For more than 2 decades, the Institute of Medicine has drawn national attention to the need for strengthening the public health infrastructure and related capabilities to protect and ensure the public's health.1,2 A strong and sustainable public health infrastructure is critical for public health departments to operate efficiently and effectively in delivering the 10 essential public health services necessary to meet the health needs of communities.

In its 2003 report, The Future of the Public's Health in the 21st Century, the Institute of Medicine called for strengthening public health performance and exploring health department accreditation as a way to ensure that public health services and programs are efficient and effective in addressing the public health challenges of today and tomorrow.3 Four years later and with support from the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation, the Public Health Accreditation Board (PHAB) was established and work began to develop a national program to improve the quality of practice and performance within public health departments. Based on the 10 essential public health services, PHAB accreditation provides a means for a health department to identify performance improvement opportunities, enhance management, develop leadership, and strengthen community relationships; leading organizations to improved accountability, credibility, and better health outcomes. The program was successfully launched in fall 2011, and the first 11 PHAB-accredited public health departments were announced in March 2013, with many more health department applications in process.4

In 2010, prior to the launch of the PHAB accreditation program, CDC's Office for State, Tribal, Local and Territorial Support introduced the National Public Health Improvement Initiative (NPHII), a 5-year cooperative agreement funded through the Prevention and Public Health Fund of the Affordable Care Act.5 In its first year, NPHII provided core funding and technical support to 76 state, tribal, local, and territorial health agencies to build their organizational capacity for conducting agency-wide performance management and quality improvement (QI) for greater public health impact.

To capitalize on the launch of accreditation, the CDC strategically reframed NPHII during the second year to align with accreditation readiness activities and standards established by PHAB while maintaining the original focus on building agencies' performance management and QI capacity.6 The alignment came naturally; both NPHII and accreditation are noncategorical efforts focusing on advancing crosscutting capacities that agencies need to better manage their business operations and disease-specific programs and services. Both promote evidence-based public health practice, performance management, and QI. And both are intended to improve agency efficiency, effectiveness, and accountability, with the ultimate goal of achieving better health outcomes. Although NPHII does not require its awardees to apply for accreditation, it does require attention to the national consensus standards established by PHAB and supports those health departments that voluntarily choose to pursue accreditation.

NPHII advances accreditation most directly through funding to support health department accreditation readiness activities. Accreditation readiness includes the necessary steps and activities an agency is encouraged to undertake or required to complete before submitting a formal application to PHAB.7 For example, NPHII grantees are to demonstrate progress toward meeting the PHAB prerequisites-complete or revise their community health assessment, develop or update their community improvement plan, and complete an agency strategic plan based on the specifications outlined by PHAB.8 Because these 3 activities are fundamental to a high-performing public health agency, these requirements benefit all NPHII grantees regardless of their intent to apply for accreditation. NPHII grantees are also required to strengthen their use of performance management practices for greater agency oversight and accountability and to conduct QI initiatives for more efficient and effective program and service delivery. These NPHII requirements align with and reinforce the PHAB standards that explicitly call for use of QI and performance management practices.8 Furthermore, NPHII encourages each grantee to conduct a self-assessment against the full set of PHAB standards to identify and address critical gaps in health department plans, policies, and practices.

Another important component of NPHII is the requirement of each grantee to hire or designate a performance improvement manager (PIM), thereby creating a national network of PIMs who share strategies and lessons learned to improve agency performance and the delivery of public health programs. Although the duties of PIMs can vary on the basis of organizational needs, their main role is to lead and assist in (1) building performance management systems and practices, (2) tracking and reporting program performance, and (3) engaging agency staff in the application and use of QI methods and approaches. While some awardees already had a PIM-like staff person or office in place prior to NPHII, the majority of awardees created such an office after NPHII began. For grantees seeking accreditation, the PIM can also serve as the accreditation coordinator. The accreditation coordinator leads and supports the agency in preparing for accreditation by fostering cross-agency participation; collecting and reviewing required documentation; and engaging agency staff and community members in completing the PHAB prerequisites. Further details in describing the role accreditation coordinators play in supporting agency readiness and QI activities can be found in the case reports published in this special issue.9

In addition, grantees may use NPHII funds to offset PHAB accreditation fees. Given the current economic environment and the corresponding decline in public health budgets, this flexibility enables many health departments to pursue accreditation despite jurisdictional resource limitations. The use of NPHII funds for payment of accreditation fees puts accreditation within reach for a greater number of health departments than would have otherwise been possible.

Grantee capacity for achieving NPHII requirements as well as agency-specific improvement goals is further enhanced by technical assistance and support through CDC's national partners. Working with the Association of State and Territorial Health Officials, the National Association of County & City Health Officials, the Public Health Foundation, the National Network of Public Health Institutes, and the American Public Health Association, NPHII grantees may seek direct technical support and assistance in completing NPHII requirements, including those associated with PHAB accreditation readiness. This provision of technical assistance from major national public health partners has established a valuable and strategic collaboration to advance NPHII and accreditation efforts.

Finally, NPHII offers new and expanded opportunities for state, local, tribal, and territorial health departments to engage in a national dialogue with the CDC, PHAB, Robert Wood Johnson Foundation, and other public health stakeholders and partners to advance the quality and performance of public health departments. Through NPHII-supported meetings, invited presentations, and the PIM network, health department grantees engage in greater peer-to-peer sharing of their successes and lessons learned in the implementation of performance management and QI practices, alignment of agency policies and practices to the PHAB standards, and agency preparation for accreditation. The impact is not limited just to NPHII grantees, as many are using their NPHII funds and technical assistance to promote accreditation readiness and QI activities among health departments within their jurisdiction.10 The breadth and depth of NPHII-funded activities foster leadership buy-in and cross-program, cross-agency engagement in QI, which, in turn, helps shape our understanding of how to build and sustain a QI culture in public health.

Conclusion

Accreditation is an important step on the road toward improvement, but the real goal is adopting and institutionalizing ongoing performance management and QI. NPHII provides dedicated funding and mutually reinforcing requirements to jumpstart the journey. It is important to note that there are other investments at the local, state, tribal, and national levels in support of accreditation and QI. Several health departments were well advanced in their accreditation preparation before NPHII was launched. For some agencies, NPHII funding accelerated activities already underway. For others, NPHII funding serves as a catalyst to initiate accreditation readiness activities that may not have otherwise occurred. Regardless of attribution, there is a strong recognition by the field that NPHII has greatly advanced accreditation readiness. Preliminary NPHII evaluation findings support this conclusion, although the findings are based primarily on year 2 activities and additional data are needed to document and substantiate progress health departments have made through the initiative.11

Strengthening the public health system is particularly challenging, given current economic times in which declining public health resources have necessitated program cuts, reductions in workforce, and furloughs. To adapt, health departments need both to strategically allocate their scarce resources to programs and services that are most effective and to use methods and approaches for greater organizational, operational, and programmatic efficiency. The application of performance management and QI practices offers health departments a way forward in meeting the economic and community health challenges of today. Both accreditation and NPHII promote performance management and QI as the foundation for health departments to operate more efficiently and effectively, ensure the delivery of high-quality programs and services, and achieve optimal performance for better health outcomes.

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