Introduction

In the state of Ohio, a public health department is a government entity that reports to the state governor. The health department strives to prevent and control the spread of infectious disease, responds to events that threaten public health, focuses on health and wellness to decrease disease, addresses health inequities and disparities, monitors environmental factors such as air, water, soil, food and physical surroundings, and regulates health care facilities and services to ensure safe care is provided. The divisions, or departments, within a health department are dictated by the residing county’s size, and government funding for that department. For the project health department, there are five (5) divisions or departments. The divisions are Nursing, Environmental Health, Health Education, Emergency Preparedness, and Administration. Each division has a responsibility to carry out the mission of the health department and provide essential public health services.

Public health department accreditation is the “measurement of health department performance against a set of nationally recognized, practice-focused, and evidence-based standards” [1]. National public health department accreditation has been developed due to a desire to improve service, value, and accountability to stakeholders. The accreditation process and standards for state, tribal, local, and territorial health departments were established by the Public Health Accreditation Board (PHAB), a national, non-profit accrediting organization seeking to advance quality and performance for health departments [2].

In 2013, the 130th Ohio General Assembly granted the Ohio Director of Health the authority to require all Ohio health districts to apply for accreditation by 2018 and become accredited by 2020 [3]. Ohio health departments were given a directive to demonstrate they are meeting or exceeding a common set of national standards, providing core public health services, and improving health services and accountability to stakeholders. If health departments fail to comply with the accreditation requirements, their state subsidy dollars will be eliminated. For health departments, achieving accreditation means they are implementing quality improvement by using a performance management system and evaluating the health department’s strengths and weakness on a continual basis. Also, accreditation achievement means the health department is providing accountability, transparency and the delivering the Ten Essential Public Health Services to their population and stakeholders.

Although national accreditation is a goal of the PHAB and the Ohio Legislature, there continues to be challenges in meeting this goal at the level of individual health departments. Many rural health departments lack the knowledge and resources, such as staff and time, to create quality indicators and Performance Management (PM) plans. To improve health outcomes, accreditation includes the development and implementation of a PM plan and a strong quality improvement foundation [4]. “Quality improvement in public health is the use of deliberate and defined improvement processes that are focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality that achieve equity and improve the health of the community” [5]. PM assists with identifying desired results, measuring progress towards the results, and making decisions based on data to improve achievement of desired results (Figure 1) [6].

Health departments are “Accreditation Ready” if they are utilizing the PM plan to develop quality improvement projects in the areas where they find weaknesses. To qualify for accreditation, the Public Health Accreditation Board Standards and Measures provides accreditation criteria under twelve domains. This project satisfied Domain 9, Standard 9.1 and 9.2 [2] which requires the development of a performance management plan and to demonstrate the incorporation of quality improvement projects to improve essential services (Table 1). The health department needed assistance on the development of a PM plan to apply for accreditation. The objective of this project was to develop a performance management plan and provide employee training so the staff may better understand the performance management process and how it can enhance population health and assist with accreditation readiness.

This study was framed by both an implementation model and a theoretical model. The four-stage problem solving model of Plan, Do, Study, Act [7] served as the implementation model. The Plan, Do, Study, Act model is a well-known problem-solving model for public health departments and serves as an ongoing model for quality improvement. The Diffusion of Innovation Theory [8,9] served as the theoretical framework and a guide to work with different levels of adopters. This theory classifies adopters into five categories: innovators, early adopters, early majority, late majority, and laggards. By assessing the employees’ level of adoption, strategies were deployed to reach those who were in the late majority and laggard categories. The late majority and laggards are usually skeptical to change and bound by tradition. Education strategies and pressure from other groups help to initiate change in them.

Methods

This was an evidence-based study with a qualitative phenomenological research design that utilized focus group interviews to evaluate the employees’ accreditation readiness and satisfaction of the PM plan and training. Prior to the beginning of the project, a needs assessment was conducted to assess the employee’s knowledge of the accreditation process, quality improvement, and performance management. The needs assessment consisted of an online survey disseminated by email to all fifteen of the health department employees. The results of the survey were utilized to guide the project and the PM training.

