Quality Improvement & Accreditation
Room: Blackberry Lilly
Wednesday, April 22, 2015, 9:00 to 10:30 AM
Moderator: Nikki Rider, ScD, MPP
Cassandra Martin Frazier, MPH, CHES
Improving the Practice and Performance of Public Health Departments: Results from the Evaluation of CDC’s National Public Health Improvement Initiative
Co-Investigator(s): Anita McLees, MPH, MA; Nikki Rider, ScD, MPP; Saira Nawaz, PhD, MPH; Laura Hsu, DrPH, MPH; Sarah McKasson, MPH; & Andrea Young, PhD
Background: From 2010 – 2014, the Centers for Disease Control and Prevention (CDC) implemented the National Public Health Improvement Initiative (NPHII). NPHII’s objectives were to (1) increase readiness for public health accreditation, (2) improve efficiency and/or effectiveness through quality improvement (QI), and (3) increase performance management capacity of public health agencies. Supported by the Prevention and Public Health Fund of the Affordable Care Act, the CDC funded 73 state, territorial, local and tribal (STLT) public health agencies. Research Objective: The NPHII evaluation sought to determine the extent to which the initiative supported improved public health practice and performance by examining whether awardees met the initiative’s objectives. The evaluation also measured reach of support to other public health organizations for QI, performance management, and/or accreditation readiness. Data Sets and Sources: Self-reported data were collected from all awardees using two data sources: annual surveys and progress reports. Four rounds of the survey were conducted between March 2011 and January 2014 to measure progress in performance management capacity. Progress reports provided data on the Public Health Accreditation Board (PHAB) prerequisites, QI initiatives and infrastructure for performance improvement. These data were collected semi-annually each initiative year. There was a 100% completion rate for each round of the surveys and progress reports. Study Design: Non-experimental evaluation using a multi-strand, sequential mixed-method design. Analysis: Descriptive statistics and cross-time analysis were used to determine status against NPHII objectives, and comparison analysis used to determine differences among STLTs. Principal Findings: As of April 2014, 81% of awardees completed one or more PHAB prerequisites; 71% completed a health assessment, 53% completed a health improvement plan, and 69% completed an organizational strategic plan. Forty-eight percent of awardees completed all three prerequisites. Additionally, 82% of awardees completed an organizational self-assessment against the PHAB Standards and Measures v.1.0; 58% of awardees reported closing gaps and documented progress in achieving standards during the last two years of NPHII. The majority of awardees (89%) completed at least one QI initiative. Ninety-five percent of these awardees demonstrated increased efficiencies and/or effectiveness. The percent of awardees that established all four NPHII-required components of an organization-wide performance management system increased from 10% at baseline to 32%. During the final year, half of the awardees (51%) used NPHII funds to support NPHII-related activities by other health organizations. Over 160 organizations received mini-grants from awardees, and nearly 800 organizations received other types of support, such as training and technical assistance. Conclusions: NPHII awardees increased the efficiency and effectiveness of their program-specific or agency-wide operations and services, and improved their readiness for PHAB accreditation. Some progress was made toward increasing performance management capacity, specifically establishing organization-wide performance management systems. Implications for Public Health Practice and Policy: NPHII aimed to improve accountability, effectiveness and efficiency of public health services and programs as a means to improve the quality of the public health system. The evaluation findings show the benefit of and need for continued systematic and comprehensive approaches to building readiness for accreditation, QI and performance management within public health agencies.
Kate Beatty, PhD, MPH
Accreditation Seeking Decisions in Local Health Departments
Co-Investigator(s): Tyler Carpenter, BS; Paul Erwin, DrPH; & Ross Brownson, PhD
Background: Accreditation of local health departments (LHDs) has been identified as a crucial strategy for strengthening the public health infrastructure. Research Objective: To identify the role of organizational and structural factors on accreditation-seeking decisions of LHDs. Of particular interest is the effect of rurality on the likelihood of seeking accreditation through the Public Health Accreditation Board (PHAB). Data Sets and Sources: Data were obtained from the NACCHO 2013 National Profile of Local Health Departments Study (2013 Profile Study). The 2013 Profile Study includes a core questionnaire (core,) that was sent to all LHDs, and two modules, sent to a sample. Variables were selected from the core and module one for this project. LHDs were coded as “urban”, “micropolitan”, or “rural” based on Rural/Urban Commuting Area codes for the zip code of the LHD address. “Micropolitan” includes census tracts with towns of between 10,000 and 49,999 population and census tracts tied to these towns through commuting. “Rural” includes census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Both “micropolitan” and “rural” categories are considered rural by the Federal Office of Rural Health Policy. Study Design: Cross-sectional. Analysis: Binary logistic regression analysis was conducted to predict PHAB accreditation decision. The variable for PHAB accreditation decision was created from the 2013 Profile Study question, “Which of the following best describes