Missouri Voluntary
Local Public Health Agency Accreditation Program

INTRODUCTION

The Missouri Institute for Community Health (MICH) is the accrediting body for Missouri’s Voluntary Accreditation Program for Local Public Health Agencies. MICH is a 501 C (3) corporation governed by a Board of Directors. Board members include health care providers, academia, human service organizations, and state and local government. The mission of MICH is “to facilitate and promote excellence in community systems for health and quality of life.”

The Missouri public health system began exploring accreditation for local public health agencies in the 1990s. Initial work began under the umbrella of the Missouri Department of Health and Senior Services, but in 2002, MICH took the lead. The first set of standards was piloted and then issued in 2003. The first local public health agency was accredited in 2003.

When accreditation standards were revised in 2006, the Operational Definition of a Functional Local Health Department created by the National Association of City and County Health Officials (NACCHO), along with the work of the Robert Wood Johnson/Multistate Learning Collaborative and the National Steering Committee on Accreditation contributed to the revision.

The Accreditation Manual has two sections:

1. Standards for Agency Performance contain indicators to describe local public health agency activities. Performance measures provide a means to evaluate the agency’s execution of the 10 essential public health services. The ten essential services are:

1. Monitor health status and understand health issues facing the community.
2. Protect people from health problems and health hazards.
3. Give people information they need to make healthy choices.
4. Engage the community to identify and solve health problems.
5. Develop public health policies and plans.
6. Enforce public health laws and regulation.
7. Help people receive health services.
8. Maintain a competent public health workforce.
9. Evaluate and improve programs.
10. Contribute to and apply the evidence base of public health.

2. Standards for Agency Infrastructure are divided into 8 domains that describe the administrative capacity needed to carry out the core public health functions and essential public health services. The performance indicators measure the following dimensions:

• a planning process
• governance and leadership
• facilities/service delivery
• financial and resource management
• workforce
• information technology
• communications
• inter-governmental issues

TYPES OF ACCREDITATION

A local public health agency may seek one of three distinct types of accreditation: primary, advanced, and comprehensive.

Performance Standards: Agencies, regardless of the level of accreditation they pursue, will need to meet all Performance Indicators. However, not all agencies need tomeet all Performance Measures. The Manual distinguishes Performance Measures by a (P) for primary, an (A) for advanced, and a (C) for comprehensive. Primary agencies are required to demonstrate compliance with only those measures followed by a (P). Advanced agencies are required to demonstrate compliance with those measures followed by an (A). Comprehensive agencies are responsible for all Performance
Measures.

The numbers of Performance Measures to be met are:
• Primary Local Public Health Agency - 230 Performance Measures
• Advanced Local Public Health Agency - 305 Performance Measures
• Comprehensive Local Public Health Agency - 322 Performance

Infrastructure Standards: All agencies, regardless of the type of accreditation they apply for, will need to meet the set of Infrastructure Standards and Measures accounting for a possible score of 91 points. The variety of and qualifications of core staff will vary by type of accreditation.

Agencies are encouraged to review the standards and performance measures that must be met for each type of accreditation and seek the level that matches resources, infrastructure, and level of involvement in the community health improvement process.

Primary Local Public Health Agency Accreditation
A primary accredited local public health agency may serve any size population or geographic area. It will have documented capacity, expertise and leadership that assures a fundamental public health presence within the community it serves. Performance measures for primary accreditation describe agency activity in performing some aspects of each of the 10 essential public health services. The agency will have a core staff that includes a qualified administrator, public health nurse, environmental public health specialist and support staff. The agency must also have full or part-time
staff, or otherwise have access to a medical consultant and individuals with expertise in health education, nutrition, computer technology and epidemiology.

Advanced Local Public Health Agency Accreditation
An advanced accredited local public health agency may serve any size population or geographic area, but will typically serve a population of 16,000 or more. An agency seeking advanced accreditation must meet 75 more performance measures than a primary agency. Some performance measures require additional analysis of data to identify specific population segments at risk, environmental risk factors, and behavioral or other risks that contribute to poor health outcomes. An advanced
accredited local public health agency will be collaborating extensively with others in the community to resolve health care access and utilization of services issues. The agency is involved in public policy development to improve health and will exhibit a high level of participation in community health planning.

