The benefits associated with accreditation may be particularly important for small local health departments—those that serve a population of less than 50,000—because of their critical role in our nation’s public health system.

The benefits of public health department accreditation through the Public Health Accreditation Board (PHAB), including enhanced quality improvement, strengthened partnerships, and improved transparency and accountability, are well-documented; however, there was limited understanding of how the benefits of accreditation differ based on local health department (LHD) size. In our article titled, “Benefits and Impacts of Public Health Accreditation for Small Local Health Departments,” we explored whether LHDs reported different benefits and outcomes of public health accreditation through PHAB based on their population size served.

Findings in this article were based on a survey conducted by NORC at the University of Chicago, supported by the Public Health Accreditation Board (PHAB) through funding from the Centers for Disease Control and Prevention (CDC). The survey was fielded to all health departments accredited between 2013 and 2022, shortly after they received notification of their accreditation status. The analytic sample included only accredited LHDs (n=266). We defined LHDs as large (population size served of 500,000 or more), medium (population size served of 50,000 to 499,999), or small (population size served of less than 50,000).

Through our analysis, we found that in some instances, small LHDs were more likely than larger LHDs to report experiencing certain benefits of public health accreditation.

What did we learn?

• Small LHDs were significantly more likely than medium or large LHDs to report that PHAB accreditation increased their agency’s use of evidence-based practices for public health programs and/or business practices. All small LHDs (100%) reported that accreditation increased their use of evidence-based practices, compared to three-quarters or less of medium and large LHDs (70% and 61%, respectively).
• Small LHDs (84%) were significantly more likely than medium or large LHDs (74% and 59%, respectively) to report that PHAB accreditation improved their board of health or governing entity’s working knowledge of the health department’s roles and responsibilities.
• Nearly all small LHDs (91%) reported that because of participating in accreditation, their health department’s staff competencies have improved, compared to three-quarters or less of medium and large LHDs (75% and 73%, respectively).
• Other benefits reported by nearly all small LHDs (93% or more) were: improved operational or public health policies, implemented new strategies for QI, and improved capacity to provide high quality program and services. Medium and large LHDs reported similar benefits.
• Nearly all small LHDs (96%) reported that they made the correct decision to apply for national accreditation through PHAB.
• Common challenges for small LHDs were similar to LHDs serving larger population sizes and included limited staff time or schedule limitations and staff turnover or loss of key staff.

What are the implications of these findings?

While there are often challenges for small LHDs to achieving accreditation, the potential benefits of accreditation for those LHDs can be significant. Many health departments experience challenges during the accreditation process, including limited staff time or other schedule limitations, and staff turnover or loss of key staff, but small LHDs often have fewer staff overall. These challenges are not inherent to the accreditation process itself; workforce and infrastructure challenges have been long-standing in public health and heighted because of the COVID-19 pandemic. Small LHDs, many of which had lower workforce capacity to begin with, may need additional support and resources to help them become accredited and experience the benefits of accreditation, such as improved capacity and performance, like larger LHDs that have pursued and achieved PHAB accreditation.

As a field, it is important to identify creative solutions for supporting and encouraging small LHDs in their efforts around capacity and performance improvement. One potential example is the Pathways Recognition Program, which is a new program launched by PHAB that can serve as an intermediary step for LHDs interested in but not yet ready to apply for initial accreditation. Additionally, there are opportunities for federal investments to support accreditation among LHDs. For example, the CDC Strengthening Public Health Infrastructure Grant Program supports the people, services, and systems needed to enhance the foundational capabilities of the public health system broadly, which may include efforts to achieve accreditation.

As described in our article, “Benefits and Impacts of Public Health Accreditation for Small Local Health Departments,” small LHDs that have achieved accreditation to date have described the benefits of achieving accreditation, but most small LHDs have not formally engaged with the accreditation process. A program such as Pathways and federal funding to support public health infrastructure may open the door for more LHDs to explore potential benefits of performance improvement efforts like accreditation.

Megan Heffernan, MPH, is a Senior Research Scientist in the Public Health Research department at NORC at the University of Chicago. She nearly a decade of experience conducting public health systems and services research. She has expertise in program evaluation, public health infrastructure, public health accreditation, rural health, and health equity, among other topics.

Alexa Siegfried, MPH, is a Senior Research Scientist in the Public Health Research department at NORC at the University of Chicago. She has expertise in qualitative program evaluation and research in the areas of public health systems, rural health, and public health emergency preparedness, among other public health topics. She has led evaluation studies related to public health accreditation for 15 years.

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