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Accreditation and Quality Improvement of Rural Health Departments: Opportunities, Challenges and Tools . Brittany Kennedy, MPH Caitlin Labranche, MPH Indiana Public Health Association . IRHA Conference: June 11, 2009 . Outline. Accreditation Overview

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Accreditation and Quality Improvement of Rural Health Departments: Opportunities, Challenges and Tools

Brittany Kennedy, MPH Caitlin Labranche, MPHIndiana Public Health Association

IRHA Conference: June 11, 2009

  • Accreditation Overview
  • Quality Improvement To Move You Toward Accreditation
  • Quality Improvement Tools You Can Use
  • Rural Health Departments Accreditation Experiences
  • Conclusion
public health accreditation board phab
Public Health Accreditation Board (PHAB)
  • National Board established to shape national public health accreditation for state and local health departments
  • Support from Centers for Disease Control (CDC) and The Robert Wood Johnson Foundation (RWJF)
  • Comprised of health officers, local boards of health, policy makers, etc.
  • Partnered with NACCHO, ASTHO, and NALBOH
voluntary accreditation
Voluntary Accreditation
  • The goal of a voluntary national accreditation program is to improve and protect the health of the public by advancing the quality and performance of state and local public health departments
operational definition
Operational Definition:
  • Defines what responsibilities every person, regardless of where they live, should reasonably expect their local health departments to fulfill.
  • Is the framework for the national accreditation standards
accreditation process

Readiness Review

Re-Accreditation / Continuous QI

Appeals Process

Self Assessment

Final Determination

Accreditation Team Site Visit

Accreditation Staff Review

Recommendation Report

Accreditation Process
ipha at the state level
IPHA at the State Level
  • Accreditation / Quality Improvement Steering Committee
  • Accreditation Advisory Body
  • Working with ISDH to give a common message to all local health departments
ipha at the district level
IPHA at the District Level
  • Opportunity to network with other LHDs
  • Receiving lots of feedback
  • Eight of the ten preparedness districts
  • 50 counties over 100 LHD staff have attended
ipha at the local level
IPHA at the Local Level
  • Multi-state Learning Collaboratives
  • One on one accreditation information – staff meetings or selected staff at local health department
  • Boards of Health accreditation information
where are we going from here
Where are we going from here?
  • Quality improvement tools and resources
  • Technical assistance to local health departments
    • Planning and monitoring
    • Facilitating meetings and creating networking opportunities
    • Health develop personal timelines for accreditation
    • Tools and strategies tailored to your health department
  • Future Education
where can you go from here
Where can you go from here?
  • Follow PHAB Progress at – sign up for updates
  • Start talking to the key people in your community
  • Prepare
    • Employ the National Public Health Performance Standards
    • Review the Operational Definition
  • Call on IPHA to come to a staff meeting, BoH meeting, or just to discuss your LHD needs
quality improvement principles
Quality Improvement Principles
  • W. Edwards Deming – grandfather of QI
    • Work in Japan post WWII
    • Purpose is to stay in business, provide jobs
  • Juran’s 85-15 Principle
    • 85% of problems are result of “system”
    • 15% or less due to employee error.
why quality improvement in public health
Why Quality Improvement in Public Health?

Quality Improvement produces amazing side effects; not only improved performance but:

  • Employees take more pride in their work.
  • Interdepartmental projects break down silos.
  • Employee morale is improved.

Deming: A firm believer that people want to do good work, are demoralized when systemic problems produce barriers.

quality improvement





Quality Improvement
  • Systematic way of looking at work processes, identifying areas for improvement, making changes and determining if they are effective.
  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?
quality improvement tools check sheet
Quality Improvement Tools - Check sheet

Purpose: Collect data in an organized manner.

Telephone Interruptions

Excerpted from Nancy R. Tague’sThe Quality Toolbox, Second Edition, ASQ Quality Press, 2004, pages 141-142.

quality improvement tools pie chart
Quality Improvement Tools – Pie Chart

Purpose: Display the volume or quantity of one item in relation to others.

quality improvement tools bar chart
Quality Improvement Tools – Bar Chart

Purpose: Arrange data for quick and easy comparison.

quality improvement tools line graph
Quality Improvement Tools – Line Graph

Purpose: Display the output of a process over time.

quality improvement tools histogram
Quality Improvement Tools - Histogram

Purpose: Determine how data are distributed.

quality improvement tools flowchart
Quality Improvement Tools – Flowchart

Purpose: Differentiate

between activities

in a process.

