Mildred Dalton Manning, the last surviving member of a group of U.S. Army and Navy nurses taken prisoner in the Philippines at the start of ...
In December 2004, the Foundation, together with the Institute of Medicine, hosted a meeting on Public Health Agency Accreditation, to discuss perspectives and to determine whether–and how–to continue working on this issue. A survey of 50 local, state and federal public health leaders was also conducted prior to the meeting. The survey was intended to gather information on the rationale, concerns, unintended consequences, financing streams and potential accrediting organizations for a governmental public health accreditation system.
Here are the questions and answers.
Increase the Profile and Visibility of Public Health
Several survey respondents stated that accreditation may increase the profile and visibility of state and local public health departments. Respondents reported that an accreditation process could create a common understanding and basic expectations for public health agency performance and capacities so that all residents know what they can expect from their public health agencies.
Many respondents believed that an accreditation system would build credibility, legitimacy and leadership recognition for public health among peers, policymakers, the public and the medical community. Respondents believed that accreditation would help to professionalize the field and clearly define public health as a profession for the 21st century, which may serve as an incentive to retain staff.
Improve Quality and Performance
Several respondents stated that an accreditation process could provide citizens and policymakers with an objective measure of the quality of the services of the public health agencies that serve their jurisdiction. Respondents reported that accreditation could act as a mechanism for accountability for the capability and infrastructure to carry out public health functions effectively in a jurisdiction.
Survey respondents also said that an accreditation process could promote quality and performance improvement in public health departments by creating metrics for judging continuous improvement. Respondents further stated that accreditation could promote a systems approach by developing measures that link to outcomes in a systems way.
Promote Consistency of Services
Survey respondents stated that accreditation could establish a national level of consistency regarding what public health agencies are expected to accomplish and a core range or services.
Advocate for Resources
Many survey respondents stated that an accreditation process would draw attention to public health needs. Respondents also said that accreditation process could enable public health officials and the public to both advocate for increased support from resource allocators and provide a rationale for adequate/increased investments in public health services.
Improve Health Outcomes
Several respondents stated that accreditation could improve our knowledge base about public health practice, thus creating a better evidence base to link practice with improved health outcomes.
Failure to Achieve Intended Goals: “the result won't be improved public health”
Many respondents were concerned that the intended goals of an accreditation process (stated as improving health outcomes, performance, quality, accountability, visibility and public and policy maker understanding of what public health agencies do to promote and protect the health of the community) would not be accomplished. They feared that if these objectives were not kept in clear focus throughout the design and implementation of a program, the end result would be a burdensome process with detrimental rather than positive effects – an added dreaded task rather than an embraced change process. Several feared that the result would be a “rating game” that would not be taken seriously as a mechanism for performance improvement. They stated concern that it would focus on process only, not on outcomes.
Too Costly: Who will pay for it?
Numerous respondents were concerned about costs in terms of personnel time and effort and money and given already strained resources, diversion of work and funds from other priorities in order to comply with preparation and assessment processes for accreditation. (“another unfunded mandate”; “huge time sink”) These costs were anticipated to be too “exorbitant” for public health agencies to absorb, If deficiencies were identified, there would need to be resources available (training, technical assistance, money) in order to make the changes necessary to meet accreditation criteria, but there was fear that no Federal financial support for improvements would be available. Respondents wanted to know who would bear the burden of the financial and personnel time costs of an accreditation system, which would pay for a new organization to manage an accreditation process. It was also noted that for an accreditation system to be meaningful, it would have to e affordable across all jurisdictions. To lessen costs, respondents suggested that obtaining the data required for assessment should prize efficient methods of data collection that would not be duplicative of other reporting processes, and be largely produced as byproducts of everyday work. Some stated that federal agencies are not viewing accreditation as a way to reduce reporting requirements – but should.
Criteria definition difficult - but critical to success
Many worried that the criteria chosen would not measure the “right” things; that they would not be linked to improved outcomes; that they would emphasize prerequisites (such as credentials, staff to population ratios) rather than performance; that they would not be evidence-based; and that they would not be simple, reasonable, credible standards with clear face value. One respondent asked “How can we accredit when we haven't even set minimum standards?” Others were concerned that external stakeholders would judge the criteria as not being objective and evidence-based, and see accreditation as a way to pursue self-serving interests of the agencies. In addition, many raised concerns that the criteria would not be flexible enough to “risk-adjust” for local differences facing different health priorities and environments, compounded by differences in resources to provide services. This was raised several times with regard to rural areas with low population density, or agencies serving economically disadvantaged communities – they are less able to bear the costs of accreditation which could, if accreditation were linked to funding programs, exacerbate disparities even father.
Hazards of setting the bar too high vs. settling for the lowest common denominator
There was a wide split of opinion on the effects of more or less stringent criteria for accreditation. Some felt that the initial goal should be for minimum achievable standards with an emphasis on improving, standards that set the floor, not the ceiling. Others felt that minimum or weak standards would not have true quality improvement potential, would diminish the field and lower the public's expectations of what agencies are capable of doing. The concern was also raised that high performing agencies might regress to lower standards. There was concern that the public and decision makers might misperceive the floor vs. ceiling issue, and that budgets might be cut or reallocations made if the agency was seen as doing more than what was needed in certain areas or overall.
