Health Forward Foundation

Kansas and Missouri Health Departments Move Toward National Accreditation

Stefanie Gaborie holds her daughter Ryleigh while nurse Kathy Colson performs a Well Child exam at the Lawrence-Douglas County Health Department.

Several public health departments in Kansas and Missouri are taking early steps to meet standards that will allow them to become nationally accredited, despite budget concerns that make it uncertain how many departments will be able to afford the process.

“It’s very costly,” said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. “Some health departments have less than 10 employees and very tight budgets. So when resources are so short and it’s not something that falls into the category of ‘have to do,’ you can see why they might not choose to do so. At least not at this time.”

Accreditation is new to most health departments in Kansas and across the U.S., but Missouri has had state-based accreditation since 2003.

In fact, the national standards now in place were modeled after those set by the Missouri Institute for Community Health, said Mahree Skala, director of the Missouri Association of Local Public Health Agencies.

“They overlap to a very great extent,” she said. “So the agencies that have been through the Missouri process are very well prepared for national accreditation.”

Currently 17 Missouri agencies are accredited by the state and eight more are going through the process, Skala said.

However only two that she knows of — Taney County’s and the Kansas City health departments — are preparing to apply for national accreditation. The barrier is the same as it is for many in Kansas: cost.

“The fee structure for national accreditation is a lot more expensive than our state process has been,” Skala said. “Many that have been accredited in Missouri are smaller agencies. I don’t know how the less wealthy departments will fare with that (national accreditation cost), frankly.

“Tremendous numbers of our agencies have had budget cuts and layoffs and cutbacks in staff hours, so that affects both their readiness for accreditation, but it also affects their ability to pay the fee and go through the process,” she said.

However, she said in Missouri there is broad agreement that accreditation is a worthwhile endeavor.

“I think one of the big questions hanging out there nationally is why bother, what’s the benefit of doing this? I think that’s been answered to a great extent in Missouri,” Skala said.

Accreditation has improved agencies internally by providing an impetus to improve quality, and externally by strengthening relationships with the community, she said.

“And I think it’s changed the way agencies think about themselves,” she said. “It’s always been the attitude that if you’ve seen one health department you’ve seen one health department. There was no standardization. This has contributed to the notion that there are standards that all health departments can be measured by. It changes the whole expectation.”

Despite the cost and other hurdles, several local departments in both states are moving forward. Accreditation for now is a voluntary process, though most local health officials expect that in the near future departments that want federal funding will need to be accredited in order to receive it. The accreditation process is designed to improve and standardize services available at agencies across the nation.

Last week in Kansas, the Lawrence-Douglas County Health Department took a first step when its board approved the agency’s strategic plan for achieving accreditation.

Assistant Director Charlotte Marthaler said the agency plans to apply for accreditation no later than November 2012.

“This is about more than just formal accreditation. This is setting a new direction for the health department,” Marthaler said. “Right now in public health, a lot of the priorities are set by state and federal government. It comes to us in the form of categorical programs. So we tend to do what we get paid to do. (The accreditation process) changes that paradigm.”

The first requirement for meeting the standards recently set by the national Public Health Accreditation Board is a locally conducted assessment of community health needs.

“Until we understand what the community wants, we’re just kind of bounding out in the ocean. This process is intended to ground us,” Marthaler said.

Piggyback on hospitals
A section in the federal health reform law of 2010 created a similar requirement for community-needs assessments at nonprofit hospitals that want to protect their tax-exempt status. While local health departments face no accreditation deadlines, the hospitals must have their community assessments complete by 2013 or face a future tax penalty of up to $50,000.

As required in Section 9007 of the Affordable Care Act, the hospitals also must make known their financial assistance policies and how much free or reduced-cost care they provide in the towns and cities they serve.

Accreditation process
The Public Health Accreditation Board (PHAB) is a nonprofit organization that regulates new quality and service standards for tribal, state, local, and territorial public health departments.

To be accredited, health departments must demonstrate that they meet PHAB’s Standards and Measures.

Before applying for accreditation, departments must first meet three prerequisites:

  • Perform a community health assessment, which typically is a 12- to 18-month process of collecting broad community input about the health of the population. The National Association of County and City Health Officials (NACCHO) suggests four surveys that collect health data, health services information, projections for changes in community demographics or the economy, and the community’s primary characteristics.
  • Use the assessment to craft a community health improvement plan, which is another months-long process bringing together public health officials, health providers, local government officials and other community leaders to build a plan that addresses problems identified by the assessment.
  • Create a strategic plan, which focuses on how the local health department will address the identified problems during a five-year period.

