstrate their accountability.  The accrediting entity should provide promotional materials for customized use and also actively promote the value of quality and performance improvement in accredited health departments.

Incentives should support the goal of improving and protecting the health of the public by advancing the quality and performance of public health departments and demonstrate accountability.

The accrediting entity should provide resources such as orientation of the applicant staff to the process, readiness review and self-assessment tools, and references for consultation on avenues to meet and exceed standards.

These might include:
Access to funding support for quality and performance improvement and infrastructure needs identified in the accreditation process
Opportunities to pilot new programs and processes based on proven performance levels
Streamlined application processes for grants and programs
Acceptance of accreditation in lieu of additional accountability processes

## Program Evaluation

- Is the accrediting entity operating effectively?
- Is the accreditation process reasonable?
- Is the orientation for applicant staff effective?
- Who is participating and are they satisfied?
- Are standards and measures reliable and valid?
- What performance improvements have resulted?
- Is the program perceived as credible by applicants and  decision-makers?

**Notes:**
The fourth component includes the evaluation of the voluntary national accreditation program emphasizing planning, development, and implementation processes, and needs to be funded accordingly. 

A logic model serves as a framework for program evaluation and for a research agenda by specifying the expected relationships  between the activities of the accreditation program and its desired outcomes.  

Accrediting entity should determine for the outset of the program which evaluation results will be kept confidential and which will be shared with the public (I.e. researchers, different organizations)

Key questions that are a part of the program evaluation of a national program:
Is the accrediting entity operating effectively?
Is the accreditation process reasonable?  
Is the orientation for applicant staff effective
Who is participating and are they satisfied?
Are standards and measures reliable and valid?
What performance improvements have resulted?
Is the program perceived as credible by applicants and by decision-makers?

## Research

- Critical for building an evidence base about the value of accreditation
- Does accreditation result in improved agency performance?
- Does agency performance influence health outcomes?

**Notes:**
To complement the evaluation process, accrediting entity and governing body should promote the funding of research to build an evidence base about the value of accreditation.  Many accreditation programs do not do this; thus the existing evidence base about the value of accreditation in other disciplines is modest.

Accreditation should result in improved performance by state and local health agencies.  Better performance by health agencies may influence community health outcomes.  Because so many different factors influence the health of a community, research is challenging, but essential.  

## Public Comment

- Comment period ends Wednesday, July 26, 2006
- Go to _[www.exploringaccreditation.org](http://www.exploringaccreditation.org/)_
- Key questions for discussion and feedback

**Notes:**
Public Comment
This proposed model is available for public comment until Wednesday, July 26.  

The Steering Committee strongly encourages participation in this process from the full range of organizations and individuals interested in public health accreditation.  A schedule of public health meetings is available on the project’s website.  We encourage you to participate in one of more of these upcoming opportunities.

Feedback opportunities are described on page 15 of the model and available on the Exploring Accreditation website at www.exploringaccreditation.org 

Key questions for public discussion and feedback:
Is this model feasible and desirable to implement?
Is there anything missing from this proposed model that is essential to its success?
What else should the Steering Committee consider in making its final recommendations?

## Next Steps

- Business Case
- Steering Committee Meeting
- Final recommendations released at the end of August

**Notes:**

During this public comment period, the Finance and Incentives Work Group also is developing a business case and refining its implementation strategy for the proposed model.

In early August, the Steering Committee will meet to review public comments, consider the business case, and make their recommendations regarding whether a voluntary national accreditation program should be established

A final report will be issued at the end of August and widely distributed

Please provide feedback!

## Implementation

- Strategic business plan
- Standards and measures
- Pilot projects

**Notes:**
If a voluntary national accreditation program is established, the details of implementation would fall on the leaders who take on the challenge of developing it.  Developing a strategic business plan is the first critical step.

Implementation should be a multi-year process, which would allow improvements in the accreditation program to make it more successful and cost-effective. 

The standards development process is the next step.

Beginning implementation could be facilitated through recognition of existing programs and using them as pilot projects to begin phasing in a national program,

There is a potential for working with existing state/institute programs as vendors, as described earlier.

## For More Information...

- _[www.exploringaccreditation.org](http://www.exploringaccreditation.org/)_
**Jennifer Jimenez      ****	****Priscilla Barnes**
**ASTHO****	****	****      ****	****NACCHO**
**(202) 371-9090****	****     ****	****(202) 783-5550 x258**

**Notes:**
Self explanatory.