RESEARCH AND PRACTICE
Local Public Health Department Characteristics Associated With Likelihood to Participate in National Accreditation Valerie A. Yeager, DrPH, Alva O. Ferdinand, JD, DrPH, Leslie M. Beitsch, MD, JD, and Nir Menachemi, PhD, MPH
Efforts to encourage voluntary participation in local health department (LHD) accreditation are under way.1---5 These efforts are motived by the expectation that adhering to accreditation standards will strengthen LHD performance and, in turn, positively affect population health.6---9 Targeted strategies addressing specific LHD barriers to pursuing accreditation are needed for widespread accreditation to occur. An important first step is informing any targeted strategies by having a better understanding of factors that are associated with current LHD intention to apply for accreditation. In addition to facilitating stakeholders assisting LHDs to overcome barriers, understanding these differences addresses several key research questions posed by the Public Health Accreditation Board in its recently published research agenda.10 To date, 2 studies have empirically examined the factors associated with intention to seek public health department accreditation. One focused on state health agencies and examined leadership attributes of state health officers who intend to pursue accreditation.11 It found that state health officers with a medical degree were more likely to indicate an intention to seek accreditation than were their counterparts. Shah et al.12 used data collected in the 2010 National Association of County and City Health Officials (NACCHO) Profile Survey to examine the relationship between LHD intention to seek accreditation and the 3 prerequisites that must be completed before submitting an accreditation application: (1) a community health assessment (CHA), (2) a community health improvement plan, and (3) a strategic plan. Shah et al. reported a negative association between recent completion of a CHA or community health improvement plan and the intention to seek accreditation. By contrast,
Objectives. We examined factors associated with completing, initiating, or intending to pursue voluntary national accreditation among local health departments (LHDs). Methods. We examined National Association of County and City Health Officials 2010 and 2013 profile data in a pooled cross-sectional design with bivariate and multivariable regression analyses. We conducted individual multivariable models with interest in accreditation and likely to accredit as outcome variables, comparing changes between 2010 and 2013. Results. LHDs with formal quality improvement programs are significantly more likely to have initiated or completed the accreditation process (odds ratio [OR] = 7.99; confidence interval [CI] = 1.79, 35.60), to be likely to accredit (OR = 2.41; CI = 1.65, 3.50), or to report an interest in accreditation (OR = 2.32; CI = 1.67, 3.20). Interest was lower among LHDs in 2013 than in 2010 (OR = 0.56; CI = 0.41, 0.77); however, there was no difference regarding being likely to accredit. LHDs with a high number of full-time equivalent employees were more likely to indicate being likely to accredit or interest in accreditation. Conclusions. Quality improvement may facilitate the accreditation process or be a proxy measure for an unmeasurable LHD attribute that predicts accreditation. (Am J Public Health. 2015;105:1653–1659. doi:10.2105/AJPH. 2014.302503)
findings also indicated that LHDs’ involvement in performance-related activities, use of quality improvement tools, having 1 or more local boards of health, and having an epidemiologist on staff increased LHD self-reported interest in pursuing future accreditation.12 Although the study by Shah et al. was important to an early understanding of factors related to intention to seek accreditation, voluntary public health accreditation had not yet launched when the 2010 Profile Survey data were collected. Since then, the first health departments received accreditation in 2012, and numerous LHDs have either initiated the process or made decisions about whether they plan to do so. Additionally, new data were collected regarding LHD accreditation status and intentions to pursue accreditation that were released in the 2013 NACCHO profile data set, well after the summer 2011 accreditation program launch date.
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We examined the organizational factors associated with and longitudinal changes in LHDs’ accreditation and intention to seek accreditation. We analyzed secondary 2010 and 2013 data from the NACCHO profile surveys, which allowed us to examine factors that may relate to the intention to participate in accreditation. Our findings will be of particular interest to the Public Health Accreditation Board and other leaders in the accreditation movement as they develop strategies to assist LHDs in planning for accreditation and addressing barriers to the process.
METHODS We acquired data from the 2010 and 2013 Profile Surveys administered by NACCHO.13,14 In addition to the main survey that is sent to the approximately 2600 LHDs in the United States, each Profile Survey contains 3 modules that are sent to a statistically representative
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sample of LHDs. Information about accreditation is collected in one of the additional modules, thus limiting the number of LHDs that are surveyed and provided information about accreditation to a sample of LHDs. In 2010, 624 LHDs were queried about accreditation and 522 responded to the survey, for an 85% response rate. In 2013, 624 LHDs were also queried about accreditation and 477 responded, for an 81% response rate.13,14 Because of data limitations, we are unable to ascertain the amount of LHD overlap in the 2 years of data; however, in our pooled crosssectional analyses we assumed that each year’s respondents are representative of national LHDs. We used a pooled cross-sectional design to analyze LHD accreditation intentions and LHD characteristics reported in the 2010 and 2013 Profile Surveys. The pooled crosssectional design allows the use of data from all responding LHDs in 2010 and 2013 whereby aggregate LHD responses in 2010 are compared with aggregate LHD responses in 2013.
Because survey questions differed slightly between the 2010 and 2013 Profile Surveys, we calibrated responses to be as similar as possible across time (Table 1). The 2010 survey asked LHDs to rate their level of agreement with the following 2 statements: “Our LHD would seek accreditation under a voluntary national accreditation program” (hereafter “interest” in accreditation) and “Our LHD would seek accreditation under a voluntary national accreditation program within the first two years of the program (2011---2012)” (hereafter “likely to accredit”). On the basis of these questions, we coded 2 variables that measured an interest in accreditation and the likelihood to pursue accreditation as determined by responses of “agree” or “strongly agree,” respectively, to the survey questions. From the 2013 Profile Survey, we coded responses for 3 variables: interest in accreditation and likelihood of accreditation (similar to the coding of the 2010 data) and an additional variable indicating whether the LHD initiated
or completed the accreditation process. The 2013 survey asked LHDs to select whether their LHD has “achieved accreditation,” “submitted an application for accreditation,” “submitted a statement of intent to pursue accreditation,” “plans to apply for accreditation but has not submitted a letter of intent,” “has not decided whether to apply for accreditation,” or “has decided not to apply for accreditation,” or to select “the state health agency is pursuing accreditation on behalf of my LHD.” We coded instances of when an LHD indicated that it had achieved accreditation, submitted an application, or submitted a letter of intention to apply for accreditation as the binary variable “completed or initiated accreditation process.” If an LHD indicated that it planned to apply for accreditation but had not submitted a letter of intent, it was asked to specify when it planned to submit a letter of intent. If the LHD indicated that it would submit the letter within 2 years, we coded this as “likelihood” of accreditation. If it indicated that it will submit a letter of intent at some point
TABLE 1—Profile Survey Questions About Accreditation and Variable Coding: Profile Survey of Local Health Departments, United States, 2010 and 2013 Questions and Response Options
Variable Coding 2010 Profile Survey of LHDs
Rate your level of agreement with the following statement: Our LHD would seek accreditation under a voluntary national accreditation program. Strongly agree or agree
Interested in accreditation
Neutral, disagree, or strongly disagree
Not interested in accreditation
Rate your level of agreement with the following statement: Our LHD would seek accreditation under a voluntary national accreditation program within the first 2 y of the program. Strongly agree or agree
Likely to accredit
Neutral, disagree, or strongly disagree
Not likely to accredit 2013 Profile Survey of LHDs
Which of the following best describes your LHD with respect to participation in the Public Health Accreditation Board’s accreditation program for LHDs? (Select only 1.) My LHD has achieved accreditation, my LHD has submitted an application for accreditation, or my LHD has submitted
Completed or initiated the accreditation process
a statement of intent to pursue accreditation. My LHD plans to apply for accreditation but has not submitted a statement of intent. Specifically, my LHD anticipates
Likely to accredit
submitting a statement of intent within the next 2 y. My LHD plans to apply for accreditation but has not submitted a statement of intent. Specifically, my LHD anticipates
Interested in accreditation
submitting a statement of intent at some point after the next 2 y. My LHD has not decided whether to apply for accreditation, my LHD has decided NOT to apply for accreditation, or the state health agency is pursuing accreditation on behalf of my LHD.
