Public Health System Accreditation

SESSION AUDIO:
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MODERATORS:
Judith A. Monroe, M.D., FAAFP

PANELISTS:

Glen Mays, Ph.D., M.P.H.

Accreditation and Local Variation in H1N1 Response in North Carolina

Co-Investigators: J. Wayne, Ph.D., M. Davis, Dr.P.H., M.S.P.H., C. Marti, B.S.N., M.P.H.

Accreditation of public health agencies has received considerable policy attention because of its potential to promote consistency, interoperability, and effectiveness in practice.  While a national accreditation program is still under development, state-based programs exist in North Carolina and several other states. The 2009 outbreak of novel H1N1 influenza provided an opportunity to test the preparedness and response capabilities of public health agencies and to compare the responses of accredited and non-accredited agencies.  This study seeks to (1) describe the nature and timing of local public health responses to H1N1 in North Carolina; (2) compare the responses taken by accredited and non-accredited agencies; and (3) identify factors that facilitated and inhibited local responses.  We used a retrospective case-control study design with nine NC local public health jurisdictions stratified by accreditation status and matched based on size and H1N1 case volume. Data were obtained through a closed-form questionnaire administered to local preparedness coordinators, and through on-site focus groups held with organizations involved in H1N1 activities in each community during August through October 2009.  Bayesian latent-variable models for multiple indicators were used to compare responses across agencies.  Agencies varied widely in the nature and timing of their H1N1 activities.  Accredited agencies performed a significantly larger scope of activities in response to the H1N1 outbreak compared to non-accredited agencies (p<0.05), and these differences were apparent across all domains of activity including planning, incident command, investigation, communication, and response and mitigation activities.  Additionally, accredited agencies appeared to implement these activities in a timelier manner, particularly for incident command and investigation activities (p<0.05).  Findings suggest that accreditation programs may be effective in motivating and/or documenting enhanced preparedness capacities among agencies that undergo accreditation.  How much of these differences are due to self-selection vs. improvement remains for further investigation.

John Wayne, Ph.D., M.B.A.

Accreditation and Public Health Preparedness in North Carolina: Conclusions from the 2005-2008 NACCHO Surveys

Co-Investigators: G. Mays, Ph.D., M.P.H., M. Davis, Dr.P.H., M.S.P.H., J. Bellamy, CNMT, M.P.H., C. Marti, B.S.N., M.P.H., B. Williams-Wood, M.P.H.

Local public health departments (LPHDs) occupy pivotal positions within the nation's emergency preparedness (EP) and response systems because of their statutory authority to perform public health (PH) functions and their ability to coordinate the public health actions of many other community organizations. Accreditation of PH agencies has received considerable policy attention because of its potential to promote consistency and interoperability in PH practice, and its ability to encourage participation in other beneficial initiatives. This study was initiated by the NCPERRC to assess the impact of one of the nation's first state-based public health agency accreditation programs on local emergency preparedness and response capabilities. The 2005-2008 NACCHO National Profiles of Local Health Departments (NPLHD) and LPHD accreditation information are the data sources for this study. The 2005-08 NPLHD included 80 common responses in NC (10 accredited in or before 2005, and 43 in or before 2008). EP activities included: Developing an EP plan; Legal review of the plan; Participating in drills; Assessing competencies; and Providing training. In 2005 accredited LPHDs were more likely to have performed all EP activities and were significantly more likely to have had a legal review of the plan (p < 0.01) and assessed competencies (p < 0.05). In 2008 accredited LPHDs were more likely to have performed most EP activities but the differences decreased.  Longitudinal results show preparedness decreasing both nationally and in NC for some measures.  However, for the LPHDs who were “not-accredited in 05 but would be accredited in 2008,” preparedness activities increased. The results show: that the preparedness and response capabilities of communities served by accredited LPHAs exceed those of non-accredited LPHAs. The ability of accreditation measures to detect meaningful differences in preparedness will be discussed. Structural and organizational attributes of LPHAs that influence their preparedness capabilities and accreditation outcomes will be presented.

Michael Meit, M.A., M.P.H.
Perspectives on Accreditation Standards: How Size and Rurality of Health Departments Shape Opinions
Co-Investigators: J. Kronstadt, M.P.P., A. Brown

This study explores whether local health department (LHD) representatives’ perspectives on the measures proposed for inclusion in the Public Health Accreditation Board (PHAB) national voluntary accreditation program differ based on the size and rurality of the LHD. Our analysis uses data collected by NORC on behalf of PHAB through the public vetting of the draft PHAB standards conducted in 2009. For each of the 109 proposed measures, respondents were asked to indicate the likelihood that their LHD would be able to meet the measure. For each of the domains (or groupings of measures, based on the 10 Essential Public Health Services (EPHS)), the team ran t-tests to determine if there are significant differences between small and non-small LHDs and rural and non-rural LHDs. Quantitative findings will be augmented by relevant comments submitted by survey respondents. Our analysis suggests that small and rural LHDs are less likely to believe that their LHDs can comply with the measures than larger and less rural LHDs. Measures in domains related to administrative capacity and governance, as well as EPHS 3, 5, and 6 pose particular challenges to these health departments. In addition, rural LHDs are less likely to agree that they will apply for accreditation. Accreditation represents an opportunity to engage HDs nationwide in performance improvement. Understanding the concerns of health departments with varying characteristics will be crucial in assuring that accreditation is accessible to all health departments.  Given that the majority of LHDs are small, the implications on accreditation participation may be particularly significant. The analyses described here demonstrate the value of this relatively new data set containing information about LHDs’ capacity. This may also serve as a baseline for data gathered once accreditation is rolled out nationally in 2011.

Mary Davis, Dr. P.H., M.S.P.H.

Accreditation Outcomes: Choosing the Right Indicators

Co-Investigators: J. M. Bowling, Ph.D., M. Cannon, M.P.H., D. Cilenti, Dr.P.H., M.P.H., M.S.W.

We examined whether 1) there are differences on performance indicators among accredited and non-accredited NC LHDs over a 10-year period and 2) there is an association between LHD performance on domains of leadership, community engagement, and policy implementation and the performance indicators and if this association is moderated by LHD accreditation status. Performance indicators are among LHD annual reporting requirements to the state. Nine of these had sufficient variability to be used in this study. Survey data on the domains of leadership, community engagement, and policy implementation were collected previously. We examined change over time in LHD rates (improvement or decline) by computing individual slopes of the logs of rates for each of the nine indicators. We also examined average rates of each indicator variable for each LHD over the years. We created composite binary variables that measured change (greater than average improvement) for each LHD and level (greater than average percent or rate of indicator). Binary variables were summed over all nine indicators and formed the performance outcome measure. Single year means of each indicator for 2008 data were computed to assess relationships between the domains of leadership, community engagement, and policy implementation and accreditation. We found no significant differences among accredited and non-accredited LHDs on the performance outcome measure or composite binary variables. Regarding performance on the domains of leadership, community engagement, and policy implementation, there were mixed findings with no discernible pattern related to accreditation. The lack of significant performance differences may be due to: a) performance indicators studied may not be appropriate accreditation outcome measures; b) there may have been insufficient time for the NCLHDA program to affect LHD performance on these indicators; and c) non-accredited LHDs are exposed to the accreditation benchmarks.