RFFlow Professional Flowcharting,

quality improvement tools barriers and aids
Quality Improvement Tools – Barriers and Aids

Purpose: Document the hindering and supporting factors that influence a planned activity.

quality improvement tools barriers and aids25
Quality Improvement Tools – Barriers and Aids

Purpose: Document the hindering and supporting factors that influence a planned activity.

quality improvement tools cause and effect diagram
Quality Improvement Tools – Cause and Effect Diagram

Purpose: Identify a set of related causes that lead to an effect or problem.

quality improvement tools brainstorming
Quality Improvement Tools - Brainstorming

Collect a large number of ideas from a group of people. Many ideas, quickly as possible.

  • One-at-a-time (everyone speaks)
  • Open door (call out ideas)
  • Write-it-down (confidentiality)


  • Be creative
  • Build on ideas of others
  • No critique allowed
quality improvement tools interviews surveys
Quality Improvement Tools – Interviews & Surveys


  • Purpose: Collect data from direct conversation.


  • Purpose: Collect data from a large number of people.
quality improvement resources
Quality Improvement Resources
  • Everyone’s Problem Solving Handbook, Michael R Kelley
  • Public Health Memory Jogger II,
  • Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook,
  • D Tews, MK Sherry, J Butler, A Martin.
  • NPHPSP Online Resource Center.
  • NACCHO Model Practices,
  • Economic Research Service Rural-Urban Commuting Areas
    • Coded and defined by the US Dept of Agriculture
    • Rural : 4-10 coding
    • A measure of population density, urbanization daily commuting, among 10 major and 30 secondary codes
who participated
Who Participated
  • Counties from states that met my definition of rural that agreed to be interviewed
    • Not all are accredited
  • Missouri
    • Accredited
      • Taney, Johnson, Pulaski, Douglas
    • Not Accredited
      • Mercer
  • Washington
    • Clallam, Mason, Walla Walla,
reasons for undergoing accreditation
Reasons for undergoing accreditation?
  • Staff wanted recognition for their hard work
  • Saw positive impacts it had on other health departments
  • Able to fund it with grant money
  • Saw the need for it in their own health department
  • Viewed it as mandatory
what incentives did you find
What incentives did you find?
  • Funding from outside sources
  • Viewed it as a mark of excellence
  • Able to jumpstart improvement projects
  • Use it as a measure of improvement over time
  • Mutual accountability for local and state health departments
  • Quality improvement
  • Recognition by community partners and public
  • Understand health department strengths and weaknesses
how to capitalize on the incentives
How to capitalize on the incentives?
  • Partner with other health departments to gain more funding and political power
  • Prepared the data for legislation on what is needed to improve standards to receive funds
  • Open and honest about the self assessments comparing past and current rankings
  • Advertised their participation and gained lots of support as a result
priority levels
Priority levels

5: Top of the to-do list

4: Near the top

3: Neutral

2: Near the bottom

1: Bottom of the to-do list

what role did local government have
What role did local government have?
  • A large gradient of support
    • In difference to full support
  • Following accreditation a continued gradient
    • Some health departments anticipate no change in the relationship
    • Some health departments believe relationships have improved as a result of the accreditation
staff attitude before accreditation
Staff Attitude Before Accreditation
  • Another task to complete, negative
  • Some complacent and some enthusiastic
  • Neutral
  • Indifferent
  • A little resistant and frightened
staff attitude during accreditation
Staff Attitude During Accreditation
  • More in favor of it and now have a personal responsibility
  • More enthusiasm the further along the project
  • Improved morale
  • Seen as doable and even eager
  • See it as less daunting now
  • Felt appreciated to share best practices
  • Much more comfortable and accepting
what barriers did you observe
What Barriers did you Observe?
  • Time to get prepared and pull resources together
  • Money
  • Lack of accreditation experience
  • Creating documentation
  • Motivating staff
  • Lack of knowledge and understanding by staff, partners and social agencies
circumventing the barriers
Circumventing the barriers
  • Schedule a department wide meeting regularly for QI projects
  • Went through each standard to see what was needed
  • Administrator acted as coordinator and each department had to satisfy documentation
  • Prepare documentation over years on an ‘as you go’ basis and focus on a specific standard each year rather than scramble
  • General education about accreditation and rearrange people’s schedules to find time to sit down together
  • Demonstrate value to senior staff and have it trickle down
regional applications
Regional applications?
  • Very mixed reactions from a variety of counties
    • Some saw no usefulness in it at all and some called regional applications ‘impossible to do without’
  • Benefits
    • Reap the benefits of already strong relationships
    • Combining resources and sharing people
  • Barriers
    • Who pays for what
    • Differences in size a capabilities
what tools would be important44
What tools would be important?