Not completed or initiated the accreditation process, not likely to accredit, and not interested in accreditation as an LHD
Note. LHD = local health department. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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after 2 years, we coded this as “interest” in accreditation. We used identical independent variables from both years of the survey to examine the relationship between the 3 accreditation intention variables (interest, likelihood, and completed or initiated accreditation) and LHD characteristics. These variables included binary measures for whether an LHD reported the use of any formal quality improvement (including agency-wide quality improvement and quality improvement within a specific programmatic area), having conducted a CHA within the past 3 years, the presence of a local board of health with governing authority (i.e., directive influence on the LHD), and whether the LHD provides comprehensive primary care services. We determined that a local board of health had governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. We included the variable for whether comprehensive primary care services were provided in the LHD in the analyses. It is assumed that if an organization is practicing clinical services its leaders may be more familiar with the concept and rationale of accreditation because of the universal presence of accreditation throughout clinical care settings. Therefore, an organization providing comprehensive primary care services may be more likely to decide to participate in voluntary national public health accreditation. In addition, we used a measure of the number of full-time equivalent (FTE) employees from the surveys in our models. We categorized this variable on the basis of quartiles for the analyses. Lastly, we included a categorical variable representing the governance structure (i.e., decentralized, centralized, shared). We performed bivariate (v2) and multivariable regression analyses to examine the relationship between the 3 accreditation intention variables (interest, likelihood, and completed or initiated accreditation) and LHD characteristics. We conducted individual logistic regression analyses with interest in accreditation and likely to accredit as
outcome variables, comparing changes between 2010 and 2013 and controlling for independent variables. One additional model had the outcome of completed or initiated accreditation. Because this variable was present in only the 2013 data, we did not examine changes over time. We conducted all analyses using Stata version 12.0 (StataCorp LP, College Station, TX).
RESULTS In 2010, 522 LHDs responded to the survey that included questions about accreditation, and in 2013, 477 responded. Thus, 999 LHD responses were available across both years. Overall, 31.1% of responding LHDs indicated being likely to accredit within the first 2 years, whereas 47.8% reported an interest in accreditation (Table 2). In 2013, 8.8% of
TABLE 2—Descriptive Statistics of Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 LHD Characteristic
2010 (n = 522), No. (%)
2013 (n = 477), No. (%)
Completed or initiated accreditation Yes
NA
34 (8.8)
No
NA
354 (91.2)
Likely to accredit Yes No Interested in accreditation
141 (31.5)
99 (30.6)
306 (68.5)
225 (69.4)
Yes
242 (53.4)
158 (41.3)
No
211 (46.6)
225 (58.7)
Any formal quality improvement Yes
255 (48.8)
280 (58.7)
No
267 (51.2)
197 (41.3)
Lowest quartile (< 9.51) 2nd quartile (9.51–24.36)
129 (25.9) 121 (24.3)
115 (24.5) 119 (25.3)
3rd quartile (24.37–74.00)
126 (25.3)
117 (24.9)
Highest quartile (> 74.00)
121 (24.3)
119 (25.3)
No. of FTE employees
Completed a CHA in the past 3 y Yes
247 (47.5)
269 (57.5)
No
273 (52.5)
199 (42.5)
252 (48.5) 268 (51.5)
205 (63.1) 120 (36.9)
Local board of health with governing authority Yes No Structural governance Decentralized
388 (74.3)
335 (70.2)
Centralized
86 (16.4)
93 (19.5)
Shared
48 (9.2)
49 (10.3)
LHD provides comprehensive primary care Yes
66 (13.0)
48 (10.3)
No
441 (87.0)
419 (89.7)
Note. CHA = community health assessment; FTE = full-time equivalent; LHD = local health department; NA = not applicable. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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responding LHDs had completed or initiated accreditation. Overall, approximately half of the LHDs reported conducting any formal quality improvement (53.6%; n = 535), completing a CHA within the past 3 years (52.2%; n = 516), or having a local board of health with governing authority (54.1%; n = 457). A majority of respondents indicated having a decentralized governance structure (72.4%; n = 723). The LHDs reported varying numbers of FTE employees, ranging from 0 to 6543, with a mean of 110.10 FTE employees across the responding LHDs. The first 25.0% of responding LHDs had 9.50 or fewer FTE employees, the second quartile had between 9.51 and 24.36 FTE employees, the third quartile had between 24.37 and 74.00 FTE employees, and the
fourth quartile included LHDs with more than 74.00 FTE employees.
Bivariate Analyses Several independent variables were associated with intention to seek accreditation in bivariate analyses (Table 3). Across both years of data, LHDs that reported conducting any formal quality improvement were more likely to report an intention to apply for accreditation regardless of how intention was measured. Additionally, a higher proportion of those with more FTE employees (second, third, and fourth quartiles) reported an interest in accreditation across each of the intention to participate variables and both years of data than did LHDs with the fewest FTE employees (the first quartile). For example, LHDs with more than
74.0 FTE employees (the fourth quartile) were more likely to report being likely to accredit in 2013 than did LHDs with 9.5 or fewer FTE employees (61.3% vs 3.8%; P < .001). LHDs that completed a CHA within the past 3 years were significantly more likely to have completed or initiated accreditation (12.56% vs 3.82%; P = .003). LHDs that provided comprehensive primary care in 2013 were significantly more likely to report being likely to accredit (60.90% vs 28.50%; P < .001) or to report an interest in accreditation (67.90% vs 40.00%; P = .004).
Multivariable Analyses Findings from multivariable logistic regressions indicated that LHDs that reported conducting any formal quality improvement were
TABLE 3—Bivariate Relationship Between Likelihood of Participation in Accreditation and Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 2010
LHD Characteristic Any formal quality improvement Yes No No. of FTE employees
Likely to Accredit (n = 141), No. (%) or P
2013 Interested in Accreditation (n = 242), No. (%) or P
Completed or Initiated Accreditation (n = 34), No. (%) or P
Likely to Accredit (n = 100), No. (%) or P
Interested in Accreditation (n = 162), No. (%) or P
< .001
< .001
< .001
< .001
< .001
92 (40.9) 49 (22.1)
143 (43.8) 99 (63.0)
32 (14.8) 2 (1.2)
80 (44.9) 19 (13.0)
118 (54.6) 40 (24.0)
< .001
< .001
< .001
0.0
3 (3.8)
17 (18.3)
< .001
.002
Lowest quartile (< 9.51)
27 (27.5)
44 (43.6)
2nd quartile (9.51–24.36)
18 (17.3)
49 (46.2)
2 (2.0)
14 (16.9)
33 (32.3)
3rd quartile (24.37–74.00)
34 (31.5)
60 (55.1)
16 (17.0)
37 (46.3)
51 (54.3)
Highest quartile (> 74.00)
49 (43.8)
75 (67.0)
16 (18.2)
46 (61.3)
59 (67.1)
Completed CHA in the past 3 y
.33
.25
.003
.02
.02
67 (29.4) 74 (33.6)
116 (50.7) 126 (56.0)
28 (12.6) 6 (3.8)
66 (35.7) 32 (23.7)
104 (46.6) 54 (34.4)
Yes No Local board of health with governing authority
.79
.43
.94
.67
.48
Yes
74 (32.2)
119 (51.5)
17 (9.3)
23 (28.1)
71 (39.0)
No
67 (31.0)
45 (43.7)
Structural governance Decentralized Centralized Shared LHD provides comprehensive primary care
122 (55.2)
10 (9.6)
49 (30.6)
.1
.002
.87
.04
.12
111 (32.4)
191 (54.9)
26 (8.4)
77 (29.1)
122 (39.4)
13 (21.0)
22 (34.9)
5 (10.4)
9 (26.5)
23 (47.9)
17 (39.5) .83
29 (67.4) .87
3 (10.0) .3
14 (51.9) .001
17 (56.7) .004
Yes
20 (32.8)
34 (54.8)
No
118 (31.4)
204 (53.7)
4 (14.3) 30 (8.5)
14 (60.9)
19 (67.9)
85 (28.5)
142 (40.0)
Note. CHA = community health assessment; FTE = full-time equivalent; LHD = local health department. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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more likely to report interest in or activities leading to accreditation (Table 4). Specifically, LHDs that reported conducting any formal quality improvement were more likely to report being likely to accredit (odds ratio [OR] = 2.41; 95% confidence interval [CI] = 1.65, 3.50), being interested in accreditation (OR = 2.32; 95% CI = 1.67, 3.20), or having completed or initiated the accreditation process (OR = 7.99; 95% CI = 1.79, 35.60). When comparing trends over time, interest in accreditation was significantly less likely in 2013 than in 2010 (OR = 0.56; 95% CI = 0.41, 0.77). In general, the number of FTE employees was significantly related to the intention to participate in accreditation after controlling for other variables. Specifically, LHDs in the second quartile (OR = 0.09; 95% CI = 0.02, 0.43) were significantly less likely to be likely to accredit than were LHDs with the highest numbers of FTE employees. (Note that there were no LHDs in the first quartile that had
accredited or initiated the accreditation process.) Similarly, LHDs with the fewest FTE employees (bottom 2 quartiles) were less likely to be interested in accreditation than were those with the most FTE employees (OR = 0.29; CI = 0.18, 0.47 for quartile group 1; OR = 0.41; CI = 0.26, 0.64 for quartile group 2). LHDs that indicated having completed a CHA within the past 3 years were significantly more likely to report completing or initiating the accreditation process (OR = 3.64; 95% CI = 1.36, 9.74) but not the other outcome measures. Lastly, LHDs in centralized governance systems were significantly less likely to report an interest in accreditation than were LHDs with decentralized governance (OR = 0.57; CI = 0.34, 0.92).
