Raising the Bar: Advancing Health Equity Through Higher Accreditation Standards

By Megan Gaydos

How do we change our institutions? This is a key question that many of us working with health departments to advance equity keep coming back to. One way is to raise or change the standards that are expected of institutions, so they can level up with clear expectations.

“Accreditation helped us have a stronger focus and a formal process that cut across the whole department, braids the departments’ work together, and helps articulate where we want to be growing… It really brought us together as an agency to work collectively on something that went beyond individual areas.”

Seven years ago, the Public Health Accreditation Board (PHAB) launched national accreditation standards “to advance the quality and performance of all public health departments in the United States.” These standards were intended to set a minimum bar of public health practice and encourage ongoing quality improvement/performance evaluation.

Earlier this year, the Public Health Accreditation Board commissioned Human Impact Partners to write a paper to better understand the state of the art and direction of governmental public health work on health equity, with the goal of ultimately updating their standards to Version 2.0. To write this paper, we convened an advisory board of health equity experts, interviewed health departments who have achieved or are pursuing accreditation and are advancing health equity, and conducted a thorough review of PHAB’s 270+ page guidance documents.

In this post, we summarize our recommendations to PHAB to “raise the bar” to systematically advance health equity across public health departments in the United States. Quotes in this post are from our project advisors and key informants. Our recommendations are specific to PHAB’s process and the revision of their accreditation Standards and Measures (for more general recommendations about advancing health equity, please visit: HealthEquityGuide.org).

☆ Lead with Equity

Our first overarching recommendation encourages PHAB to be bold and explicit that health equity is central to — and indeed, much of the basis for — governmental public health practice.

Virtually every health department in the nation faces health disparities and organizes its work to close those disparities. What would it mean if health departments framed their agencies efforts’ with a proactive vision and plan for health equity?

As an accrediting body, PHAB has the ability to set the floor for what is expected of governmental public health. By leading with health equity, PHAB could normalize equity activities and illustrate that it is both possible and recommended to operationalize health equity in public health practice. As stated by one of our project key informants:

“With all the documentation we have to identify, review, and provide, it is easy for health equity to fall through the cracks unless it is specifically requested within the guidance. Equity should be a guiding principle for accreditation — just like quality improvement and performance management.”

To lead with health equity, we recommend that PHAB:

• Explain in all PHAB materials and orientations why health equity is fundamental to health department practice and, ultimately, the root of what virtually all health departments seek to achieve in their work.
• Define health equity in PHAB’s Standards and Measures document, not only in the accompanying/separate Glossary of Terms. We recommend using this definition of health equity adapted from Paula Braveman and colleagues’ definition.
• Create a very visible platform to illustrate how jurisdictions are doing health equity work. Highlight/profile good examples of pre-requisite documents (e.g. CHA, CHIP. Strategic Plan, Emergency Operations Plan) with a strong health equity focus.

☆ Integrate Health Equity into Strategic and Program Planning

“Health Equity has served as an organizational compass for where our department was and is heading and why quality improvement was and is important to help advance our systems change work.”

Both our project’s advisors and key informants highlighted how advancing health equity and pursuing accreditation can be complementary and synergistic processes for health departments. Both processes can help improve coordination and communication across the health department to achieve a goal beyond individual program goals. When planned and implemented with intention, accreditation processes can help advance health equity and health equity processes can help prime organizations for pursuing accreditation.

To integrate health equity into strategic and program planning, we recommend that PHAB:

• Require that health departments have explicit health equity goals/objectives, data/indicators, and performance or evaluation measures. Clarify that the aim is to integrate health equity across programs and plans, not to have health equity be compartmentalized or siloed from other health department activities. Plans need to be contextual, evolving, and flexible.
• Require that health departments be explicit about how and whether they are moving the needle towards health equity. This would include serious reflection about whether health inequities are being reduced, and if not, what needs to be done differently to make an impact on health outcomes, or key factors that lead to health outcomes.
• Provide concrete examples of policy, systems, and environment change work, as well as community engagement work that has been or could be “counted” in the accreditation process (e.g., health department housing conditions report being cited by the city council in approval of tenant protections and rent control; life expectancy being included in the city’s business plan; health department testifying to the health benefits of a paid family leave in city or state policy deliberations).
• Consider developing a tiered quality improvement (QI) system with standard QI improvements to generally improve the health department, along with “Innovative QI goals” that encourage risk-taking, especially around health equity work. Health equity work requires planting many seeds that may not all come to fruition. Innovative QI measures could help document and value a commitment to systems change while also trying to track long-term impact.

☆ Center Community Engagement on those Most Impacted by Inequities

PHAB should be more clear about the importance of engaging community members most impacted by health inequities and create measures to ensure that these communities are meaningfully engaged. As noted by one project informant:

“Things look different if you have deep meaningful community engagement, and you get to different solutions and changes needed if inequities are what’s driving your prioritization process.”

Public health accreditation currently requires extensive community engagement, but is not always clear on who the community to be engaged is. Without explicit guidance, “community” can refer to hospital and business executives or to low-income residents living in substandard housing and/or at risk for deportation.

To promote meaningful community engagement, we recommend that PHAB:

• Explain the “why” — Establish a principle that “community engagement” is for the purpose of decreasing power imbalances and historical disenfranchisement among communities most impacted by health inequities.
• Highlight that meaningful engagement requires bi-directional learning and capacity-building. Health departments have as much, or more, to learn from community members. Acknowledge that working with community organizers can help engage those most impacted by inequities, build community power and facilitate more inclusive and accountable government processes.
• Emphasize that coordinated collaboration with other constituencies — including government agencies, health/hospital systems, and others — is also important to advancing equity (for example through a Health in All Policies approach), but partnership with impacted communities also needs to occur.

Our final report includes hundreds of recommended resources to advance equity, examples of health equity work by health departments, and recommendations by PHAB domain on how to advance equity.

Many thanks to our 12 project advisors and 13 key informants who provided valuable insights and feedback on the report and its recommendations! Thank you also to our original advisors in the development of the Health Equity Guide, which was used and is referenced extensively in this paper.

Following completion of the report, PHAB invited HIP to participate in their Health Equity Think Tank, to discuss the recommendations outlined in the paper with invited health equity experts and organizational representatives. These discussions will inform PHAB revisions of their Standards and Measures. Updates on Version 2.0, including opportunities for public comment and review, will be available on the PHAB website.

Megan Gaydos works as a part-time consultant with Human Impact Partners, managing Health Equity Guide work and supporting various research projects. A former epidemiologist, she is incredibly inspired by the work that health departments and communities are doing to advance health equity around the US.