Funded by the Robert Wood Johnson Foundation

Local Public Health Certification and Accreditation in Illinois: Blending the Old and the New Laura B. Landrum, Elissa J. Bassler, Georgeen Polyak, Mark Edgar, Christopher Giangreco, and Jonathan C. Dopkeen Funded by the Robert Wood Johnson Foundation through the Multi-State Learning Collaborative, the Illinois Accreditation Development Project is developing a proposal to reengineer the 15-year-old Illinois local health department certification process. The Project is addressing a variety of political, technical, and resource issues in its attempt to develop a new approach to a mature program that will incorporate more meaningful performance and capacity measures for all local public health practice standards. Both statewide strategic planning and the evolving national momentum toward local public health agency accreditation are motivating the enhancements to the Illinois program. A new proposal that blends the current mandatory certification program with a new voluntary local public health accreditation program is discussed. The proposed new structure enhances the state-operated certification program with specific performance measures and creates a three-tiered voluntary accreditation process governed by a third party accreditation board. KEY WORDS: accreditation, local public health practice, performance measurement In 2005, Illinois initiated the Illinois Accreditation Development Project (IADP) under the auspices of the Multi-State Learning Collaborative (MLC), funded by the Robert Wood Johnson Foundation. The IADP reflects Illinois historic interest in performance improvement and certification of local health departments (LHDs). In the early 1990s, Illinois became one of the first states to establish a mandatory LHD certification program, requiring that LHDs demonstrate their compliance with state-established performance standards every 5 years. But, given recent national and state- J Public Health Management Practice, 2007, 13(4), 415 421 Copyright C 2007 Wolters Kluwer Health Lippincott Williams & Wilkins level developments in performance measurement, performance management, and quality improvement, Illinois is using its MLC funding to reengineer its LHD certification process to incorporate more meaningful performance and capacity measures across all practice standards. The IADP was formulated to rebalance the current program s emphasis on assessment and planning related to community health risks and outcomes to include a more significant measurement of overall LHD performance and realign the Illinois program with current national thinking. Background Anticipating some of the issues that were later illuminated in the 1988 IOM report, The Future of Public Health, the Illinois Department of Public Health (IDPH) convened a statewide strategic planning process in the late 1980s that resulted in the 1990 report, The Road to Better Health for All of Illinois, a plan that called for the implementation of a number of initiatives to build LHD capacity. 1 Key among these recommendations was the need to develop standards enabling local health jurisdictions to conduct local health needs assessments and to be responsive to identified community health needs. In 1993, a new LHD certification Corresponding author: Laura B. Landrum, MUPP, Illinois Public Health Institute, 100 W Randolph, Suite 6-600, Chicago, IL 60601 (Laura.Landrum@illinois.gov.) Laura B. Landrum, MUPP, is Special Projects Director, Illinois Public Health Institute, Chicago. Elissa J. Bassler, MFA, is Executive Director, Illinois Public Health Institute, Chicago. Georgeen Polyak, PhD, is Director of Public Health, Village of Oak Park, Illinois. Mark Edgar, PhD, MPH, is Director of Assessment and Planning, Illinois Public Health Institute, Chicago. Christopher Giangreco, PhD, is Program Manager, Illinois Public Health Institute, Chicago. Jonathan C. Dopkeen, MA, PhD, is Assistant Director (former), Illinois Department of Public Health, Chicago. 415