DISCUSSION With the intention of positively influencing population health, efforts to encourage voluntary participation in public health department
accreditation are under way.6 More information about factors that relate to the likelihood of participating in accreditation is necessary in developing targeted strategies for encouraging LHDs to become accredited. Using secondary data collected by the NACCHO, we examined LHD factors that relate to intention to participate in national voluntary accreditation in 2010 and 2013. Data from 2010 and 2013 indicate that LHDs with formal quality improvement programs are significantly more inclined to pursue accreditation in both the near term and the future. Ongoing efforts to expand and encourage the use of formal quality improvement in LHDs may positively affect readiness and willingness to complete the accreditation process. However, quality improvement may also be a proxy measure for an unmeasurable LHD attribute that predicts accreditation. LHDs that conduct quality improvement already are likely different from LHDs that do not in ways that may influence pursuing and
TABLE 4—Multivariable Relationship Between the Likelihood of Participating in Accreditation and Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 LHD Characteristic Any formal quality improvement
Completed or Initiated Accreditation, 2013 Only (n = 266), OR (95% CI)
Likely to Accredit (n = 712), OR (95% CI)
Interest in Accreditation (n = 773), OR (95% CI)
7.99** (1.79, 35.60)
2.41*** (1.65, 3.50)
2.32*** (1.67, 3.20)
Year of self-report 2010 (Ref) 2013 No. of FTE employees
NA
1.00
NA
1.04 (0.73, 1.48)
1.00 0.56*** (0.41, 0.77)
. . .a
0.23*** (0.13, 0.39)
0.29*** (0.18, 0.47)
0.09** (0.02, 0.43)
0.24*** (0.14, 0.40)
0.41*** (0.26, 0.64)
3rd quartile (24.37–74.00)
0.87 (0.38, 1.99)
0.59** (0.38, 0.92)
0.68*** (0.44, 1.06)
Highest quartile (> 74.00; Ref)
1.00
Lowest quartile (< 9.51) 2nd quartile (9.51–24.36)
1.00
1.00
3.64* (1.36, 9.74)
0.82 (0.58, 1.17)
0.86 (0.63, 1.17)
Local board of health with governing authority
1.74 (0.72, 4.21)
1.09 (0.76, 1.57)
0.87 (0.62, 1.20)
Structural governance Decentralized (Ref)
1.00
1.00
0.92 (0.23, 2.85)
0.57 (0.32, 1.04)
Completed a CHA in the past 3 y
Centralized
1.00 0.57* (0.35, 0.92)
Shared
0.42 (0.28, 3.07)
0.84 (0.27, 2.55)
1.20 (0.51, 2.83)
LHD provides comprehensive primary care
0.82 (0.23, 2.86)
0.78 (0.45, 1.35)
0.78 (0.46, 1.31)
Note. CHA = community health assessment; CI = confidence interval; FTE = full-time equivalent; LHD = local health department; NA = not applicable; OR = odds ratio. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, approves the LHD budget, can adopt public health regulations, sets and imposes fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials. a There were no observations (in this category) that had been accredited at the time of the survey. *P < .05; **P < .01; ***P < .001.
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achieving accreditation. For example, LHDs that decide to pursue accreditation may have more effective leadership or more resources than do LHDs not conducting quality improvement. This is one of the challenges facing national voluntary accreditation—LHDs that are not already focused on quality may actually avoid accreditation altogether despite several years of quality improvement support and encouragement. This may further distinguish LHDs that are focused on performance improvement from those that are not, thus the voluntary element of accreditation may not result in widespread quality improvement. Nonetheless, because a primary goal of accreditation is to strengthen health department performance, a strong foundation in quality improvement is instrumental in overall agency improvement.15 Therefore, there must be a better understanding of what predicates quality improvement in LHDs. Two previous studies have examined internal16 and external17 factors that relate to the use of quality improvement in LHDs. In 2010 Beitsch et al. found that larger LHDs and LHDs with centralized governance structures reported higher rates of quality improvement implementation.16 In 2013 Yeager et al. found that LHDs were less likely to report engaging in quality improvement when faced with greater public health concerns, such as increased obesity rates or smoking prevalence.17 Yeager et al. hypothesized that greater complexity in a LHD’s external environment adds more difficult and time-consuming issues and causes less focus on strategic efforts to improve internal quality. Future research that provides more information on organizational culture or other possible factors that distinguish LHDs that engage in quality improvement and accreditation would be valuable in planning widespread quality improvement and accreditation. To date, substantial resources have been invested by government and philanthropy to develop and further strengthen the quality improvement capacity across health departments nationally through programs such as the National Public Health Improvement Initiative and the Multi-State Learning Collaborative.1,4,5,18,19 This ties in directly with our findings and suggests that these investments may provide dividends in the form of future
participation in the national voluntary accreditation program if investment support continues. It also indicates that additional future sustainable investment should be considered to maintain a steady pipeline of LHDs intending to seek accreditation and ultimately reaccreditation. Recent qualitative research examining the effects of public health accreditation in the state of North Carolina found that LHDs reported improved funding and improved relationships with partners after becoming accredited.1 Clearly, more research into the value of accreditation and efforts to encourage quality improvement and performance management is needed. Considering changes over time, interest in accreditation was the only thing that differed between 2010 and 2013. Therefore, although interest in accreditation has significantly decreased over time, there was no change in the number of LHDs that reported being likely to accredit. As accreditation processes have become more widely understood, LHDs may be moving from being interested in accreditation to being likely to participate and may be replacing LHDs that have moved from being likely to participate to having initiated or completed the accreditation process. This may also indicate that LHDs that were not previously interested are not becoming interested and, thus, are not replacing the numbers of LHDs that are moving further along the spectrum toward accreditation. Although it is important to start by examining the factors that relate to the decision to participate in accreditation, future research should examine the factors that matter in an LHD’s decision to not participate in accreditation. Key findings also indicate that having completed a CHA within the past 3 years was positively related to having initiated or completed the accreditation process in 2013. The role that the CHA plays in accreditation intent must be interpreted with the understanding that CHAs are an accreditation prerequisite and must be completed no more than 5 years before the date of application. In 2010 Shah et al. found a negative association between recent completion of a CHA and intention to seek accreditation.12 However, although raw data indicate that a higher proportion of LHDs responding in 2013 completed the CHA within
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the past 3 years, are interested in accreditation, and are likely to accredit, we found no significant differences in bivariate or multivariable analyses. The negative association between the recent completion of a CHA and intention to seek accreditation that Shah et al. found and the lack of any association despite the raw increase in recently completed CHAs that we found suggest that completing a CHA alone does not motivate LHDs to want to participate in accreditation. This may be because LHDs that have completed a CHA are familiar with the amount of resources and effort required for such tasks and may be concerned about committing to another resource-intense endeavor such as accreditation. Drawing any conclusions about this phenomenon was outside the scope of our study, but this is a topic that should be considered in future accreditation studies. It is also important to note that LHDs with higher numbers of FTE employees were almost always more likely to indicate an intention or likelihood to participate in accreditation. It is possible that having more resources, especially human resources, translates into the ability to do more intensive planning and assessment associated with the accreditation process. Interestingly, although empirical data are not yet available from the Public Health Accreditation Board, an anecdotal review of the Public Health Accreditation Board Web site suggests that LHDs of all sizes have initiated the accreditation process.6 As more empirical data become available, future studies will be able to examine the relationship between LHD size and other factors, such as experiences with the accreditation process and perceived benefits of accreditation. LHD size may also relate to the ease of the process and whether the LHD identifies benefits from it but may not itself be a bar to pursuing accreditation successfully. Lastly, in multivariable models, LHDs in states that have centralized governance models were less likely to report interest in accreditation, which may be related to having less authority to make strategic decisions for the LHD. Additionally, in centralized systems there is often shared documentary evidence, which may facilitate system-wide application rather than individual LHD pursuit of accreditation. There were no significant relationships
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between intention to apply for accreditation and the presence of a local board of health with governing authority or the provision of primary care among LHDs that responded in 2010 or 2013.