Description of Intervention

A performance improvement plan was developed to guide the development of the entire project. (Table 2) The health department leadership and accreditation team members were included in the process of choosing programs, creating goals for the programs, identifying key measures, and selecting quality indicators to monitor within the plan. There are five divisions within the health department: Nursing, Environmental Health, Administration, Health Education, and Emergency Preparedness. The leader of each division served as the spokesperson for that division. The division leaders, health commissioner, and the project lead held several meetings to decide what programs to monitor. The program leaders chose to start small with one or two programs for each division to include in the PM plan. This allowed the departments to begin measuring and fulfilling their accreditation requirements. All the divisions planned to add programs to the plan as they began to feel more comfortable with the process. The employees chose programs with an identified weakness, to promote a quality improvement project. The PM plan was maintained on a laptop that was purchased specifically for accreditation which was kept in a central location within the health department. Each division designated an employee to oversee inputting data for that division’s programs.

After the performance plan was developed, all the employees were trained on the use of the PM system. Two one-hour, interactive, group training sessions were offered to all employees. This involved training all the employees on how to access their division, what programs they were measuring, and how to input data. Two weeks after the training, the project lead returned to the site for a follow up and was able to meet one-on-one with the staff to offer technical assistance and answer questions.

Approval was obtained from the Ohio University Institutional Review Board (IRB 17-X-377) and written consent was obtained from the study participants. Thirteen health department employees participated in the education and focus group evaluations.

Focus Groups

The focus group interviews were conducted at the health department utilizing a set of eight pre-determined questions. The questions were created by the project lead, a community expert, and a faculty member. The questions focused on accreditation readiness, knowledge of the process, the importance of the PM plan, quality improvement projects, and employee satisfaction with the education/training received. The questions used for the focus group interviews are listed below:

• Please describe your knowledge and satisfaction with the accreditation process and performance measurement system.

• Describe your feelings about the value of the performance measurement system and how, if at all, the system will help public health.

• Please describe your feelings about the training/education you received for the performance measurement system.

• Tell me about the process of identifying the key measures for the performance measurement system.

• Tell me your thoughts about collecting and analyzing data from the key measures.

• Please describe anticipated system-wide or personal barriers the health department might encounter during the accreditation process.

• Provide your thoughts on quality improvement projects and describe how, if at all, they will be helpful in preparing you for accreditation readiness.

• In closing, do you have any remarks or personal reflections to add to the interview?

Data Analysis

After the focus group sessions, transcripts were transcribed verbatim. The transcripts were reviewed by the project lead, a community expert, and a faculty member. Each reviewer looked for dominant themes by using narrative analysis. The researchers found agreement amongst the three themes identified.

Results

Three themes emerged from the interview data (Table 3). The themes were identified as knowledge and perceived value of the PM plan, quality improvement as an advantage of PM, and the value of the training and education in the PM plan.

Themes from the Focus Group Interviews

Knowledge and Perceived Value: Overall the responses were favorable, although, they felt accreditation is very time consuming. After the training, the employees felt that they were more prepared for accreditation and that the PM plan is valuable.

Employees made comments such as:

• “In the end, it will be good thing.”

• “It’s very valuable and not only for accreditation, but to make us accountable.”

• “You can see the potential for being helpful in providing the data and keeping us accountable.”

• “I think that it makes us more productive.”

• “It makes us look at an organized way to be more productive, and do our jobs better, and be accountable,”

• “It helped us figure it out because we were not sure what we should be keeping.”