416 Journal of Public Health Management and Practice program was launched, the purpose of which was to assure quality public health services are delivered to Illinois citizens. Established in the Illinois Administrative Code, the program requires that certified LHDs carry out the core public health functions of assessment, policy development, and assurance by meeting specified practice standards. The adoption of the core functions and practice standards in 1993 represented a groundbreaking shift away from the traditional model of requiring that LHDs implement specific categorical programs to LHD accountability for carrying out public health core functions in the community. The state and local agencies play distinct organizational roles in the current certification program: the IDPH is the governing entity that reviews applications, supports training and technical assistance, and provides the data resources necessary for compliance with the community health assessment component. LHDs are responsible for allocating adequate resources to maintain compliance with the Code and engaging their communities in the development of the community health assessment and plan. The IDPH funds its activities related to certification primarily from the federal Preventive Health and Health Services Block Grant. Illinois general revenue dollars are also used to support administrative, data, and program-specific expertise. The IDPH provides state funding, in the form of a $17M Local Health Protection Grant (LHPG), to certified LHDs, and this serves as an incentive to maintain certification. 2 No specific funding is awarded by the IDPH to support local certification activities. The basis for certification in Illinois is the organizational practice standards (which preceded the Ten Essential Public Health Services) that define the local public health agency activities necessary to perform the core functions. 3,4 In the Illinois Code, 10 practice standards must be met for certification (Table 1). The centerpiece of the current certification process is the Illinois Project for Local Assessment of Needs (IPLAN), providing a framework to meet most community assessment and policy development practices. 5 IPLAN initially used An Assessment Protocol for Excellence in Public Health (APEX-PH), a community health planning model, but provides flexibility for LHDs to use a Mobilizing for Action through Planning and Partnerships (MAPP) 6 or other equivalent process to meet the practice standards. To accomplish IPLAN, LHDs must involve the community in conducting a community health needs assessment, analyzing a comprehensive set of indica- Title 77: Public Health, Chapter 1: Department of Public Health, Subchapter H:Local Health Departments. Part 600: Certified Local Health Department Code. Section 600.100: Statement of Purpose. TABLE 1 Illinois local health department certification standards Assessment practices Assess the health needs of the community by establishing a systematic needs assessment process that periodically provides information on the health status and health needs of the community. Investigate the occurrence of adverse health effects and health hazards in the community by conducting timely investigations that identify the magnitude of health problems, duration, trends, location, and populations at risk. Policy development practices Advocate for public health, build constituencies, and identify resources in the community by generating supportive and collaborative relationships. Develop plans and policies to address priority health needs by establishing goals and objectives. Set priority health needs Analyze risk and contributing factors for each priority to determine populations at risk and adequacy of resources. Assurance practices Manage resources and develop organizational structure. Implement programs and other arrangements assuring or providing direct services for priority health needs identified in the community health plan. Evaluate programs and provide quality assurance in accordance with applicable professional and regulatory standards. Inform and educate the public on public health issues of concern in the community. tors contained in the IPLAN data system, and developing priority health needs, objectives, and strategies for intervention. In addition, LHDs must conduct an organizational capacity assessment focusing on internal agency capabilities or the agency s capacities within the community health environment. Research conducted by Turnock and colleagues before 1992 and immediately after the first IPLAN round in 1994 found that Illinois LHDs appear to have significantly increased the extent to which they carry out the ten practices related to public health s three core functions. The self-reported performance of Illinois LHDs in 1994 shows improvement for practices associated with all three core functions, but most notably for those associated with the assessment and policy development functions. Improved performance scores were found among LHDs serving small as well as large populations and for LHDs in urban, suburban, and rural settings. 7 The evaluation also found that there was a large increase in the number of LHDs undertaking new or expanded activities. For several practices, the percentage of health departments engaging in a particular practice activity doubled (only the Implement practice area saw a small decrease in reported activities). A subsequent iteration of the survey in 1999 found

Local Public Health Certification 417 FIGURE 1 Percentage of Illinois Local Health Departments (LHDs) Performing Selected Practice Performance Measures, 1992 1999 continuing progress or maintenance of high levels of functioning for 8 of 10 organizational practices (Figure 1). While the Illinois certification program has served the state well, it was established nearly 15 years ago. Illinois program was groundbreaking when it began, but since then, there have been many developments in the field of performance measurement and accountability. Some of these more recent developments include the expanding national dialogue occurring on the role and merits of accreditation of health agencies; the creation of a public health performance management framework by the Turning Point Performance Management National Excellence Collaborative 8 ; the development and use of the National Public Health Performance Standards for public health systems 9 ; and the National Association of County and City Health Officials (NACCHO) work to develop the Operational Definition of a Functional Local Health Department. 10 Key Issues in Illinois Several forces of change are at work in Illinois, prompting stakeholder interest in rethinking the current certification program. First, the recent split of a single local health administrators association into three geographically based associations has produced several different advocacy positions representing local public health interests. For example, the larger and more populous areas of the northeastern part of the state seek state programs that can change to meet their complex needs, while the southern part of the state is represented by an association that seeks the maintenance of existing accountability processes. The diversity of local interests was among the drivers of the second force of change, the 2004 IDPH-convened Enrich and Strengthen initiative. Enrich and Strengthen is a statewide strategic planning process, examining emerging operational issues in governmental public health. Through this process, the state and LHDs expressed their interest in using standards, in strengthening accountability, and in exploring accreditation processes in Illinois. A third force of change was the disinvestment in the IDPH s program administration, technical assistance, and training to LHDs to help LHDs meet certification requirements. Tension between LHDs and IDPH also developed over the administration of the current certification program. LHDs have stated their view that IDPH review of their IPLAN submissions can be overly directive and intrusive, especially given the local partnership-based assessment and planning processes that are the foundation of their certification applications. This tension around the IDPH administration of the certification program is an additional indicator of the need to enhance the current program. In light of these unique forces of change, the Illinois Accreditation Task Force faced the challenges of building a new consensus among three local public health organizations, Boards of Health, and IDPH; and expanding local and state capacity-building activities to carry out and sustain new approaches. To organize the project, the Task Force developed a series of principles to guide their work. A new certification and/or accreditation program in Illinois should strengthen public health infrastructure statewide; contribute to quality improvement in public health practice;