Strengths and Limitations Our study has numerous noteworthy strengths and limitations. To our knowledge, it is the first study to examine factors associated with LHD intention to apply for accreditation since national voluntary accreditation began. Additionally, by examining these factors in 2010 and 2013 it is possible to see if there are any aggregated changes since national accreditation has been under way. In terms of limitations, the differences in questions and available responses on the 2010 and 2013 Profile Surveys add a layer of complexity when trying to examine changes over time. Additionally, the intent to apply for accreditation and the nature of quality improvement within the LHD are both self-reported indicators that may be subject to social desirability bias. It would be interesting to examine changes in accreditation intentions across individual LHDs; however, this was not plausible because of data limitations. Lastly, although the NACCHO profile surveys provide valuable data about LHDs, the representatives who completed the survey may not be familiar with all aspects of LHDs’ plans and operations.
Conclusions Our results may provide a future roadmap for stakeholders seeking to support national voluntary accreditation participation among LHDs. In addition they validate the efforts already completed or in process by funders like the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation. Ongoing support for the development of formal quality improvement and CHAs could serve to lessen the reluctance of LHDs pondering their future course. However, with the recent loss of National Public Health Improvement Initiative funding through rare congressional action,20---22 reversal of the positive trends observed to date is possible, and further study is indicated to track the impact of diminished specific federal support that strengthens the readiness capacity of health departments to apply for accreditation. j
About the Authors Valerie A. Yeager is with the Tulane School of Public Health and Tropical Medicine, New Orleans, LA. Alva O. Ferdinand is with the Texas A&M Health Science Center and School of Public Health, College Station, TX. Leslie M. Beitsch is with the Florida State University College of Medicine, Tallahassee. Nir Menachemi is with the University of Alabama, Birmingham School of Public Health, Birmingham. Correspondence should be sent to Valerie Yeager, 1440 Canal Street, Suite 1900, New Orleans, LA 70112 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 1, 2014.
Contributors
9. Ingram RC, Scutchfield FD, Charnigo R, Riddell MC. Local public health system performance and community health outcomes. Am J Prev Med. 2012;42(3):214---220. 10. Riley WJ, Lownik EM, Scutchfield FD, Mays GP, Corso LC, Beitsch LM. Public health department accreditation: setting the research agenda. Am J Prev Med. 2012;42(3):263---271. 11. Madamala K, Sellers K, Beitsch LM, Pearsol J, Jarris P. Quality improvement and accreditation readiness in state public health agencies. J Public Health Manag Pract. 2012;18(1):9---18. 12. Shah GB, Beatty K, Leep, C. Do PHAB accreditation prerequisites predict local health departments’ intentions to seek voluntary national accreditation? Front Public Health Serv Syst Res. 2013;2(3):Article 4.
V. A. Yeager and L. M. Beitsch wrote the article with revisions and content contributions from N. Menachemi and A. O. Ferdinand. All authors collectively designed this study and analyzed and interpreted the data.
13. National Association of County and City Health Officials. National profile of local health departments. 2010. Available at: http://nacchoprofilestudy.org/wpcontent/uploads/2014/01/2010_Profile_main_reportweb.pdf. Accessed July 15, 2014.
Acknowledgments
14. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC; 2013.
Early findings from this study were presented at the Keeneland Conference for Public Health Services and Systems Research in April 2014.
Human Participant Protection This study was exempt from human participant ethical review because no human participants were involved.
References 1. Davis MV, Cannon MM, Stone DO, Wood BW, Reed J, Baker EL. Informing the national public health accreditation movement: lessons from North Carolina’s accredited local health departments. Am J Public Health. 2011;101(9):1543---1548. 2. Beitsch LM, Corso LC, Davis MV, Joly BM, Kronstadt J, Riley WJ. Transforming public health practice through accreditation (a user guide for the special accreditation issue). J Public Health Manag Pract. 2014;20(1):2---3. 3. McLees AW, Thomas CW, Nawaz S, Young AC, Rider N, Davis M. Advances in public health accreditation readiness and quality improvement: evaluation findings from the national public health improvement initiative. J Public Health Manag Pract. 2014;20(1): 29---35. 4. Monteiro E, Fisher JS, Daub T, Zamperetti MC. CDC/NACCHO Accreditation Support Initiative: advancing readiness for local and tribal health department accreditation. J Public Health Manag Pract. 2014;20(1): 14---19. 5. Thielen L, Leff M, Corso L, Monteiro E, Fisher JS, Pearsol J. A study of incentives to support and promote public health accreditation. J Public Health Manag Pract. 2014;20(1):98---103.
15. Davis MV, Mahanna E, Joly B, et al. Creating quality improvement culture in public health agencies. Am J Public Health. 2014;104(1):e98---e104. 16. Beitsch LM, Leep C, Shah G, Brooks RG, Pestronk RM. Quality improvement in local health departments: results of the NACCHO 2008 survey. J Public Health Manag Pract. 2010;16(1):49---54. 17. Yeager VA, Menachemi N, Ginter PM, Sen BP, Savage GT, Beitsch LM. Environmental factors and quality improvement in county and local health departments. J Public Health Manag Pract. 2013;19(3): 240---249. 18. Thomas CW, Pietz H, Corso L, Erlwein B, Monroe J. Advancing accreditation through the national public health improvement initiative. J Public Health Manag Pract. 2014;20(1):36---38. 19. Mays G, Beitsch LM, Corso L, Chang C, Brewer R. States gathering momentum: promising strategies for accreditation and assessment activities in multistate learning collaborative applicant states. J Public Health Manag Pract. 2007;13(4):364---373. 20. Executive Office of the President of the United States. Budget of the United States Government, Fiscal Year 2015. Washington, DC: US Government Printing Office; 2014. 21. National Association of County and City Health Officials. Local Health Department Budget Cuts and Job Losses: Findings From the 2014 Forces of Change Survey. Washington, DC; 2014. 22. Association of State and Territorial Health Officials. Budget Cuts Continue to Affect the Health of Americans. Washington, DC; 2013.
6. Public Health Accreditation Board. Available at: http://www.phaboard.org. Accessed June 24, 2014. 7. Joly BM, Polyak G, Davis MV, et al. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract. 2007;13(4): 349---356. 8. Kanarek N, Stanley J, Bialek R. Local public health agency performance and community health status. J Public Health Manag Pract. 2006;12(6):522---527.
