摘要：To advance understanding of public health accreditation, we analyzed data on the North Carolina Local Health Department Accreditation program. We surveyed accredited health departments on barriers to and supports of accreditation preparation, performance on accreditation standards, and benefits and improvements after accreditation. All 48 accredited agencies responded to the survey. All agencies improved policies to prepare for accreditation and met most accreditation standards. Forty-six percent received local funds for accreditation preparation. The most common barrier to accreditation preparation was time and schedule limitations (79%). Fifty percent of agencies acted on suggestions for improvement, and 67% conducted quality improvement activities. Benefits of accreditation included improvements in local partnerships. Agencies of all sizes conducted accreditation activities, were successfully accredited, and experienced benefits resulting from accreditation. A key strategy for improving the functioning of local health departments (LHDs) is to institute a public health accreditation system that requires LHD capacity and performance to be measured against benchmarks or standards. 1 A voluntary national accreditation program for local public health agencies, the Public Health Accreditation Board (PHAB), was recently established. 2 PHAB's mission is to facilitate improvement of state, local, and tribal public health departments while emphasizing that accreditation is not the ultimate goal but rather part of an overall strategy to improve the health of the nation. Although the PHAB standards have been developed, the PHAB process beta test is complete, and state accreditation programs are under way, several public health accreditation issues are still being debated. These include the level of performance at which standards are written (i.e., capacity vs outcomes), accreditation's costs relative to its benefits, barriers to preparing for accreditation, benefits of accreditation, and the ability of health departments of varying sizes and structures to meet accreditation standards. 3 – 7 Chief among the debated issues is how to design an accreditation program that supports and fosters a quality improvement mindset in public health, rather than encouraging practitioners to see accreditation as an end in itself. 2 Literature from the health care, education, social service, and public service fields suggests that public health accreditation can have positive effects on service quality, operations, and service-related outcomes. 8 However, the literature on public health accreditation's impact on service capacity, delivery, and quality is in its nascent phase. 9 The PHAB program is modeled on several state-based LHD accreditation systems, including the North Carolina Local Health Department Accreditation (NCLHDA) program. The NCLHDA history and program elements have been previously described. 6 , 10 Initiated in 2004, with final state rules in place in 2006, this legislatively mandated program's primary objectives are to increase the capacity, accountability, and consistency of the policies and practices of all North Carolina LHDs. Accreditation benchmarks are written primarily at the capacity-achievement level. 10 As of July 2009, 48 of the 85 North Carolina LHDs had achieved accredited status under final state rules. (Two additional agencies received accreditation under pilot standards but had not achieved accreditation under the final rules.) Ten LHDs per state fiscal year will go through initial accreditation review, and all LHDs are required to have been reviewed by 2014. Each LHD was allowed to choose the first fiscal year during which it would undergo initial accreditation. Accreditation status is valid for 4 years, after which LHDs must go through a reaccreditation process. Crosswalks between PHAB and North Carolina accreditation standards yield 95% overlap on the content of the standards. NCLHDA partners built evaluation into the program from its inception to ensure that the program performed as intended and met the needs of stakeholders. 11 Program evaluation reports reveal that 86% of participants (health directors, LHD staff, site visitors, and North Carolina Division of Public Health staff) are very satisfied with the accreditation administrator's management of the program, and 92% of LHD directors report that they are satisfied with the accreditation program's outputs relative to the time they and their staff spent to prepare for accreditation. 12 – 14 The NCLHDA program's outputs are LHD achievement of accreditation standards and LHD activities after accreditation to continue infrastructure and service improvements. To date, no study has examined outputs of public health accreditation programs in light of LHD preparation activities, barriers to preparation, and benefits of participating in the program. To advance understanding of public health accreditation, we examined the extent to which the 48 accredited North Carolina LHDs (1) conducted accreditation preparation activities, experienced barriers to accreditation preparation, received support for accreditation preparation, and met the accreditation program standards; (2) conducted quality improvement activities after achievement of accredited status; and (3) experienced benefits as a result of being accredited.