Continuous Quality Improvement as an Aspect of Performance Management: Many of the employees have been involved with QI projects in the past but they indicated previous experiences were not positive. The development of the PM system helped them make an appropriate selection of QI projects. The employees made comments such as:

• “We can see in the future how our performance is in certain areas; whether we are improving in areas or that we are maybe falling off and what things we need to change to make programming better and helpful for the community,”

• “If we see an area we need to improve on, we can do a continuous quality improvement project to improve in that area. So, if there is data where there is a problem, then you have a process to try to fix the problem, so I think it will be huge,”

• “It will keep us accountable for where we need to improve.”

Training and Education: Many positive comments about the actual training of the PM system were noted. The training was perceived to be helpful and easy to understand. The employees made comments such as:

• “I think you being an outside help with the performance management is a priceless artifact as far as this is concerned,”

• “I think that everybody has a good idea of what to do in that system, or at least we’ve got a good start on that. So, I think It is a benefit having the training,”

• “It was easy to understand. As far as our training, I think it was basic enough that every different skill level could understand.”

• “It was comfortable enough. We could ask questions if we didn’t understand.”

Discussion

The responses generated from the initial survey found that many of the employees had a moderate understanding of accreditation and its importance; however, many of the employees responded that they were not sure how accreditation would help them better serve the public. For quality improvement, over half of the staff responded that they had been involved with at least one or two quality improvement projects but felt that they needed more training. The results of the survey indicated a need for further education on accreditation, PM, and quality improvement.

The PM plan was a new concept for the health department. Initially the employees saw the PM plan as a difficult task due to the lack of time and experience. However, most employees were supportive and understood the benefit to both the community and the individual health departments. Education for the PM plan was a key strategy in assisting with the late majority and the laggards. The education sessions along with group discussions about the PM process, assisted the late majority adopters and the laggards to recognize how the plan could assist the employees in making positive changes to the services that are provided to the public. Prior to this project, several members of the health department tasked with the accreditation process, attended professional development to learn about developing a PM plan. However, due to the limited human, fiscal and other resources in the community health department, accreditation was a monumental hurdle.

The training allowed the employees to see how the plan’s data was going to assist the health department in the areas of accountability and the subsequent development of quality improvement projects. As a result, all the divisions began using the PM plan and tracking their data. After the training, the employees began to plan other health department programs that can be measured with the PM plan in the future.

Strengths and Limitations

This pilot project successfully assisted the employees of the health department to meet Domain 9, Standard 9.1and 9.2 of the Public Health Accreditation Board’s requirements and to develop a more in-depth understanding of a PM plan and how it can lead the department towards quality improvement. This pilot study contributed to the health departments’ overall accreditation readiness and satisfaction with the process of PM training.

There could be some limitations to expanding this project to other health departments. These might include the health department’s organizational culture, its size and number of employees, its geographical location, and the community that it serves. It is noted that the positive comments in the training and education theme could be biased due to the project leader serving in both the trainer and the interview role. The project had a small sample size and may be perceived as a limitation. This study may be strengthened by duplication of the study to other health departments.

Implications for Policy and Practice

This project has potential to be duplicated and implemented in other rural health departments to assist with accreditation readiness.

For nursing, the PM system can be utilized to track data and measures within the nursing division. This will assist the nurses with the implementation of quality improvement projects and ultimately improve population health.

Conclusion

The purpose of the study was to assist a rural southeastern Ohio health department with accreditation readiness by the development of a PM plan and the subsequent employee training on its use. As a result of this project, the employees of the health department indicated increased knowledge of the accreditation process, satisfaction with the education and training, and increased understanding of the quality improvement process. Furthermore, the employees developed an understanding of the PM plan, accountability for the plan, and strategies to manage the time commitment. Employees felt that quality improvement would increase due to the ability to identify weak or challenging areas. Overall, the employees indicated satisfaction with the education and training process related to accreditation.

Funding

None.

Financial Disclosure

No funding to disclose.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgements

Angela Derolph, MPH, Perry County Health Commissioner.

Human Participant Compliance Statement

Approval was obtained by the Ohio University Institutional Review Board (IRB 17-X-377) and written consent was obtained by the study participants.

References

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