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Local Public Health Department Characteristics Associated With Likelihood to Participate in National Accreditation Valerie A. Yeager, DrPH, Alva O. Ferdinand, JD, DrPH, Leslie M. Beitsch, MD, JD, and Nir Menachemi, PhD, MPH
Efforts to encourage voluntary participation in local health department (LHD) accreditation are under way.1---5 These efforts are motived by the expectation that adhering to accreditation standards will strengthen LHD performance and, in turn, positively affect population health.6---9 Targeted strategies addressing specific LHD barriers to pursuing accreditation are needed for widespread accreditation to occur. An important first step is informing any targeted strategies by having a better understanding of factors that are associated with current LHD intention to apply for accreditation. In addition to facilitating stakeholders assisting LHDs to overcome barriers, understanding these differences addresses several key research questions posed by the Public Health Accreditation Board in its recently published research agenda.10 To date, 2 studies have empirically examined the factors associated with intention to seek public health department accreditation. One focused on state health agencies and examined leadership attributes of state health officers who intend to pursue accreditation.11 It found that state health officers with a medical degree were more likely to indicate an intention to seek accreditation than were their counterparts. Shah et al.12 used data collected in the 2010 National Association of County and City Health Officials (NACCHO) Profile Survey to examine the relationship between LHD intention to seek accreditation and the 3 prerequisites that must be completed before submitting an accreditation application: (1) a community health assessment (CHA), (2) a community health improvement plan, and (3) a strategic plan. Shah et al. reported a negative association between recent completion of a CHA or community health improvement plan and the intention to seek accreditation. By contrast,
Objectives. We examined factors associated with completing, initiating, or intending to pursue voluntary national accreditation among local health departments (LHDs). Methods. We examined National Association of County and City Health Officials 2010 and 2013 profile data in a pooled cross-sectional design with bivariate and multivariable regression analyses. We conducted individual multivariable models with interest in accreditation and likely to accredit as outcome variables, comparing changes between 2010 and 2013. Results. LHDs with formal quality improvement programs are significantly more likely to have initiated or completed the accreditation process (odds ratio [OR] = 7.99; confidence interval [CI] = 1.79, 35.60), to be likely to accredit (OR = 2.41; CI = 1.65, 3.50), or to report an interest in accreditation (OR = 2.32; CI = 1.67, 3.20). Interest was lower among LHDs in 2013 than in 2010 (OR = 0.56; CI = 0.41, 0.77); however, there was no difference regarding being likely to accredit. LHDs with a high number of full-time equivalent employees were more likely to indicate being likely to accredit or interest in accreditation. Conclusions. Quality improvement may facilitate the accreditation process or be a proxy measure for an unmeasurable LHD attribute that predicts accreditation. (Am J Public Health. 2015;105:1653–1659. doi:10.2105/AJPH. 2014.302503)
findings also indicated that LHDs’ involvement in performance-related activities, use of quality improvement tools, having 1 or more local boards of health, and having an epidemiologist on staff increased LHD self-reported interest in pursuing future accreditation.12 Although the study by Shah et al. was important to an early understanding of factors related to intention to seek accreditation, voluntary public health accreditation had not yet launched when the 2010 Profile Survey data were collected. Since then, the first health departments received accreditation in 2012, and numerous LHDs have either initiated the process or made decisions about whether they plan to do so. Additionally, new data were collected regarding LHD accreditation status and intentions to pursue accreditation that were released in the 2013 NACCHO profile data set, well after the summer 2011 accreditation program launch date.
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We examined the organizational factors associated with and longitudinal changes in LHDs’ accreditation and intention to seek accreditation. We analyzed secondary 2010 and 2013 data from the NACCHO profile surveys, which allowed us to examine factors that may relate to the intention to participate in accreditation. Our findings will be of particular interest to the Public Health Accreditation Board and other leaders in the accreditation movement as they develop strategies to assist LHDs in planning for accreditation and addressing barriers to the process.
METHODS We acquired data from the 2010 and 2013 Profile Surveys administered by NACCHO.13,14 In addition to the main survey that is sent to the approximately 2600 LHDs in the United States, each Profile Survey contains 3 modules that are sent to a statistically representative
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sample of LHDs. Information about accreditation is collected in one of the additional modules, thus limiting the number of LHDs that are surveyed and provided information about accreditation to a sample of LHDs. In 2010, 624 LHDs were queried about accreditation and 522 responded to the survey, for an 85% response rate. In 2013, 624 LHDs were also queried about accreditation and 477 responded, for an 81% response rate.13,14 Because of data limitations, we are unable to ascertain the amount of LHD overlap in the 2 years of data; however, in our pooled crosssectional analyses we assumed that each year’s respondents are representative of national LHDs. We used a pooled cross-sectional design to analyze LHD accreditation intentions and LHD characteristics reported in the 2010 and 2013 Profile Surveys. The pooled crosssectional design allows the use of data from all responding LHDs in 2010 and 2013 whereby aggregate LHD responses in 2010 are compared with aggregate LHD responses in 2013.
Because survey questions differed slightly between the 2010 and 2013 Profile Surveys, we calibrated responses to be as similar as possible across time (Table 1). The 2010 survey asked LHDs to rate their level of agreement with the following 2 statements: “Our LHD would seek accreditation under a voluntary national accreditation program” (hereafter “interest” in accreditation) and “Our LHD would seek accreditation under a voluntary national accreditation program within the first two years of the program (2011---2012)” (hereafter “likely to accredit”). On the basis of these questions, we coded 2 variables that measured an interest in accreditation and the likelihood to pursue accreditation as determined by responses of “agree” or “strongly agree,” respectively, to the survey questions. From the 2013 Profile Survey, we coded responses for 3 variables: interest in accreditation and likelihood of accreditation (similar to the coding of the 2010 data) and an additional variable indicating whether the LHD initiated
or completed the accreditation process. The 2013 survey asked LHDs to select whether their LHD has “achieved accreditation,” “submitted an application for accreditation,” “submitted a statement of intent to pursue accreditation,” “plans to apply for accreditation but has not submitted a letter of intent,” “has not decided whether to apply for accreditation,” or “has decided not to apply for accreditation,” or to select “the state health agency is pursuing accreditation on behalf of my LHD.” We coded instances of when an LHD indicated that it had achieved accreditation, submitted an application, or submitted a letter of intention to apply for accreditation as the binary variable “completed or initiated accreditation process.” If an LHD indicated that it planned to apply for accreditation but had not submitted a letter of intent, it was asked to specify when it planned to submit a letter of intent. If the LHD indicated that it would submit the letter within 2 years, we coded this as “likelihood” of accreditation. If it indicated that it will submit a letter of intent at some point
TABLE 1—Profile Survey Questions About Accreditation and Variable Coding: Profile Survey of Local Health Departments, United States, 2010 and 2013 Questions and Response Options
Variable Coding 2010 Profile Survey of LHDs
Rate your level of agreement with the following statement: Our LHD would seek accreditation under a voluntary national accreditation program. Strongly agree or agree
Interested in accreditation
Neutral, disagree, or strongly disagree
Not interested in accreditation
Rate your level of agreement with the following statement: Our LHD would seek accreditation under a voluntary national accreditation program within the first 2 y of the program. Strongly agree or agree
Likely to accredit
Neutral, disagree, or strongly disagree
Not likely to accredit 2013 Profile Survey of LHDs
Which of the following best describes your LHD with respect to participation in the Public Health Accreditation Board’s accreditation program for LHDs? (Select only 1.) My LHD has achieved accreditation, my LHD has submitted an application for accreditation, or my LHD has submitted
Completed or initiated the accreditation process
a statement of intent to pursue accreditation. My LHD plans to apply for accreditation but has not submitted a statement of intent. Specifically, my LHD anticipates
Likely to accredit
submitting a statement of intent within the next 2 y. My LHD plans to apply for accreditation but has not submitted a statement of intent. Specifically, my LHD anticipates
Interested in accreditation
submitting a statement of intent at some point after the next 2 y. My LHD has not decided whether to apply for accreditation, my LHD has decided NOT to apply for accreditation, or the state health agency is pursuing accreditation on behalf of my LHD.