Insufficient “buy-in” by agencies and political and governance bodies
Several comments reflected concerns about who would drive the process - that an accreditation process that had not achieved acceptance by local agencies would be “pushed” on them by the state or CDC. There was concern that standards would be “imposed from outside” that were not perceived as meaningful to the health agencies. Some stated that both local and state agencies should be accredited, but feared that states will resist being subject to accreditation or that states and locals would not work together, but instead create separate processes.
Others were concerned that accreditation might be valued by the agency, but not by resource allocators or the public. They feared that there would not be buy-in by political and governance bodies – particularly if they might have to bear some of the costs.
Duplicates efforts already under development in many states
Several raised concern that a national movement toward accreditation would lead to duplication of existing processes, or be uncoordinated with them. There was concern that there would be no “grandfathering in” for agencies that had already met their state's system.
Accrediting organization inadequacies
Concerns were raised that the organization charged with accreditation would be uninformed about the world of public health agencies. Alternatively, that the accrediting body would be seen as political, or lacking independent credibility. One respondent worried that accreditation would have no impact on public support due to “wishy-washy” reporting.
Voluntary system won't work vs. only a voluntary system could work
Some stated that state and local agencies who did not buy-in to accreditation would ignore it if not forced to address it. A voluntary system would require clear and compelling incentives. However, some feared that resource allocators may disregard the presence of absence of accreditation, while others feared that the potential for accreditation to affect funding decisions was dangerous. Some felt that getting accredited could hurt an agency if public and political groups perceived this as the agency not needing any further support to continue strengthening their programs. More feared that not being accredited would be punitive, that agencies would lose credibility and find it difficult to explain that they are still performing vital functions to protect public health. One respondent's greatest concern was that stakeholders would be unable to reach a consensus, and that would prevent moving forward with a voluntary system
Many of the responses to this item overlapped with those to question #2 on concerns, and were synthesized with those. The bullets below highlight potential unintended consequences.
Almost all survey respondents commented that the costs should be shared by the federal government (CDC, HRSA), state and local public health agencies and possibly private foundations.
Many survey respondents stated that federal dollars should provide core support for the accrediting body. Respondents felt that federal funding should be used to develop the infrastructure of the system and ensure broad participation. Some respondents commented that federal funding should be new monies (not diverted from current funding allocations), specifically earmarked for a national system of public health agency accreditation. Respondents further felt that some of the dollars that are currently being used for federal reporting/monitoring could be redirected to state and local agencies.
Local and State Agencies
Many survey respondents stated that costs should be shared by the state and local agencies being accredited. Some respondents suggested that the system eventually be self-supported by user fees. The user fees could be set based on the size and complexity of the agency and its ability to pay. Costs should be within the grasp of most agencies and should be viewed as a reasonable cost of doing business.
Some respondents stated that associations should invest in the process to ensure their seat at the accreditation table.
Although most respondents stated that the system should be publicly financed, some respondents thought that major foundations could help to move accreditation forward by providing funding for infrastructure, particularly in the initial stages of the process (i.e., the first 4-5 years).
Most survey respondents agreed that an independent, nonprofit organization that is national in scope should be the accrediting body, if an accreditation system is pursued. Most did not believe that a state, local, or federal government agency or an academic body should be in charge of the accreditation process. Survey respondents suggested many variations on the type of independent organization that would do the accrediting. Some suggested that each state could have its own accreditation organization as long as it meets national standards; some thought that an organization or accrediting commission should be established expressly for the purpose of public health agency accreditation; some stated that existing organizations that already manage accreditation processes (but not for public health) could play this role; some stated that public health institutes currently administer state-wide accreditation process and a “national public health institute” could be created to administer state and local accreditation nationwide; and some thought that an organization that with expertise in state health department operations and population level health outcomes should be responsible for the accreditation process.
Survey respondents overwhelmingly felt that the accrediting organization should have strong ties with the membership associations, but the organization should be distinct. Many survey respondents stated that the organization should be governed by a broad based board of directors, including representatives from a full array of public health stakeholders, including federal, state, and local public health agencies, professional societies, governmental bodies, voluntary and community-based organizations, health professions schools, and other relevant organizations. Many respondents suggested that the Board should have a significant presence of those who would be accredited.
Survey respondents stated that the following groups should not be the accrediting organization:
Over half of the survey respondents would like to leave the meeting with a consensus decision on whether or not to pursue the issue of public health agency accreditation (14 of 25 responses). One respondent stated that at a minimum, meeting participants should agree to make major investments in the improvement of public health performance management systems as a vehicle to enable system improvement.
Develop Framework/Action Plan
If moving forward with an accreditation process is a common goal, survey respondents stated that they would like to develop an initial, focused framework and action plan to begin the process. The action plan should be operational with clear next steps and designated work assignments. It should also include short-term and long-term next steps and a timeline.
Respondents stressed that it is important to find areas of agreement and develop follow-up activities that will enable the discussion to move forward in a positive way. To the extent possible, it is important to understand possible competing agendas and resolve issues.
Learning, Recognition and Sharing
Survey respondents stated that they would like to learn from other and strengthen relationships with one another. Respondents hope that attendees have the opportunity to provide honest, straight forward input to ensure that there is a clear understanding of views, concerns and shared interests. One respondent would specifically like clarity on funding for accreditation.
Agree on Principles
Some principles/definitions that must be discussed include:
One respondent did not want to allow single organizations to have veto power over progress on accreditation.
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