About the Study
Quantifying the Cost of Local
Public Health Accreditation
Julia Heany, Ph.D.
Shannon Laing, M.S.W.
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Impetus
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Driving Questions
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What costs do local health departments (LHDs) face when pursuing
accreditation? What benefits balance these costs?
How might these costs be measured?
How might these costs be minimized?
Overarching Goal
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Michigan Public Health Institute
Office of Accreditation & Quality Improvement
Voluntary National Accreditation & concerns about cost
To create measures that can be used to quantify the cost of
accreditation to LHDs, in order to inform questions about the cost of
becoming accredited under the voluntary national accreditation
model.
Findings from the Literature
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Methods
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Affordability is critical (EAP, Meit et al.), but costs
and benefits of accreditation have been poorly
enumerated (Beitsch et al.)
Published & unpublished studies in PH and non-PH
contexts indicate:
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Focus Groups
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4 facilitated, recorded, & transcribed groups that
discussed:
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Costs & benefits related to accreditation
Factors that affect time and effort
Current capacity to track staff time and resources
Participants:
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24 administrative officers and financial directors from 20
Michigan health departments
10 directors and administrators from local health
agencies and accreditation programs in North Carolina,
Illinois, and Florida
Time tracking is feasible & time tracking instruments have been used
There are ‘hard costs’ and ‘soft costs’
Labor is the most significant cost, and should be collected based on
activity & job function
Activities intensify as accreditation site visit approaches
Organizations make trade offs between accreditation preparation &
other responsibilities like patient care
In-depth Interviews
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Protocol developed to guide discussion of:
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Preparation activities under different systems
Feedback on preliminary cost measures developed based
on the literature review & focus groups
Participants
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10 stakeholders from states with accreditation or
accreditation-like programs (MI, IL, MO, FL, WA, NC)
4 LHD administrators, 6 state health department or
accreditation program coordinators
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Cost & Efficiencies Survey
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Online tool distributed via email to contacts at each
state
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Survey structure
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N=84, representing 6 states
Findings
Labor and non-labor measures
Labor categories divided into phases of accreditation
process (pre-review, review, post-review)
Assessed relevance, feasibility, & accuracy for each
proposed measure
Should brining performance into
compliance with standards be counted?
The Big Question
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What costs and activities should be counted
as part of the cost of accreditation?
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More specifically, should the cost of bringing
performance into compliance with standards be
counted?
Competing perspectives
“Your survey is totally flawed if
you do not count the cost of
reviewing compliance and gaining
compliance. There are
requirements mandated through
the accreditation process that are
not relevant to providing quality
services.”
“Short of putting together the
binders at the end, just to be
able to show the evidence –
that’s the only thing you would
really do above and beyond what
you normally do.”
“Everything you do is preparation
for accreditation”
No
Yes
† It can be the most time † If standards reflect
consuming and
what all LHDs should
expensive part of the
be doing, then all LHD
process
expenses would be
counted as part of the
† Standards do not
cost of preparing for
necessarily reflect the
accreditation
priorities of a specific
LHD
Our Answer
“Accreditation includes only the tasks and activities that are
required and/or directly related to preparing for and completing
the accreditation process in your state. Accreditation does not
include activities to improve performance in order to be compliant
with minimum standards, or activities required based on the
Operational Definition of a Functional Local Health Department
or the 10 Essential Public Health Services. For example, time
spent reviewing accreditation guidance documents is part of the
accreditation process; however, time spent bringing files up to
date in order to meet minimum standards is not considered part
of the accreditation process.”
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ACCREDITATION TIME TRACKING FORM
Proposed Measures
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This form is designed to track the costs associated with accreditation. It should be completed on a weekly basis throughout the
accreditation process by each health department employee that plays a role in accreditation. Please be as accurate as possible
in your estimates.
Strong consensus across participants regarding which
measures should be included
Decision rules for inclusion & exclusion based on study of
our data
Findings suggest that an instrument based on these measures
must:
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Allow for flexibility in the accreditation timeline for different LHDs
Capture staff time by staff salary
Specify tasks and activities identified as part of preparing for
accreditation
Ease the burden of time tracking as much as possible
Be designed for prospective rather then retrospective measurement
1. Please indicate your role in the health department by checking one of the following boxes:
Management
Program/professional
Administrative/clerical
2. Please indicate your annual salary by checking one of the following boxes:
under $20,000
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
$100,000 and above
Review
Pre-review
Using the following table and starting at the date reported below, please indicate how much time you personally spent on each
activity during each week leading up to your health department’s review. You may report either the total number of hours on
each activity per week or the percentage of 1.0 FTE (40 hours) you spent on that activity.
Using the following table, please indicate how much time you personally spent on each activity during your health department’s
review. Please report the total number of hours you spent on each activity.
6. On what date did your review start and end?
Start: ______/______/______ (mm/dd/yyyy)
End: ______/______/______ (mm,dd,yyyy)
Only report time spent on tasks and activities that are required and/or directly related to preparing for and completing the
accreditation process in your state. Activities to improve performance in order to be compliant with minimum standards, or
activities required based on the Operational Definition of a Functional Local Health Department or the 10 Essential Public
Health Services should not be included in time estimates. For example, time spent reviewing accreditation guidance documents
is part of the accreditation process; however, time spent bringing files up to date in order to meet minimum standards is not
considered part of the accreditation process.