5: Very important

4: Somewhat important

3: Neutral

2: Somewhat unimportant

1: Not important at all

what recommendations do you have
What recommendations do you have?
  • There is a lot of good help available out there if you are willing to explore
  • Give yourselves enough time
  • Keep an open mind. Accreditation provides an excellent tool to use to talk to the public and officials on how you are doing as a public health system. You can use it to point out what resources you need to meet needs and show results of public health efforts and inputted resources. Don’t be afraid of it.
what recommendations do you have46
What recommendations do you have?
  • It will be easier as a collaborative. Extra hands help.
  • Don’t let it overwhelm you, it really isn’t that bad. Look for resources and partners.
  • Get your documentation filed now, don’t wait.
  • Start early and train in QI/QA and process improvement.
  • Be committed to work through doubts before you begin.
  • Get staff buy in and orient everyone.

Results from Study on Rural Health Department Accreditation: Conducted by National Network of Public Health Institutes with funding from the Centers for Disease Control

motivators for seeking accreditation among rural health departments
Motivators for Seeking Accreditation Among Rural Health Departments
  • Establishing consistent standards
  • Improving Quality
  • Increasing Accountability
  • Increasing Staff Moral
  • Developing Best Practices
effect of rurality on accreditation
Effect of Rurality on Accreditation
  • Don’t view accreditation as a priority
  • Staff members are not bought on the concept
  • Specific characteristics of the rural LHD
    • Size
    • Jurisdiction type
    • Population served
  • Capacity to meet standards
  • Funding and resources
  • Staff training and coverage
challenges for seeking accreditation
Challenges for Seeking Accreditation
  • Resources
  • Lack of short term benefits
  • Organizational capacity
  • Workforce capacity
  • Perceived lack of applicability to rural jurisdictions
  • Distribution Authority for Public Health
  • Workforce capacities
  • Infrastructure
  • Diversity of population served
  • Funding
Inadequate fiscal and human resources were identified as major barriers associated with accreditation
  • Inadequate staff knowledge of accreditation
  • Lack of formal public health training among LHD staff
  • Shortages of resources
  • Structural barriers
  • Lack of adequate funding
strategies for rural lhd accreditation
Strategies for Rural LHD Accreditation
  • Demonstrate the value of accreditation to local decision-makers
  • Generate concrete outcomes: action, improvements
  • Use innovative funding strategies to support accreditation efforts
  • Use tiered or phased approaches to accreditation
  • Form partnerships with academic institutions
accreditation can be a tool to communicate the functions of public health
Accreditation can be a tool to communicate the functions of public health
  • Communicate the benefits of public health to county commissioners, board of health members, governors, and other state and local policy makers in order to leverage and/or sustain funds and support for public health activities
  • Foster interaction among stakeholders
  • Encourage collaboration to meet high standards
  • Avoid duplication of efforts in communities
  • Maximize returns from scarce resources
  • Educating the public, staff and other stakeholders
improving capacity and quality of services are perceived as key benefits of accreditation
Improving capacity and quality of services are perceived as key benefits of accreditation
  • Adhere to a set of standards
  • Improved quality of services
  • Setting bar for health departments to achieve certain capacities
  • Promote uniformity in the quality of services delivered across health departments
  • Monitor agencies’ performance and document outcomes for strategic planning and quality improvement initiatives.
  • Enable LHDs to more effectively compete for more grant money from governmental and non-governmental sources.
educating health department staff and policy makers are key strategies for rural lhd accreditation
Educating health department staff and policy makers are key strategies for rural LHD accreditation
  • Education to LHD staff on rationale and benefits
  • Demonstrate the value to county commissioners and mayors
contact ipha
Contact IPHA
  • Brittany Kennedy, MPHbkennedy@inpha.org317.221.3139
  • Jerry Kingjking@inpha.org317.221.2392
  • Caitlin Labranche, MPHclabranche@inpha.org260.755.9614