“Clearly, the intent is to start having hospitals look more systematically at how they’re addressing community needs,” said Sheldon Weisgrau, a Kansas health policy consultant working with the Health Reform Resource Project.

The IRS will use the hospital assessments and financial disclosures to help “determine whether (the hospitals) are actually meeting their charitable purposes,” Weisgrau said.

Ponce said public health departments situated in a city, county or region with a nonprofit hospital could collaborate on the community-needs assessment process. The hospital would get what it needs for the IRS and the local health department could get what it needs for accreditation.

The timing of the hospital requirement presents an opportunity for health departments with thin resources, she said.

“You don’t want a health assessment occurring without public health at the table. You also don’t want to come around six months or a year later and try to get all those stakeholders back to the table to do it again,” Ponce said. “Now is the time.”

The Kansas Hospital Association estimates that as many as 80 to 100 hospitals will be required to do a community assessment. It’s not yet known exactly how many and which nonprofit hospitals in the state will be affected, said Cindy Samuelson, a spokesperson for the association.

Kansas has 100 local health departments, one for nearly each of the state’s 105 counties, so there seems to be potential for a large amount of overlap.

In Johnson County, the health department since March has been working with four nonprofit hospitals on a needs assessment that will soon be completed, according to Barbara Mitchell of the health department.

Mitchell said the agency could be ready to submit its accreditation application by the end of next year.

Regional approach
Another way that health departments can stretch their resources as they work toward accreditation is through collaboration with other local departments in the region.

In Douglas County, Marthaler reprioritized duties for virtually all of the department’s 37 full-time employees in order to make her agency’s application goal.

“We carved out of the resources we currently had to get this done,” she said.

And while most everyone at the agency is involved in the process to some degree, accreditation is now her top job duty.

“This is not quite 100 percent,” Marthaler said. “But I need to be doing everything I can toward it.”

Douglas County has one of the state’s larger local health departments. Dedicating all or most of an employee’s time for the work isn’t an option for most other health departments, Ponce said.

However, some regional collaborations are under way that pool the resources of several local departments. And the national Public Health Accreditation Board (PHAB) is developing a process that would allow local departments to earn joint accreditation as a regional entity.

Shirley Orr of the PHAB said some indication of what that regional process might look like should be forthcoming when the board meets on Dec. 8 and 9.

“Definitely, it’s a need and it’s certainly on PHAB’s radar. I think there will be lots of information coming forth fairly shortly,” Orr said.
Meanwhile, at least one group of Kansas departments is taking steps to apply as a region.

In July, the East Central Kansas Public Health Coalition was awarded $35,000 to work toward accreditation and serve as a model for other potential regional applicants.

The coalition comprises Chase, Coffey, Franklin, Greenwood, Lyon, Morris, Osage, and Wabaunsee counties. It was one of 12 organizations nationwide from among 127 applicants to receive demonstration grants provided by the National Association of County & City Health Officials (NACCHO).

Midge Ransom, director of the Franklin County Health Department, said she has been working on accreditation off-and-on for three years. Some weeks, she spends 65 percent of her time on it.

“If we had the money, there’s certainly enough work to justify hiring a full-time person to do this,” she said.

But by pooling resources, the eight agencies in the coalition have made headway and hope to apply for accreditation in 2013.

Gauging interest
State officials are now trying to determine how many local departments intend to apply for accreditation.

Last week, the Kansas Department of Health and Environment sent a survey.

Responses were still coming in this week, said Jane Shirley, director of KDHE’s Bureau of Community Health Systems.

“So far we’ve seen a fair number that would like to apply for accreditation, but they see time and finances as a barrier,” she said. “A fair number have also expressed interest in applying regionally. And there are those that do not intend to apply.”

Of the 84 respondents so far, 24 indicated they intend to apply for accreditation either individually or as part of a region. Another 37 indicated they would like to apply for accreditation but do not have the resources to do so.

Accreditation costs vary from department to department. But the expense of a full-time person to work on accreditation would range from $50,000 to $100,000. On top of that would be application fees ranging from $13,000 to $30,000 per agency.

An online tool with resources to help with the accreditation process is nearing completion. The site — — currently requires a password but will be open to the general public in January.
It is the product of an 18-month collaboration involving the Kansas Health Institute, KDHE, the hospital and local health department associations, the Kansas Health Foundation, the Kansas Association for the Medically Underserved and the United Way.

The KHI News Service is an editorially independent program of the Kansas Health Institute and is committed to timely, objective and in-depth coverage of health issues and the policy-making environment.

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