Reflections of the Accreditation Committee

This entry is part 7 of 41 in the series Focus on Accreditation and Innovation

by Douglas Scutchfield, MD; Robin Wilcox, MPA; and Wilma J. Wooten, MD, MPH

The Accreditation Committee of the Public Health Accreditation Board (PHAB) is charged with determining the accreditation status of Tribal, state, local, and territorial governmental public health departments. Appointed by the PHAB Board of Directors, Committee members have current or recent experience in leadership positions in health departments.

The Committee’s accreditation decisions are based on a site visit report developed by a team of PHAB-trained volunteer reviewers. This team of peer reviewers develops the report after a comprehensive review of documentation and a department site visit. The site visit report provides the Committee with information concerning how well the health department demonstrated conformity with the approximately 100 nationally adopted measures in the PHAB Standards and Measures.

The Accreditation Committee meets quarterly to review site visit reports. The Committee has rigorous conflict of interest procedures to guard against real or perceived conflicts in the decision-making process. They thoroughly discuss the findings of each site visit report. The Committee is careful to make decisions that are consistent across health departments but that also address the individual health department’s strengths and opportunities for improvement. There is, therefore, no numerical formula for reaching its decisions; accreditation determination is made based on the totality of the information in the site visit report, including narrative descriptions of the health department’s conformity with the measures. The Committee places emphasis on the community health assessment, community health improvement plan, strategic plan, and quality improvement efforts.

Importantly, the focus of the Committee’s process and decisions is on quality and performance improvement. If a health department is accredited, the Accreditation Committee will identify specific measures where there are opportunities for the health department’s improvement. The health department will be required to report progress on addressing those measures in its Annual Report that it is required to submit to PHAB. In this way, PHAB ensures that accredited health departments engage in continuous improvement.

If the health department cannot be accredited based on the site visit report, the department will have an opportunity to continue working towards accreditation. The Committee will specify which measures require work, and the health department will submit an Action Plan that will detail how it will achieve conformity with those measures. Upon approval of the Action Plan by the Committee, the health department will complete the work steps in the Plan and will submit documentation that the plan has been implemented. After review and assessment of this documentation by PHAB volunteer reviewers, the Committee will review the assessments and determine if the health department can be accredited or is not accredited. To date, all health departments that have gone through the Action Plan process have achieved accreditation. A short video of two health department directors’ experience with an Action Plan can be accessed at

The PHAB accreditation process is designed to encourage continuous quality and performance improvement. This is true from the health department’s very first steps to prepare for accreditation through receipt of accreditation and maintenance of accreditation status.

Douglas Scutchfield, MD, is the initial incumbent in the Peter P. Bosomworth Professorship in Health Services Research and Policy at the University of Kentucky. He holds faulty appointments in the College of Public Health and the College of Medicine. [Full bio]



Robin Wilcox, MPA, is the Chief Program Officer of the Public Health Accreditation Board (PHAB), which administers the national, voluntary accreditation program for state, Tribal, local, and territorial public health departments. Ms. Wilcox joined PHAB in August 2007. [Full bio]



Wilma J. Wooten, MD, MPH, has been with the County of San Diego Health and Human Services Agency since 2001, initially as Deputy Health Officer and, since 2007, as the Public Health Officer. Trained in family medicine, public health, and preventive medicine, she has oversight for almost 500 employees and a budget of over $100M, serving a county of 3.1 million residents. [Full bio]


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