418 Journal of Public Health Management and Practice minimize economic burden on already underresourced LHDs; provide adequate financial resources to support the program; establish a framework in which standards are achievable regardless of LHD size (while still promoting high standards); be driven by participants/stakeholders; do no harm to the current mandatory certification program (and end up with less than Illinois has in place now); and create choices for LHDs, not new mandates. The Proposed Illinois Model The Illinois Accreditation Task Force made an early decision to retain the organizational practice standards that are the backbone of the current certification program. Substantial congruence between the Illinois practice standards and the Ten Essential Public Health Services was determined through analysis. From this decision point, two tracks of work ensued: one to develop performance measures for the existing standards and one to design an operational structure that embodies the Task Force principles. To develop a more performance-based program, the elements of the current Code requirements and the NACCHO Operational Definition of a Functional Local Health Department were used to develop a panel of specific measures for each practice standard. Potential evidence that could be used to demonstrate compliance was identified for each basic performance measure. 11 The Task Force reached consensus on a new structure for the conduct of a voluntary accreditation program, with the condition that the current mandatory certification program remain in place (Figure 2). In the proposed new model, governance of the new accreditation program would ultimately be carried out by the Illinois Accreditation Board (IAB), a third party entity independent of the IDPH. The full operation of the IAB would be phased in over a 5-year period, during which LHDs may choose (1) to be certified within the current IDPH program using enhanced basic performance measures or (2) accredited by the IAB at basic or advanced accreditation levels. LHDs undergoing the accreditation process will be deemed to be certified by the IDPH, thus preserving the LHPG incentive for all certified LHDs. At the end of the 5-year phase-in period, the IAB would begin to operate independently of the IDPH but work in concert with the IDPH to assure an overall unified program direction. In addition to the dual governance in the new structure, the administration of certification would remain with the IDPH, while the accreditation program would be administered by a third party entity staffing the IAB. IAB staff would organize the review process and provide materials to the IAB for their accreditation decisions. During the phase-in period, the IAB would make recommendations to the IDPH about accreditation status of applicants; posttransition, the IAB would confer accreditation status directly. During the phase-in period, the IAB would develop measures and/or evidence that would be required for the intermediate and advanced accreditation tiers. The tiered structure will provide several options for LHDs to choose a level at which their performance will be appropriately measured and recognized. The several tiers also offer steps and benchmarks for improving the quality of local performance by working toward accreditation at increasingly higher levels. Incentives will likely be needed for the voluntary accreditation approach to attract applicants. The current incentive of the LHPG is maintained for both certified and accredited LHDs. The accreditation process itself may provide an incentive for LHDs committed to performance improvement. The accreditation process will focus on quality improvement, rather than simple compliance and regulation. Site visits, self-assessments, and technical assistance will be organized to foster quality improvement (Figure 3). Since Illinois partners view quality improvement in LHDs as the most important benefit of accreditation in Illinois, it is critical that the accreditation process be designed and implemented with that in mind. To move the accreditation program design forward using a performance management framework, it will be necessary to fully develop, test, evaluate, and revise the program s quality improvement features over the next year. 12,13 Summary and Implications Changes to the Illinois local public health certification program are a work in progress. The thorough reengineering of the program s focus, processes, and relevance is a challenging undertaking that has raised fundamental issues of equity, organizational development, and systems relationships. In many respects, Illinois can be viewed as a microcosm of the nation, in its diverse geography, population, and size of LHDs. Many of the challenges in the Illinois project to develop a more performance-based system of certification and accreditation will likely be faced in the development of a national voluntary accreditation program. The consensus reached by the IADP has many positive implications. First, the process maintains the core requirements of certification the meaningful

Local Public Health Certification 419 FIGURE 2 Illinois Revised Certification/Accreditation Program Model. community development effort made tangible by a community health assessment and plan in every local public health jurisdiction. This preserves the strength of the current system and strives to prevent a more regulatory approach focused only on conformity with measures. Second, the universal consensus around a quality improvement focus to accreditation opens the door to creative new features of the program (accreditation tiers, site visits, postaccreditation quality improvement plans and projects) that will instigate improvements in public health practice. Third, the use of NACCHO s Operational Definition proved to be extremely helpful in prompting thinking about elements of local public health practice that should be measured.