your LHD with respect to participation in the PHAB’s accreditation program for LHDs?” LHDs that selected “My LHD has submitted an application for accreditation” or “My LHD has submitted a statement of Intent” were coded as “Seeking PHAB Accreditation.” LHDs that selected “My LHD has decided NOT to apply for accreditation” or “The state health agency is pursuing accreditation on behalf of my LHD” were coded as “Not Seeking PHAB Accreditation.” Predictors included variables related to rurality, governance, funding, and workforce. Findings: From a sample of 448, approximately 6% of LHDs surveyed had either submitted their letter of intent or full accreditation application. Over two-thirds were either not seeking accreditation or deferring to the state agency. LHDs located in urban communities were 30.6 times (95% CI: 10.1, 93.2) more likely to seek accreditation compared to rural LHDs. LHDs with a local board of health were 3.5 times (95% CI: 1.6, 7.7) more likely to seek accreditation (controlling for rurality). Additionally, employing an epidemiologist (aOR=2.4, 95% CI: 1.2, 4.9), having a strategic plan (aOR=14.7, 95% CI: 6.7, 32.2), and higher per capita revenue (aOR=1.02, 95% CI: 1.01, 1.02) were associated with higher likelihood of seeking PHAB accreditation. Conclusions: Specific geographic, governance, leadership, and workforce factors were associated with intention to seek accreditation. Implications: Rural LHDs are less likely to seek accreditation. This lower likelihood of seeking accreditation likely relates to a myriad of challenges (e.g., lower levels of staffing and funding). Simultaneously, rural populations experience health disparities related to risky health behaviors, health outcomes, and access to medical care. Through accreditation, rural LHDs can become better equipped to meet the needs of their communities.
Valerie A. Yeager, DrPH
A Longitudinal Analysis of National Voluntary Public Health Accreditation: Are More Local Health Departments Intending to Take Part?
Co-Investigator(s): Jiali Ye, PhD; Jessica Kronstadt, MPP; Nathalie Robin, MPH; Carolyn J. Leep, MPH, MS; & Leslie M. Beitsch, MD, JD
Background: As a tangible demonstration of how important accreditation may be for improving organizational performance of governmental public health, the Public Health Accreditation Board (PHAB) has been tasked to ensure that, by the end of 2015, at least 60% of the US population is served by accredited health departments. Despite the likelihood of reaching this milestone, the majority of local health departments (LHDs) have not initiated the accreditation process. Approximately 10% of LHDs had initiated the process as of July 2014. Thus, it is important to continue to explore whether more LHDs are queuing up and if interest in accreditation has changed over time, specifically during the period spanning the first year of accreditation. Research Objective: This paper examines LHD participation and intentions to participate in national voluntary accreditation and reasons for not seeking accreditation. Specifically, it compares the results of national surveys among LHDs in 2010, 2013, and 2014. Data Sets and Sources: Data from the 2014 Forces of Change Survey and the 2010 and 2013 NACCHO Profile studies were used. Study Design: Longitudinal cohort study Analysis: Proportion analyses were conducted to assess changes across time periods. Multivariate analyses examined the LHDs’ level of engagement in PHAB accreditation in relation to the main independent variable of state health department (SHD) participation in accreditation controlling for LHD governance and population size. Principal Findings: 2014 data indicated that 1% of LHDs achieved accreditation and 11% had submitted an application or a statement of intent, compared to 6% of LHDs that submitted an application or a statement of intent in 2013. The percent of LHDs that indicated they planned to apply for accreditation but had not submitted a statement of intent declined from 27% in 2013 to 22% in 2014. In multivariate models controlling for governance category and jurisdiction population size, LHDs in states where the state health department participated in e-PHAB had higher odds of being favorably inclined toward accreditation than those located in states where the SHD was not in the e-PHAB system (OR=2.82, 95% C.I.: 1.81-4.41). Across 2013 and 2014 and across small and large LHDs, the top two reasons for deciding not to apply for accreditation were the time/effort required exceeded the benefits (67%) and fees were too high (46%). Conclusions: LHDs in accreditation “committed” states, with other independent variables being controlled, are almost three times more likely to be favorably disposed toward seeking accreditation. Health department governance structure and jurisdiction population size are associated with LHD accreditation decisions. The top two reasons LHDs indicated for not proceeding with accreditation were time/effort exceed benefit and fees perceived as too high. Implications for Public Health Practice and Policy: A major contribution of this research is delineating the key role SHDs play as mediators influencing LHD attitudes toward accreditation. LHDs with state or shared governance systems were over nine times more likely to be favorably inclined toward accreditation. In addition, the percent of locally governed LHDs that were favorably inclined declined significantly from 2010 to 2014. Perhaps LHDs with state/shared governance have economies of scale (e.g. resources to cover fees and provide capacity) useful in preparing for accreditation – something that LHDs with local governance may not have. This phenomenon may provide some justification for LHDs with local governance structures to consider accreditation through the multijurisdictional option.