7. Please report the number of hours you spent on each activity.
3. On what date did you personally begin actively preparing for this round of accreditation.
______/______/______ (mm/dd/yyyy)
Using the following table and ending at the date reported below, please indicate how much time you personally spent on each
activity during each week following your health department’s review. You may report either the total number of hours on each
activity per week or the percentage of 1.0 FTE you spent on that activity.
4. Will you be reporting hours or FTE?
Hours
FTE
7. On what date did you complete post-review activities?
______/______/______ (mm/dd/yyyy)
5. Please report time/FTE spent each week on each activity (add rows as needed to reflect the number of weeks you
spent preparing).
Week
Training on
Accreditation
Process
Collecting
Evidence/
Documentation
Completing
Accreditation
Documents
Review
Standards &
Guidance
Documents
Internal
Audits/ File
Review
Meetings
Other
TOTAL
HOURS
1
2
3
4
5
6
TOTAL
Meetings with Reviewers
Gathering Evidence
Travel for Review
Other
Total Hours
TOTAL HOURS:
Post-review
8. Will you be reporting hours or FTE?
Hours
FTE
9. Please report the number of hours/FTE you spent on each activity each week (add rows as needed).
Week
Post-review
Meetings
External
Communication
Preparing
Deliverables
Training on
Accreditation
Post-review
Travel
Other
Total Hours
1
2
3
4
5
6
7
8
Total
TOTAL HOURS:
TOTAL HOURS:
ACCREDITATION EXPENSE TRACKING FORM
This form is designed to track the non-labor expenses associated with accreditation. It should be completed by a specified
health department employee. Only report dollars spent on expenses that were required and/or directly related to completing the
accreditation process in your state. Please be as accurate as possible in your estimates.
1. Please report dollars spent to prepare for accreditation on each of the following.
Cost in
Dollars
Consultant fees
Additional employees
Overtime
Application/review fees
Travel costs
Copies
Other
TOTAL:
Additional Themes
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$
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2. If you reported ‘other’ expenses, please specify these costs:
Other Item
Cost in
Dollars
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The vast majority of the cost of accreditation is
labor.
The first cycle of accreditation often involves getting
the health department up to standards.
The process of measuring the cost of accreditation
may place a burden on health department staff.
There are many ‘hidden’ costs of accreditation that
will be complicated to capture.
TOTAL: $
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Additional Themes
Perceived Benefits of Accreditation
Factors that increase costs or create efficiencies:
Priorities for performance improvement
87.9%
83.3%
Increased staff knowledge
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External
Changes of performance
standards or review criteria
Inconsistencies between
reviewers
Inconsistencies across cycles
Number & specificity of
indicators
Use of technology
Supports (TA, guidance docs)
Lack of funding to support
preparation
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Internal
Experience with the program
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Cycle
Retention/turnover
Staff motivation
Use of technology
Degree to which accreditation
requirements are incorporated
into business processes
The Other Big Empirical Question
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What are the costs of accreditation relative to
the benefits?
“I believe it is possible to accurately determine the cost
of accreditation, which is an important factor to local
public health agencies, and which can be used as an
encouraging factor in relation to the benefits gained.”
Increased accountability for staff
Benefits of Accreditation
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81.3%
78.1%
Staff buy-in for performance improvement
Use of guidance materials
68.3%
Relationship with state or accrediting body
67.7%
Increased communication across jurisdictions
64.1%
Improved health outcomes
61.5%
Increased staff knowledge of other areas in LHD
60.9%
Improved credibility-agencies
59.4%
Improved credibility-public
58.7%
% of Respondents Responding Positively
Weighing Cost vs. Benefits
“I think there is a strong assumption among some academics that
accreditation is a good thing. My experience and those of my peers
who have even more accreditation experience…is that accreditation's
costs outweigh its benefits….I am confident that the overwhelming
majority would attest that they have had to cut client services to pay
for [accreditation]. Therefore, accreditation results in less client
service. Please research this with real world local health departments
before pushing accreditation. Also, please research local health
department support for accreditation before promoting it. Please
proceed with the perspective that the LHD administrators actually
doing the job are the ones best positioned to understand what is and
isn't helpful. To do otherwise is to perform a disservice to the local
health departments and everyone served by them.”
Weighing Cost vs. Benefits
“In preparation for this meeting, I actually asked people.. ‘I’m
going to go talk about costs, tell me what you think about costs.’
And they said, well, the financial cost, we don’t feel that it’s a
burden, we don’t see it as an issue.’ Their reaction was much
more that it’s the change that accreditation produces in how you
do business that is really, to them, the more interesting question.
How, as a result of going through this, how are you a different
organization? Not what did it cost you, so much, because they
felt like it was a bargain, basically, the costs are low, compared to
the transformation in their own understanding of what they’re
supposed to be doing.”
Questions & Comments
Dr. Julia Heany
jheany@mphi.org
517.324.7349
www.mphi.org
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