Monday, September 2, 2013

Fixing Public Health? (Accreditation!)

This will probably seem like a very wonky post, unless you worry about the fact, as I do, that the public health system in the United States is broken, and ponder ways to fix it. People who worry about public health have converged on the concept of national public health accreditation as one way to address this challenge. 

Over the past ten years public health folks have participated in an intensive effort to create a system of national public health accreditation, which would align the work of local, state and federal public health agencies while ensuring that every one of them is really doing what it ought to be. With tremendous support from the CDC and the Robert Wood Johnson Foundation, among many other national caliber players, they have launched the Public Health Accreditation Board (PHAB) which has just accredited its first batch of public health agencies, including our sister Central Michigan District Health Department.  This effort is very important and well overdue, but it faces several vexing challenges, the most important being Washington DC weirdness. This post is about how we are trying to embrace national accreditation, while fixing its flaws, here in Michigan.

The story begins 25 years ago, long before anyone was thinking of national accreditation, when Michigan created its own state system for accrediting local health departments, known as the Michigan Local Public Health Accreditation Program (MLPHP). This system was needed because, in the United States, local public health is funded through myriad idiosyncratic grants and contracts from various federal agencies, which are disbursed by states. In the past, ensuring compliance with this rococo array of funding streams was a bureaucratic car wreck. MLPHP folded these compliance activities, along with compliance with the state's public health code, into a single streamlined process, saving time and money. MLPHP is governed by a Commission representing most organizations concerned with public health in Michigan, and it has had an ongoing quality improvement process, which has vastly improved communication between the state and local public health. MLPHP has been very effective. Since the inception of the program the performance of local health departments has steadily improved. Today, on average, most local health departments miss four or fewer of the approximately 190 indicators used in MLPHP during the review process.

How would a system of national accreditation compare to MLPHAP? There are 57 states and territories. A national system of public health accreditation could never take all the vagaries of state and local laws and regulations into account.  Instead, when PHAB created its national standards and measures it used a theoretical framework called The Ten Essential Services which describes the cycle of research-policy development-enforcement-evaluation that all public health agencies engage in, in one form or another. The application of this framework can be bracing for health departments. Governmental public health can slip into bureaucratic complacency--giving shot after shot, performing inspection after inspection--without asking if the effort is worthwhile. Undergoing national accreditation, staff at a local health department may feel for the first time that they really understand the mission of public health while gaining renewed respect for our special skill sets. So while local accreditation teaches the jot and tittle of the law, national accreditation imparts the heart and soul of public health: the science, methodologies and social and political context. An important distinction before proceeding: compliance with federal contracts is mandatory, but accreditation by PHAB, which is a free-standing non-profit corporation, is voluntary.


So there is the first "vexing challenge" to national accreditation: many state systems of accreditation are so effective at ensuring compliance with the law--increasing efficiency and saving money--that locals may be unwilling to adopt the voluntary national system, in spite of its virtues. You see, the national system does not eliminate the need for compliance with federal grants and contracts. All the contract grunt work continues, with national standards slathered on top as an extra layer. In this age of the Sequester, it can be too much to bear.

And there is your second "vexing challenge": it’s that the darn CDC itself, along with its brother agencies Environmental Quality and Agriculture, on the one hand splatter public health with a fire hose of contractual reporting requirements, and at the same time cooked up the Ten Essential Services and created PHAB and want us to do that dance, too, without funding any of it.

Why, oh why, didn't CDC and PHAB fold contract compliance into national accreditation, so we could do it once and be done? The requirements of the various siloed federal public health programs reflect the structure of the federal budget, and thus congressional priorities, not best practices in public health. Congressionally mandated reporting requirements are only going to increase, not decrease, at the same time that federal ardor for national accreditation grows hotter. It is what it is.

The third "vexing challenge" is funding. PHAB was created by people who care about public health, to help us rediscover our mission and basic public health science. But it is not an official federal program, and so it is not funded.  Thus PHAB has to charge fees for participation, which can run into tens of thousands of dollars, depending on the size of the health department. That’s right: we aren’t funded to comply with national accreditation, we have to take money from services to pay for it!

Amazingly, several local health departments in Michigan are doing both local and national accreditation--eating the costs and working their staff hard--in an effort to make their departments the best they can be.  MMDHD itself just completed local accreditation (missing only one indicator which has been corrected) and intends to apply for national accreditation by the end of 2013.

What about it? Can we fix what the Feds broke? Once again Michigan is at the forefront. Michigan has convened an ad-hoc Committee on Accreditation Efficiencies (I am a Co-Chair) to explore ways to merge the two systems (And we know for sure that PHAB is hopeful this experiment will bear fruit).  The Committee wants to see if it is possible to make the two accreditation systems feel like one system.  It is asking the following questions: 1) If a health department meets certain PHAB measures, can they be deemed to be in compliance with indicators in MLPHAP? 2) Are there MLPHAP indicators which, if met, PHAB would consistently accept as meeting PHAB measures? 3) How can we pay for a merged system? Would there be any savings in contract compliance costs from cross-walking the two systems that would enable the state to, at least partly, help defray locals’ PHAB fees?

Again, sorry about the wonk factor in this post.  But I feel like it is important for folks to know that people in public health aren’t just accepting the dysfunction in government that is out there, but are trying to find ways to make things work for our communities. I also feel like it is important for people to know how incredibly weird and difficult it gets when you try to do that. It is what it is.