摘要：Objectives. We examined the relationship between quality improvement (QI) maturity and accreditation attributes of US local health departments (LHDs), specifically those in Nebraska. Methods. Using 2011 Nebraska LHD QI survey data, we conducted Spearman correlation analyses between QI maturity domains and accreditation attributes. Using the 2010 National Association of County and City Health Officials’ National Profile of LHDs, we conducted logistic regression analyses to examine the relationships between specific QI strategies and attitude toward seeking accreditation. Results. Leaders’ commitment to and length of time engaged in QI were positively associated with LHDs’ general attitude toward seeking accreditation. Use of QI strategies and integration of QI policies and practices were positively associated with LHDs’ confidence in their capacity to obtain accreditation. LHDs that had used at least 1 QI framework and at least 1 QI technique in the past year were more likely to agree that they would seek accreditation within 2 years of the national accreditation program. Conclusions. Experience with and expertise in QI implementation play an important role in LHDs’ decision to seek accreditation, and their accreditation-seeking efforts may benefit from prior implementation of systematic QI strategies. Since early in this century, national, state, and local organizations have sought to develop a process for accreditation of local health departments (LHDs). Several attempts have been made to identify public health accreditation criteria at the state and local levels. In 2002, the National Association of County and City Health Officials developed a set of 45 public health standards matched to the 10 essential public health services and associated metrics, which became known as an operational definition of a functional LHD. 1 The operational definition served as a base for the development of other accreditation tools. In addition, the National Public Health Performance Standards Program was initiated in 1998 as a collaborative effort of 7 national public health organizations that were coordinated and funded by the Centers for Disease Control and Prevention. 2 The National Public Health Performance Standards Program represented an attempt to define public health practice standards for state and local public health systems and governing bodies. 2 In 2002, it released 3 assessment instruments framed around the 10 essential public health services. 2 These tools provided the basis for a national voluntary accreditation program. Building on these previous efforts, in 2004 the Exploring Accreditation Project was developed as a joint initiative of the National Association of County and City Health Officials, the Association of State and Territorial Health Officials, the National Association of Local Boards of Health, and the American Public Health Association to determine the implications and feasibility of a national public health accreditation system. 3 In accordance with the recommendations of the Exploring Accreditation Project Steering Committee, the Public Health Accreditation Board (PHAB) was formed to implement and oversee national public health department accreditation. 4 The key focus of the PHAB accreditation program is to strengthen the public health infrastructure. 5 Although the process of accreditation can be arduous, it has several benefits to the LHD, including identifying performance improvement areas and improving management, leadership, and relationships within the community. 6 Paralleling the PHAB’s efforts, the Multistate Learning Collaborative on Performance and Capacity Assessment or Accreditation of Public Health Departments worked with states with existing assessment or accreditation as natural laboratories to enhance existing initiatives and disseminate the findings of these mature programs. 3 The collaborative’s efforts have yielded valuable information. For instance, some LHDs observed benefits of the accreditation process in the standardization of measures for accountability and the development of morale among LHD staff members. 5 However, other LHDs experienced problems during the accreditation process, including the redundant documentation of standards and difficulty understanding how to meet the documentation standards. 3 In addition, some LHDs found that the short period of onsite review and the lack of funding made accreditation difficult. 6 Moreover, researchers have noted that marketing accreditation to LHDs without offering incentives could be challenging, and such processes may cause anxiety and reluctance to participate. These challenges are also likely to be exacerbated by the different types and sizes of LHDs. 7 Much previous research on accreditation has focused on the role of financing and incentives in voluntary adoption of accreditation standards. Accreditation can be an expensive and time-consuming process for LHDs, but these efforts are rewarded during the accreditation process when the LHD’s quality efforts are documented. 8 One of the key features that has been highlighted throughout the literature is the role of quality improvement (QI) in the accreditation process. QI, regardless of where a department stands on accreditation, is an essential activity for all health departments. 9 QI has been incorporated as a central concept throughout PHAB’s Standards and Measures Version 1.5, 10 with a strong focus on the QI processes used by the LHD. Domain 9 of the PHAB standards and measures focuses on the evaluation of all programs, interventions, and the key public health process, as well as the implementation of a formalized QI process. 10 LHDs that have already implemented a continuous QI plan or performance management system can document this existing system and submit it to fulfill this requirement. 10 Although QI implementation is essential in LHDs, a number of barriers to its implementation exist, including program requirements and lack of funding, incentives for implementation, leadership, and additional technical assistance resources. 11 In addition, the language used to describe QI processes is not uniform across LHDs, making it difficult to study QI activities. More important, although QI activities are essential for accreditation, little has been written about the relationship between QI and accreditation and how LHDs can better integrate QI and accreditation strategies. In 2013, Shah et al. 12 examined the relationship between PHAB accreditation prerequisites and LHDs’ intention to seek PHAB accreditation. Although their study provides an understanding of how conducting a community health assessment, community health improvement planning, and strategic planning are associated with LHDs’ intent to seek accreditation, the specific characteristics of QI implementation and the effect of implementation on LHDs’ intention to seek accreditation have not been examined. We examined the relationship between QI maturity and strategies and accreditation attributes in the United States, specifically Nebraska.