One additional public health nurse is needed to meet workforce standards for advanced accreditation, and educational qualifications for some core staff members are higher than primary accreditation.

Comprehensive Local Public Health Agency Accreditation
A comprehensive accredited local public health agency may serve any size population or geographic area, but will typically serve a metropolitan area. A comprehensive accredited local public health agency must meet 17 more performance measures than an agency seeking advanced accreditation. A comprehensive accredited agency ensures all aspects of the 10 essential public health services to its service area. The agency works with community partners to evaluate the health care system and assure health care access for all members of the community.

In addition to core staff required for other levels of accreditation, the comprehensive accredited agency will have a full-time assistant administrator, nursing supervisor, health educator, nutritionist, epidemiologist, computer specialist, and community planner. Additionally, the agency is required to have access to a medical consultant, public information officer, and a statistician.

BENEFITS OF ACCREDITATION
FOR A LOCAL PUBLIC HEALTH AGENCY

Usually, an administrator considering accreditation will review the standards and roughly measure how closely the agency’s performance matches standards requirements. Then, the administrator might discuss accreditation with staff and the agency’s governing body. At each phase in the process from consideration of accreditation to actual application; from preparation and self-assessment to on-site review, a few questions will be asked repeatedly:

• Why should our agency seek accreditation, knowing how much time and work it might take?
• How will our agency and/or our community be rewarded if the agency is successful?
• What happens if we fail to meet the scoring threshold?

Accredited agencies in Missouri and in other states share very similar comments about their experiences. Common themes describe hard work that is rewarded many times over. Agency staff describes non-monetary rewards that illustrate how accreditation benefited agencies internally, and externally benefited the communities they serve. Finally, some administrators affirmed that the self-assessment process was the best quality improvement project their agency had ever undertaken.
Following are examples of what agencies cited as advantages for their agency and their community at four stages of the accreditation process:

Pre-Application Benefits
• Merely exploring the possibility of accreditation sets in motion a process of self-evaluation to identify agency strengths and areas for improvement.
• Identification of areas needing improvement, whether staff education and training, administrative policy development, a documentation system, or a more thorough community health assessment provides a focus for efforts in planning for improvement.
• Deficits in capacity identified through standards review can be used to garner support from the governing body or the community for resource development.

Self-Assessment Process Benefits
• Self-assessment compels agency leadership to think critically about what services and programs are offered in relation to the identified community problems and needs.
• Ineffective and inefficient processes are identified during self assessment and addressed.
• Staff pride and morale improve as the agency works as a team toward a common goal.
• Staff follow through with attaining additional education or training.
• Agencies organize documentation, logs, policy, personnel files, etc. which improves operational systems.
• Actual improvement occurs in the thoroughness of mandated activities such as community health assessment and dissemination of health status information.
• Agencies are more involved and take on stronger leadership roles in community partnerships and community health improvement planning.
• An opportunity is provided to identify new leaders within the agency.
• Obvious deficits in infrastructure, capacity, and performance are identified so that planning for and implementing improvement changes can occur.
• Overall, the local public health agency as an organization becomes stronger, and the community is better served as a result of the agency going through the self assessment.

On-Site Review Benefits
• A team of reviewers evaluates agency performance and capacity in relation to industry standards and provides feedback regarding strengths and areas for improvement.
• Effective practices are identified by the on-site review team which, with agency permission, are shared with peer agencies and lead to improvement throughout the public health system.

Benefits of Accreditation Award
• Brings distinction and credibility to the agency among community partner organizations.
• Strengthens community’s and policy makers’ confidence that the local public health agency is fulfilling its responsibility.
• Demonstrates a commitment to excellence.
• Fosters continuous organizational development and continuous quality improvement.
• Increases the agency’s effectiveness and capacity to protect and promote health.
• Provides opportunity for public recognition and publicity.
• Provides an opportunity for agency staff celebration.
• Allows the promotional use of an accreditation seal with the media, as an endorsement in grant applications, and to provide a competitive advantage when marketing the agency.

Agency accreditation demonstrates to customers that agency leadership has accepted the challenge to improve services and activities, so that the community is served by an effective agency and a qualified public health workforce.