HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Electronic Letters to:

EDITOR'S CHOICE: Leslie M. Beitsch and Liza C. Corso Accountability: The Fast Lane on the Highway to Change Am J Public Health 2009; 99: 1545 [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Accreditation and Accountability for Local Health Departments: Is the cart before the horse?

Douglas R. Wholey, Katie M. White, Heidi Kader   (20 August 2009)

Accreditation and Accountability for Local Health Departments: Is the cart before the horse? 20 August 2009
Douglas R. Wholey, Professor University of Minnesota, Katie M. White, Heidi Kader Send letter to journal: Re: Accreditation and Accountability for Local Health Departments: Is the cart before the horse? whole001{at}umn.edu Douglas R. Wholey, et al.	As “Accountability: The Fast Lane on the Highway to Change” points out, public health accreditation appears to be similar to a train with a strong head of steam. The train’s destination of improving population health by improving public health management is laudable. The arguments behind holding local public health departments accountable with accreditation are that it will improve population health, that marginal benefits outweigh marginal costs and that undesirable unintended consequences can be mitigated. The logic model is that accountability will result in improved population health (1, 2). Since accreditation strongly focuses on the essential services functions rather than content, the implicit argument is that performing the essential service functions well are a sufficient cause of improved population health. This accreditation effect presumably occurs either because (a) accreditation leads to enhanced legitimacy which leads to resource acquisition which supports performance of content activities, such as those related to achieving Healthy People 2010 goals (3), or (b) accreditation leads to better performance of content activities. The improved implementation of content activities presumably results in improved population health. The causal mechanism implication is that content activities mediate between legitimacy, the essential services functions and population health. The over emphasis on functions to the neglect of content may result in accreditation not having its desire effects. The over emphasis on functions to the exclusion of content may make reaching accreditation goals more difficult and may be harmful to achieving these goals. While the difficulty with specifying accreditation standards in terms of content is understandable (4), did the pendulum swing too far towards functions? This note raises questions about whether accreditation with a strong focus on functions is the best method for creating effective accountability for local health departments. This note raises six distinct issues, the: (1) difficulty of emphasizing function over content; (2) lack of evidence base for accreditation; (3) costs and benefits of accreditation; (4) unintended consequences of accreditation; (5) weakly acknowledged contribution of related health professionals; and (6) local health department economics. First, accreditation’s functional emphasis emerged from the difficulty in agreeing on content standards (4) and Handler, Issel and Turnock on core functions (5). This important work for implementing the essential public standards for health and organizing communities provides guidance for developing effective management. But, this has not been balanced by an emphasis on content – what public health does for communities. In comments about the proposed accreditation standards submitted to the Public Health Accreditation Board, the Minnesota Department of Health had the same concern(6): “Currently, most measures are process measures. In the long term, quality improvement efforts should demonstrate not only process improvement, but should also be linked to public health goals and overall improvements in population health outcomes.” Professions gain legitimacy by effectively addressing content – by improving outcomes. In fact, it is likely that professions with effective programs, such as reducing STDs or teen pregnancies, are more likely to garner support from funders than professions that simply demonstrate they can perform functions. The emphasis on functions may also be harmful because professionalization theory argues that professions emphasizing functional knowledge to the exclusion of content are likely to be weak professions (7). Second, in this day of evidence based management, it seems reasonable to expect that accountability is based on good evidence. To date, we have little or weak evidence that establishes a causal link between accreditation and population health outcomes. As Beitsch et al. state “A painful truth separating public health from other scientific endeavors is the relative dearth of evidence supporting what actually works in the field.”(8) Having good evidence is important because as a recent New York Times article on diabetes care pointed out, inappropriate use of guidelines and standards can be harmful (9). The lack of evidence in public health is in part due to the variety of causes of public health outcomes which weakens the relationship between functions and outcomes. It would seem the best way to develop evidence would be to show how functions are implemented effectively in content activities in specific health domains. This would allow an evidence base to be developed so that accreditation would meet the same standard as those desired for public health activities – that it be evidence based. Furthermore, it will be probably much more difficult to develop strong, useful evidence about the relationship between functions and population health than it will be to develop evidence on how functions are related to content activities and then to population health in specific health domains. Adding an accountability focus on content may make easier the development of a strong evidence base. Third, an argument for accreditation is that benefits exceed costs (10). Costs can be classified into four categories based on whether they are start-up or ongoing and direct or opportunity. Heany et al. suggest that most direct costs will be labor costs and that start-up costs will be significantly greater than operating costs(10). They point out that these costs will be a function of context. Meit et al., for example, suggest that rural health departments may face significant human resource and financial barriers to accreditation(11). There are also opportunity costs. The benefits are presumably better performance of content activities. Unfortunately, in contrast to other types of health care organizations, accreditation may not result in access to greater funds. Opportunity costs occur because while staff is involved in accreditation functions, either as start-up or ongoing, some of their efforts on content related work must be curtailed. If “public health is tasked too much while resourced too little,”(8) then both the start-up and