420 Journal of Public Health Management and Practice FIGURE 3 Illinois Accreditation Development Task Force Draft Illinois and Accreditation Processes IAB indicates Illinois Accreditation Board; IPLAN, Illinois Project for Local Assessment of Needs; LHD, local health department. This represents an early use of the definition to develop state-based performance measures and evidence. Finally, we have found that a mature certification process can adapt to structural and content changes that align it better with new developments in public health practice. The challenges that lie ahead in Illinois are, however, very real. They begin with resources an essential ingredient to support two separately administered programs in certification and accreditation. A new notfor-profit organization, the IAB, will need to be created, supported, and ultimately sustained in an environment of scarce resources. Second, marketing voluntary accreditation to LHDs without incentives may pose major difficulties in the uptake of the accreditation process. LHDs need to see their participation in accreditation as worth the trouble and expense that will likely be necessary. Third, the uneasiness felt by LHDs around possible changes to the current certification process must be tempered to reduce their anxiety and reluctance to participate. Fourth, the split in LHD associations further accentuates the needs of different types of LHDs (smaller vs larger; rural vs urban). The IAB will need to navigate these various needs to ensure that all LHDs can participate fairly in voluntary accreditation. Finally, the new program design must capitalize on the opportunity to identify and communicate lessons learned; facilitate cross-organizational learning; and utilize evaluation findings to improve quality. Despite these challenges, Illinois has an extraordinary opportunity as a result of the convergence of several unique factors the idiosyncratic history of certification in Illinois; the commitment on the part of the state health department to explore ways to enrich and strengthen the local and state public health system; the active involvement of administrators and board of health members from local health agencies both large and small; and, not least, the funding from the Robert Wood Johnson Foundation to initiate the project. As development of public health practice continues to advance and change, both the certification and accreditation processes must adapt and incorporate new practice improvements. The IADP represents just such an adaptation. REFERENCES 1. The Roadmap Implementation Task Force. The Road to Better Health for All of Illinois. Springfield, IL: Illinois Department of Public Health; March 1990.

Local Public Health Certification 421 2. Rudis GS, Robinson GT. Accreditation of local public health practice in Illinois, 1993 1998. J Public Health Manag Pract. 1998;4(4):16 18. 3. Turnock BJ, Handler A, Hall W, Potsic S, Nalluri R, Vaughn EH. Local health department effectiveness in addressing the core functions of public health. Public Health Rep. 1994; 109(5):653 658. 4. US Department of Health and Human Services. Public health in America. http://www.health.gov/phfunctions/ public.htm. Accessed 5. Illinois Department of Public Health. Illinois Project for Local Assessment of Needs. http://app.idph.state.il.us/. Accessed 6. National Association of County and City Health Officials. Mobilizing for Action Through Planning and Partnerships. http://mapp.naccho.org/mapp Home.asp. Accessed 7. Turnock BJ, Handler A, Hall W, Lenihan DP, Vaughn E. Capacity-building influences on Illinois local health departments. J Public Health Manag Pract. 1995;1(3):50 58. 8. Public Health Foundation. Performance management collaborative. http://www.phf.org/pmc.htm. Accessed 9. Centers for Disease Control and Prevention. National Public Health Performance Standards Program. http://www.cdc. gov/od/ocphp/nphpsp/. Accessed 10. National Association of County and City Health Officials. Operational definition of a functional local health department. http://www.naccho.org/topics/infrastructure/ documents/operationaldefinitionbrochure.pdf. Accessed 11. Illinois Public Health Institute. Illinois Accreditation Development Project. http://www.iphionline.org/index. asp?type=b BASIC& SEC/{38622CD8-D860-4BD9-A52D- 99AB33683C44}. Accessed 12. Landrum LB, Baker SL. Managing complex systems: performance management in public health. J Public Health Manag Pract. 2004;10(1):13 18. 13. Turning Point Performance Management National Excellence Collaborative. From Silos to Systems: Using Performance Management to Improve the Public s Health; Seattle Washington: Turning Point National Program Office at the University of Washington; 2002.