Not completed or initiated the accreditation process, not likely to accredit, and not interested in accreditation as an LHD
Note. LHD = local health department. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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after 2 years, we coded this as “interest” in accreditation. We used identical independent variables from both years of the survey to examine the relationship between the 3 accreditation intention variables (interest, likelihood, and completed or initiated accreditation) and LHD characteristics. These variables included binary measures for whether an LHD reported the use of any formal quality improvement (including agency-wide quality improvement and quality improvement within a specific programmatic area), having conducted a CHA within the past 3 years, the presence of a local board of health with governing authority (i.e., directive influence on the LHD), and whether the LHD provides comprehensive primary care services. We determined that a local board of health had governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. We included the variable for whether comprehensive primary care services were provided in the LHD in the analyses. It is assumed that if an organization is practicing clinical services its leaders may be more familiar with the concept and rationale of accreditation because of the universal presence of accreditation throughout clinical care settings. Therefore, an organization providing comprehensive primary care services may be more likely to decide to participate in voluntary national public health accreditation. In addition, we used a measure of the number of full-time equivalent (FTE) employees from the surveys in our models. We categorized this variable on the basis of quartiles for the analyses. Lastly, we included a categorical variable representing the governance structure (i.e., decentralized, centralized, shared). We performed bivariate (v2) and multivariable regression analyses to examine the relationship between the 3 accreditation intention variables (interest, likelihood, and completed or initiated accreditation) and LHD characteristics. We conducted individual logistic regression analyses with interest in accreditation and likely to accredit as
outcome variables, comparing changes between 2010 and 2013 and controlling for independent variables. One additional model had the outcome of completed or initiated accreditation. Because this variable was present in only the 2013 data, we did not examine changes over time. We conducted all analyses using Stata version 12.0 (StataCorp LP, College Station, TX).
RESULTS In 2010, 522 LHDs responded to the survey that included questions about accreditation, and in 2013, 477 responded. Thus, 999 LHD responses were available across both years. Overall, 31.1% of responding LHDs indicated being likely to accredit within the first 2 years, whereas 47.8% reported an interest in accreditation (Table 2). In 2013, 8.8% of
TABLE 2—Descriptive Statistics of Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 LHD Characteristic
2010 (n = 522), No. (%)
2013 (n = 477), No. (%)
Completed or initiated accreditation Yes
NA
34 (8.8)
No
NA
354 (91.2)
Likely to accredit Yes No Interested in accreditation
141 (31.5)
99 (30.6)
306 (68.5)
225 (69.4)
Yes
242 (53.4)
158 (41.3)
No
211 (46.6)
225 (58.7)
Any formal quality improvement Yes
255 (48.8)
280 (58.7)
No
267 (51.2)
197 (41.3)
Lowest quartile (< 9.51) 2nd quartile (9.51–24.36)
129 (25.9) 121 (24.3)
115 (24.5) 119 (25.3)
3rd quartile (24.37–74.00)
126 (25.3)
117 (24.9)
Highest quartile (> 74.00)
121 (24.3)
119 (25.3)
No. of FTE employees
Completed a CHA in the past 3 y Yes
247 (47.5)
269 (57.5)
No
273 (52.5)
199 (42.5)
252 (48.5) 268 (51.5)
205 (63.1) 120 (36.9)
Local board of health with governing authority Yes No Structural governance Decentralized
388 (74.3)
335 (70.2)
Centralized
86 (16.4)
93 (19.5)
Shared
48 (9.2)
49 (10.3)
LHD provides comprehensive primary care Yes
66 (13.0)
48 (10.3)
No
441 (87.0)
419 (89.7)
Note. CHA = community health assessment; FTE = full-time equivalent; LHD = local health department; NA = not applicable. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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responding LHDs had completed or initiated accreditation. Overall, approximately half of the LHDs reported conducting any formal quality improvement (53.6%; n = 535), completing a CHA within the past 3 years (52.2%; n = 516), or having a local board of health with governing authority (54.1%; n = 457). A majority of respondents indicated having a decentralized governance structure (72.4%; n = 723). The LHDs reported varying numbers of FTE employees, ranging from 0 to 6543, with a mean of 110.10 FTE employees across the responding LHDs. The first 25.0% of responding LHDs had 9.50 or fewer FTE employees, the second quartile had between 9.51 and 24.36 FTE employees, the third quartile had between 24.37 and 74.00 FTE employees, and the
fourth quartile included LHDs with more than 74.00 FTE employees.
Bivariate Analyses Several independent variables were associated with intention to seek accreditation in bivariate analyses (Table 3). Across both years of data, LHDs that reported conducting any formal quality improvement were more likely to report an intention to apply for accreditation regardless of how intention was measured. Additionally, a higher proportion of those with more FTE employees (second, third, and fourth quartiles) reported an interest in accreditation across each of the intention to participate variables and both years of data than did LHDs with the fewest FTE employees (the first quartile). For example, LHDs with more than
74.0 FTE employees (the fourth quartile) were more likely to report being likely to accredit in 2013 than did LHDs with 9.5 or fewer FTE employees (61.3% vs 3.8%; P < .001). LHDs that completed a CHA within the past 3 years were significantly more likely to have completed or initiated accreditation (12.56% vs 3.82%; P = .003). LHDs that provided comprehensive primary care in 2013 were significantly more likely to report being likely to accredit (60.90% vs 28.50%; P < .001) or to report an interest in accreditation (67.90% vs 40.00%; P = .004).
Multivariable Analyses Findings from multivariable logistic regressions indicated that LHDs that reported conducting any formal quality improvement were
TABLE 3—Bivariate Relationship Between Likelihood of Participation in Accreditation and Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 2010
LHD Characteristic Any formal quality improvement Yes No No. of FTE employees
Likely to Accredit (n = 141), No. (%) or P
2013 Interested in Accreditation (n = 242), No. (%) or P
Completed or Initiated Accreditation (n = 34), No. (%) or P
Likely to Accredit (n = 100), No. (%) or P
Interested in Accreditation (n = 162), No. (%) or P
< .001
< .001
< .001
< .001
< .001
92 (40.9) 49 (22.1)
143 (43.8) 99 (63.0)
32 (14.8) 2 (1.2)
80 (44.9) 19 (13.0)
118 (54.6) 40 (24.0)
< .001
< .001
< .001
0.0
3 (3.8)
17 (18.3)
< .001
.002
Lowest quartile (< 9.51)
27 (27.5)
44 (43.6)
2nd quartile (9.51–24.36)
18 (17.3)
49 (46.2)
2 (2.0)
14 (16.9)
33 (32.3)
3rd quartile (24.37–74.00)
34 (31.5)
60 (55.1)
16 (17.0)
37 (46.3)
51 (54.3)
Highest quartile (> 74.00)
49 (43.8)
75 (67.0)
16 (18.2)
46 (61.3)
59 (67.1)
Completed CHA in the past 3 y
.33
.25
.003
.02
.02
67 (29.4) 74 (33.6)
116 (50.7) 126 (56.0)
28 (12.6) 6 (3.8)
66 (35.7) 32 (23.7)
104 (46.6) 54 (34.4)
Yes No Local board of health with governing authority
.79
.43
.94
.67
.48
Yes
74 (32.2)
119 (51.5)
17 (9.3)
23 (28.1)
71 (39.0)
No
67 (31.0)
45 (43.7)
Structural governance Decentralized Centralized Shared LHD provides comprehensive primary care
122 (55.2)
10 (9.6)
49 (30.6)
.1
.002
.87
.04
.12
111 (32.4)
191 (54.9)
26 (8.4)
77 (29.1)
122 (39.4)
13 (21.0)
22 (34.9)
5 (10.4)
9 (26.5)
23 (47.9)
17 (39.5) .83
29 (67.4) .87
3 (10.0) .3
14 (51.9) .001
17 (56.7) .004
Yes
20 (32.8)
34 (54.8)
No
118 (31.4)
204 (53.7)
4 (14.3) 30 (8.5)
14 (60.9)
19 (67.9)
85 (28.5)
142 (40.0)
Note. CHA = community health assessment; FTE = full-time equivalent; LHD = local health department. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, can approve the LHD budget, can adopt public health regulations, can set and impose fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials.