ongoing opportunity costs can pose significant risk. Fourth, there are likely to be unintended consequences. The old saying, “we manage to what we measure” reveals a potential unintended consequence. Measuring functions rather than content risks over-allocating resources to functions rather than content, such as health education, WIC, MCH, immunizations, STD testing, or environmental safety. As well as reducing the amount of content related efforts, the emphasis on functions risks demoralizing staff because it takes them away from the work that drew them to public health in the first place. Accreditation efforts may distract health departments from identifying and addressing local health concerns. Finally it may result in wasting financial resources. Assessment, for example, is an important function. But, how much assessment is enough assessment? The answer to this is content specific. The neglect of content in accreditation standards may result in the resource misallocation. Fifth, it is hard to discern from reading the accreditation standards that allied professions, such as environmental health specialists, health educators, or public health nurses, provide essential public health contributions. These professions are key contributors to content activities. Among other activities, public health nurses contribute to mass immunization preparedness exercises and engage in direct contact with the public through service delivery activities. These activities build trust between the health department and the local community which facilitates collaboration. It also provides public health situational awareness, the real-time assessment of emerging public health issues in the community. Given the importance of these professions to doing public health, it would seem reasonable that a key dimension of accountability is making sure that local health departments have a work force that has the knowledge, skills, and ability necessary to do public health rather than just manage public health. Ironically, accreditation’s focus on functionality means that the accreditation cannot even hold a local health department accountable for the essential service of assuring a competent public and personal health workforce. Without knowing what services need to be provided, the content of public health, how do we know a local health department is staffed with individuals who have the necessary knowledge, skills, and ability to do those activities? Sixth, the accreditation standards gloss over local public health department economics. Many health departments generate revenue from services, such as immunizations, STD testing, the WIC program, and environmental health inspections. While we understand that these are not population services, these services generate important revenue streams and legitimacy. They help health departments reach scale economies so that support staff, such as grant writers, grant managers, and individuals who are capable of doing assessment, can be employed. These services are visible and valued products in the community that build local health department legitimacy. If service delivery provides some of the financial foundation for implementing the essential services and increases legitimacy, it seems reasonable to recognize that contribution. Ignoring the health department economics may result in not “every community (no matter how small or remote)”(4) being able to meet the proposed accreditation standards. Is the accreditation process meeting the accountability goals it set for itself for inclusion of all communities? We have raised a number of questions about the current accreditation and accountability approach. We agree with the goal of improving population health and increasing health department capability. We disagree with the emphasis on functionality to the exclusion of other important issues. We argue that accreditation should also take into account (a) content of specific activities, (b) costs and benefits, (c) unintended consequences, (d), the important contributions of allied professions, and (e) the economics of health departments. An alternative to the current accreditation may be using a quality improvement approach, such as that recommended for health departments and by developing evidence about the use of essential services by specific content (health domain). It may get us to the desired goals of better public health organization and improved population health outcomes more quickly and effectively than the current approach. As Robert Pestronck, NACCHO’s Executive Director, commented at the 2009 Keeneland Conference on Public Health Systems, improving public health organization is a long term project. Going more slowly and carefully will allow the development of a meaningful evidence-base that is health domain and context sensitive and is more likely to produce useful knowledge for public health managers. It will also minimize the risk of marginalizing public health that may occur when functionality is over-emphasized rather than balanced with content. REFERENCES 1. Corso LCW, Paul J. Halverson, Paul K. Brown, Carol K. Using the Essential Services as a Foundation for Performance Measurement and Assessment of Local Public Health Systems. Journal of Public Health Management & Practice 2000;6(5):1. 2. Joly BM, Polyak G, Davis MV, Brewster J, Tremain B, Raevsky C, et al. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract 2007;13(4):349-56. 3. Beitsch LM, Corso LC. Accountability: The Fast Lane on the Highway to Change. American Journal of Public Health 2009:AJPH.2009.172957. 4. Tilson HH. Public Health Accreditation: Progress on National Accountability. Annual Review of Public Health 2008;29(1). 5. Handler A, Issel M, Turnock B. A Conceptual Framework to Measure Performance of the Public Health System. 2001;91(8):1235-1239. 6. Minnesota Department of Health. National Public Health Standards for State Health Departments, Summary of Recommendations from the Spring, 2009 Vetting Process, Submitted to the Public Health Accreditation Board. In. St. Paul, MN: Minnesota Department of Health; 2009. 7. Abbott A. The System of Professions: An Essay on the Division of Labor. Chicago: The University of Chicago Press; 1988. 8. Beitsch LM, Mays G, Corso L, Chang C, Brewer R. States gathering momentum: Promising strategies for accreditation and assessment activities in multistate learning collaborative applicant states. Journal of Public Health Management and Practice 2007;13(4):364-373. 9. Meier B. Diabetes Case Shows Pitfalls of Treatment Rules New York Times 2009 August 18, 2009 10. Heany J, Laing S, Austin J, Blackinton P, Sherry MK, Martin A. Quantifying the Cost of Accreditation in Local Public Health. In: Academy Health. Okemos, MI: Michigan Public Health Institute, Center for Healthcare Excellence; 2009. 11. Meit M, Harris K, Bushar J, Piya B, Molfino M. Challenges, Opportunities, and Stratgies for Rural Public Health Agencies Seeking Accreditation. Chicago, IL: NORC: Walsh Center for Rural Health Analysis; 2008.