A Longitudinal Analysis of National Voluntary Public Health Accreditation: Are more local health departments intending to take part? Valerie A. Yeager, 1 Jiali Ye, 2 Jessica Kronstadt, 3 Nathalie Robin, 2 Carolyn J. Leep, 2 & Leslie M. Beitsch 4 1 Tulane University School of Public Health and Tropical Medicine, 2 National Association of County and City Health Officials, 3 Public Health Accreditation Board, 4 Florida State University College of Medicine PH H H

Background Voluntary public health accreditation has the goal of improving and protecting the health of the public by advancing the quality and performance of Tribal, state, local, and territorial public health departments. Public health departments that participate in national voluntary accreditation will be assessed against a set of national consensus standards developed by the public health community Standards are based on the 10 Essential Public Health Services plus 2 additional domains for governance and management/administration. 2

Background 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. 3

Background While many of states (29) are accredited or have started the formal accreditation process, the majority of local health departments (LHDs) have not initiated the accreditation process. Approximately 10% of LHDs had initiated the process as of April

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. 5 Accreditation Activity as of April 2015

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

Data Sets and Sources Data from the 2014 Forces of Change Survey and the 2010 and 2013 NACCHO Profile studies were used. Data from the registry of state health departments in the e- PHAB system by February 1, 2014 were also used. No state or local identifiers are presented in this study. 7

Design and Analysis Pooled cross-sectional examination of data from 3 LHD surveys (2010, 2013, and 2014) 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. 8

Design and Analysis Table 1. Defining “Favorably Inclined” 9 Year Classified as “Favorably Inclined” to Pursue PHAB Accreditation Profile Agree or strongly agree with the statement “Our LHD would seek accreditation under a voluntary national accreditation program” 2013 Profile Had achieved accreditation, submitted an application, submitted a Statement of Intent, planned to apply, or the state health agency was pursuing accreditation on their behalf Forces of Change

Findings 10 Notes: LHD is Local Health Department. LHDs were classified as favorably inclined to pursue PHAB accreditation if they rated their agreement with the statement “Our LHD would seek accreditation under a voluntary national accreditation program” as agree or strongly agree on the 2010 survey. For all other years, favorably inclined was determined if the LHD indicated that they had achieved accreditation, submitted an application, submitted a Statement of Intent, planned to apply, or indicated the state health agency was pursuing accreditation on their behalf. Percent Favorably Inclined Figure 1: LHDs Favorably Inclined Toward Accreditation

Findings Table 2. Level of Engagement in PHAB Accreditation, 2013 and Level of Engagement Profile Survey Forces of Change Survey p value January 2013 (n=448) January 2014 (n=609) Achieved Accreditation0%1%< Submitted an Application or a Statement of Intent 6%11%< Plans to Apply, No Statement of Intent 27%22%< State Health Agency will Pursue Accreditation on Behalf of LHD* 13%12% Undecided40%36% Not Applying15%17% Notes: PHAB is Public Health Accreditation Board. FoC is Forces of Change. LHD is Local Health Department. *In the 2013 Profile Study, the language in the survey is “The state health agency is pursuing accreditation on behalf of my LHD.” In the 2014 Force of Change survey, the language is “The State health agency is pursuing PHAB accreditation as an integrated system that includes my LHD.” 2014 data indicated: 1% of LHDs achieved accreditation 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 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.

Findings Table 2. Level of Engagement in PHAB Accreditation, 2013 and Level of Engagement Profile Survey Forces of Change Survey p value January 2013 (n=448) January 2014 (n=609) Achieved Accreditation0%1%< Submitted an Application or a Statement of Intent 6%11%< Plans to Apply, No Statement of Intent 27%22%< State Health Agency will Pursue Accreditation on Behalf of LHD* 13%12% Undecided40%36% Not Applying15%17% Notes: PHAB is Public Health Accreditation Board. FoC is Forces of Change. LHD is Local Health Department. *In the 2013 Profile Study, the language in the survey is “The state health agency is pursuing accreditation on behalf of my LHD.” In the 2014 Force of Change survey, the language is “The State health agency is pursuing PHAB accreditation as an integrated system that includes my LHD.” 2014 data indicated: 1% of LHDs achieved accreditation 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 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.

Findings Table 2. Level of Engagement in PHAB Accreditation, 2013 and Level of Engagement Profile Survey Forces of Change Survey p value January 2013 (n=448) January 2014 (n=609) Achieved Accreditation0%1%< Submitted an Application or a Statement of Intent 6%11%< Plans to Apply, No Statement of Intent 27%22%< State Health Agency will Pursue Accreditation on Behalf of LHD* 13%12% Undecided40%36% Not Applying15%17% Notes: PHAB is Public Health Accreditation Board. FoC is Forces of Change. LHD is Local Health Department. *In the 2013 Profile Study, the language in the survey is “The state health agency is pursuing accreditation on behalf of my LHD.” In the 2014 Force of Change survey, the language is “The State health agency is pursuing PHAB accreditation as an integrated system that includes my LHD.” 2014 data indicated: 1% of LHDs achieved accreditation 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 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.

Findings 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.: ). 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%). 14

Conclusions LHDs in accreditation “committed” states, with other independent variables being controlled, are almost 3 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. 15

Implications for Practice and Policy SHDs are powerful mediators of LHD attitudes toward accreditation. LHDs with state or shared governance systems were over 9 times more likely to be favorably inclined toward accreditation. While the overall percent of LHDs “favorably inclined” towards accreditation increased modestly over time, the percent of locally governed LHDs that were “favorably inclined” declined significantly from 2010 to