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more likely to report interest in or activities leading to accreditation (Table 4). Specifically, LHDs that reported conducting any formal quality improvement were more likely to report being likely to accredit (odds ratio [OR] = 2.41; 95% confidence interval [CI] = 1.65, 3.50), being interested in accreditation (OR = 2.32; 95% CI = 1.67, 3.20), or having completed or initiated the accreditation process (OR = 7.99; 95% CI = 1.79, 35.60). When comparing trends over time, interest in accreditation was significantly less likely in 2013 than in 2010 (OR = 0.56; 95% CI = 0.41, 0.77). In general, the number of FTE employees was significantly related to the intention to participate in accreditation after controlling for other variables. Specifically, LHDs in the second quartile (OR = 0.09; 95% CI = 0.02, 0.43) were significantly less likely to be likely to accredit than were LHDs with the highest numbers of FTE employees. (Note that there were no LHDs in the first quartile that had
accredited or initiated the accreditation process.) Similarly, LHDs with the fewest FTE employees (bottom 2 quartiles) were less likely to be interested in accreditation than were those with the most FTE employees (OR = 0.29; CI = 0.18, 0.47 for quartile group 1; OR = 0.41; CI = 0.26, 0.64 for quartile group 2). LHDs that indicated having completed a CHA within the past 3 years were significantly more likely to report completing or initiating the accreditation process (OR = 3.64; 95% CI = 1.36, 9.74) but not the other outcome measures. Lastly, LHDs in centralized governance systems were significantly less likely to report an interest in accreditation than were LHDs with decentralized governance (OR = 0.57; CI = 0.34, 0.92).
DISCUSSION With the intention of positively influencing population health, efforts to encourage voluntary participation in public health department
accreditation are under way.6 More information about factors that relate to the likelihood of participating in accreditation is necessary in developing targeted strategies for encouraging LHDs to become accredited. Using secondary data collected by the NACCHO, we examined LHD factors that relate to intention to participate in national voluntary accreditation in 2010 and 2013. Data from 2010 and 2013 indicate that LHDs with formal quality improvement programs are significantly more inclined to pursue accreditation in both the near term and the future. Ongoing efforts to expand and encourage the use of formal quality improvement in LHDs may positively affect readiness and willingness to complete the accreditation process. However, quality improvement may also be a proxy measure for an unmeasurable LHD attribute that predicts accreditation. LHDs that conduct quality improvement already are likely different from LHDs that do not in ways that may influence pursuing and
TABLE 4—Multivariable Relationship Between the Likelihood of Participating in Accreditation and Local Health Department Characteristics: Profile Survey of Local Health Departments, United States, 2010 and 2013 LHD Characteristic Any formal quality improvement
Completed or Initiated Accreditation, 2013 Only (n = 266), OR (95% CI)
Likely to Accredit (n = 712), OR (95% CI)
Interest in Accreditation (n = 773), OR (95% CI)
7.99** (1.79, 35.60)
2.41*** (1.65, 3.50)
2.32*** (1.67, 3.20)
Year of self-report 2010 (Ref) 2013 No. of FTE employees
NA
1.00
NA
1.04 (0.73, 1.48)
1.00 0.56*** (0.41, 0.77)
. . .a
0.23*** (0.13, 0.39)
0.29*** (0.18, 0.47)
0.09** (0.02, 0.43)
0.24*** (0.14, 0.40)
0.41*** (0.26, 0.64)
3rd quartile (24.37–74.00)
0.87 (0.38, 1.99)
0.59** (0.38, 0.92)
0.68*** (0.44, 1.06)
Highest quartile (> 74.00; Ref)
1.00
Lowest quartile (< 9.51) 2nd quartile (9.51–24.36)
1.00
1.00
3.64* (1.36, 9.74)
0.82 (0.58, 1.17)
0.86 (0.63, 1.17)
Local board of health with governing authority
1.74 (0.72, 4.21)
1.09 (0.76, 1.57)
0.87 (0.62, 1.20)
Structural governance Decentralized (Ref)
1.00
1.00
0.92 (0.23, 2.85)
0.57 (0.32, 1.04)
Completed a CHA in the past 3 y
Centralized
1.00 0.57* (0.35, 0.92)
Shared
0.42 (0.28, 3.07)
0.84 (0.27, 2.55)
1.20 (0.51, 2.83)
LHD provides comprehensive primary care
0.82 (0.23, 2.86)
0.78 (0.45, 1.35)
0.78 (0.46, 1.31)
Note. CHA = community health assessment; CI = confidence interval; FTE = full-time equivalent; LHD = local health department; NA = not applicable; OR = odds ratio. We determined completed or initiated accreditation process if an LHD indicated having already achieved accreditation, submitted an application for accreditation, or submitted a statement of intent to pursue accreditation. We determined local board of health with governing authority if an LHD indicated that any 3 of the following 5 characteristics were true of the local board of health’s authority: can hire or fire the agency head, approves the LHD budget, can adopt public health regulations, sets and imposes fees, can impose taxes for public health. The Profile Survey of Local Health Departments is administered by the National Association of County and City Health Officials. a There were no observations (in this category) that had been accredited at the time of the survey. *P < .05; **P < .01; ***P < .001.
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achieving accreditation. For example, LHDs that decide to pursue accreditation may have more effective leadership or more resources than do LHDs not conducting quality improvement. This is one of the challenges facing national voluntary accreditation—LHDs that are not already focused on quality may actually avoid accreditation altogether despite several years of quality improvement support and encouragement. This may further distinguish LHDs that are focused on performance improvement from those that are not, thus the voluntary element of accreditation may not result in widespread quality improvement. Nonetheless, because a primary goal of accreditation is to strengthen health department performance, a strong foundation in quality improvement is instrumental in overall agency improvement.15 Therefore, there must be a better understanding of what predicates quality improvement in LHDs. Two previous studies have examined internal16 and external17 factors that relate to the use of quality improvement in LHDs. In 2010 Beitsch et al. found that larger LHDs and LHDs with centralized governance structures reported higher rates of quality improvement implementation.16 In 2013 Yeager et al. found that LHDs were less likely to report engaging in quality improvement when faced with greater public health concerns, such as increased obesity rates or smoking prevalence.17 Yeager et al. hypothesized that greater complexity in a LHD’s external environment adds more difficult and time-consuming issues and causes less focus on strategic efforts to improve internal quality. Future research that provides more information on organizational culture or other possible factors that distinguish LHDs that engage in quality improvement and accreditation would be valuable in planning widespread quality improvement and accreditation. To date, substantial resources have been invested by government and philanthropy to develop and further strengthen the quality improvement capacity across health departments nationally through programs such as the National Public Health Improvement Initiative and the Multi-State Learning Collaborative.1,4,5,18,19 This ties in directly with our findings and suggests that these investments may provide dividends in the form of future
participation in the national voluntary accreditation program if investment support continues. It also indicates that additional future sustainable investment should be considered to maintain a steady pipeline of LHDs intending to seek accreditation and ultimately reaccreditation. Recent qualitative research examining the effects of public health accreditation in the state of North Carolina found that LHDs reported improved funding and improved relationships with partners after becoming accredited.1 Clearly, more research into the value of accreditation and efforts to encourage quality improvement and performance management is needed. Considering changes over time, interest in accreditation was the only thing that differed between 2010 and 2013. Therefore, although interest in accreditation has significantly decreased over time, there was no change in the number of LHDs that reported being likely to accredit. As accreditation processes have become more widely understood, LHDs may be moving from being interested in accreditation to being likely to participate and may be replacing LHDs that have moved from being likely to participate to having initiated or completed the accreditation process. This may also indicate that LHDs that were not previously interested are not becoming interested and, thus, are not replacing the numbers of LHDs that are moving further along the spectrum toward accreditation. Although it is important to start by examining the factors that relate to the decision to participate in accreditation, future research should examine the factors that matter in an LHD’s decision to not participate in accreditation. Key findings also indicate that having completed a CHA within the past 3 years was positively related to having initiated or completed the accreditation process in 2013. The role that the CHA plays in accreditation intent must be interpreted with the understanding that CHAs are an accreditation prerequisite and must be completed no more than 5 years before the date of application. In 2010 Shah et al. found a negative association between recent completion of a CHA and intention to seek accreditation.12 However, although raw data indicate that a higher proportion of LHDs responding in 2013 completed the CHA within
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the past 3 years, are interested in accreditation, and are likely to accredit, we found no significant differences in bivariate or multivariable analyses. The negative association between the recent completion of a CHA and intention to seek accreditation that Shah et al. found and the lack of any association despite the raw increase in recently completed CHAs that we found suggest that completing a CHA alone does not motivate LHDs to want to participate in accreditation. This may be because LHDs that have completed a CHA are familiar with the amount of resources and effort required for such tasks and may be concerned about committing to another resource-intense endeavor such as accreditation. Drawing any conclusions about this phenomenon was outside the scope of our study, but this is a topic that should be considered in future accreditation studies. It is also important to note that LHDs with higher numbers of FTE employees were almost always more likely to indicate an intention or likelihood to participate in accreditation. It is possible that having more resources, especially human resources, translates into the ability to do more intensive planning and assessment associated with the accreditation process. Interestingly, although empirical data are not yet available from the Public Health Accreditation Board, an anecdotal review of the Public Health Accreditation Board Web site suggests that LHDs of all sizes have initiated the accreditation process.6 As more empirical data become available, future studies will be able to examine the relationship between LHD size and other factors, such as experiences with the accreditation process and perceived benefits of accreditation. LHD size may also relate to the ease of the process and whether the LHD identifies benefits from it but may not itself be a bar to pursuing accreditation successfully. Lastly, in multivariable models, LHDs in states that have centralized governance models were less likely to report interest in accreditation, which may be related to having less authority to make strategic decisions for the LHD. Additionally, in centralized systems there is often shared documentary evidence, which may facilitate system-wide application rather than individual LHD pursuit of accreditation. There were no significant relationships
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between intention to apply for accreditation and the presence of a local board of health with governing authority or the provision of primary care among LHDs that responded in 2010 or 2013.
Strengths and Limitations Our study has numerous noteworthy strengths and limitations. To our knowledge, it is the first study to examine factors associated with LHD intention to apply for accreditation since national voluntary accreditation began. Additionally, by examining these factors in 2010 and 2013 it is possible to see if there are any aggregated changes since national accreditation has been under way. In terms of limitations, the differences in questions and available responses on the 2010 and 2013 Profile Surveys add a layer of complexity when trying to examine changes over time. Additionally, the intent to apply for accreditation and the nature of quality improvement within the LHD are both self-reported indicators that may be subject to social desirability bias. It would be interesting to examine changes in accreditation intentions across individual LHDs; however, this was not plausible because of data limitations. Lastly, although the NACCHO profile surveys provide valuable data about LHDs, the representatives who completed the survey may not be familiar with all aspects of LHDs’ plans and operations.
Conclusions Our results may provide a future roadmap for stakeholders seeking to support national voluntary accreditation participation among LHDs. In addition they validate the efforts already completed or in process by funders like the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation. Ongoing support for the development of formal quality improvement and CHAs could serve to lessen the reluctance of LHDs pondering their future course. However, with the recent loss of National Public Health Improvement Initiative funding through rare congressional action,20---22 reversal of the positive trends observed to date is possible, and further study is indicated to track the impact of diminished specific federal support that strengthens the readiness capacity of health departments to apply for accreditation. j
About the Authors Valerie A. Yeager is with the Tulane School of Public Health and Tropical Medicine, New Orleans, LA. Alva O. Ferdinand is with the Texas A&M Health Science Center and School of Public Health, College Station, TX. Leslie M. Beitsch is with the Florida State University College of Medicine, Tallahassee. Nir Menachemi is with the University of Alabama, Birmingham School of Public Health, Birmingham. Correspondence should be sent to Valerie Yeager, 1440 Canal Street, Suite 1900, New Orleans, LA 70112 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 1, 2014.
Contributors
9. Ingram RC, Scutchfield FD, Charnigo R, Riddell MC. Local public health system performance and community health outcomes. Am J Prev Med. 2012;42(3):214---220. 10. Riley WJ, Lownik EM, Scutchfield FD, Mays GP, Corso LC, Beitsch LM. Public health department accreditation: setting the research agenda. Am J Prev Med. 2012;42(3):263---271. 11. Madamala K, Sellers K, Beitsch LM, Pearsol J, Jarris P. Quality improvement and accreditation readiness in state public health agencies. J Public Health Manag Pract. 2012;18(1):9---18. 12. Shah GB, Beatty K, Leep, C. Do PHAB accreditation prerequisites predict local health departments’ intentions to seek voluntary national accreditation? Front Public Health Serv Syst Res. 2013;2(3):Article 4.
V. A. Yeager and L. M. Beitsch wrote the article with revisions and content contributions from N. Menachemi and A. O. Ferdinand. All authors collectively designed this study and analyzed and interpreted the data.
13. National Association of County and City Health Officials. National profile of local health departments. 2010. Available at: http://nacchoprofilestudy.org/wpcontent/uploads/2014/01/2010_Profile_main_reportweb.pdf. Accessed July 15, 2014.
Acknowledgments
14. National Association of County and City Health Officials. 2013 National Profile of Local Health Departments. Washington, DC; 2013.
Early findings from this study were presented at the Keeneland Conference for Public Health Services and Systems Research in April 2014.
Human Participant Protection This study was exempt from human participant ethical review because no human participants were involved.
References 1. Davis MV, Cannon MM, Stone DO, Wood BW, Reed J, Baker EL. Informing the national public health accreditation movement: lessons from North Carolina’s accredited local health departments. Am J Public Health. 2011;101(9):1543---1548. 2. Beitsch LM, Corso LC, Davis MV, Joly BM, Kronstadt J, Riley WJ. Transforming public health practice through accreditation (a user guide for the special accreditation issue). J Public Health Manag Pract. 2014;20(1):2---3. 3. McLees AW, Thomas CW, Nawaz S, Young AC, Rider N, Davis M. Advances in public health accreditation readiness and quality improvement: evaluation findings from the national public health improvement initiative. J Public Health Manag Pract. 2014;20(1): 29---35. 4. Monteiro E, Fisher JS, Daub T, Zamperetti MC. CDC/NACCHO Accreditation Support Initiative: advancing readiness for local and tribal health department accreditation. J Public Health Manag Pract. 2014;20(1): 14---19. 5. Thielen L, Leff M, Corso L, Monteiro E, Fisher JS, Pearsol J. A study of incentives to support and promote public health accreditation. J Public Health Manag Pract. 2014;20(1):98---103.
15. Davis MV, Mahanna E, Joly B, et al. Creating quality improvement culture in public health agencies. Am J Public Health. 2014;104(1):e98---e104. 16. Beitsch LM, Leep C, Shah G, Brooks RG, Pestronk RM. Quality improvement in local health departments: results of the NACCHO 2008 survey. J Public Health Manag Pract. 2010;16(1):49---54. 17. Yeager VA, Menachemi N, Ginter PM, Sen BP, Savage GT, Beitsch LM. Environmental factors and quality improvement in county and local health departments. J Public Health Manag Pract. 2013;19(3): 240---249. 18. Thomas CW, Pietz H, Corso L, Erlwein B, Monroe J. Advancing accreditation through the national public health improvement initiative. J Public Health Manag Pract. 2014;20(1):36---38. 19. Mays G, Beitsch LM, Corso L, Chang C, Brewer R. States gathering momentum: promising strategies for accreditation and assessment activities in multistate learning collaborative applicant states. J Public Health Manag Pract. 2007;13(4):364---373. 20. Executive Office of the President of the United States. Budget of the United States Government, Fiscal Year 2015. Washington, DC: US Government Printing Office; 2014. 21. National Association of County and City Health Officials. Local Health Department Budget Cuts and Job Losses: Findings From the 2014 Forces of Change Survey. Washington, DC; 2014. 22. Association of State and Territorial Health Officials. Budget Cuts Continue to Affect the Health of Americans. Washington, DC; 2013.
6. Public Health Accreditation Board. Available at: http://www.phaboard.org. Accessed June 24, 2014. 7. Joly BM, Polyak G, Davis MV, et al. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract. 2007;13(4): 349---356. 8. Kanarek N, Stanley J, Bialek R. Local public health agency performance and community health status. J Public Health Manag Pract. 2006;12(6):522---527.
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