Statement A PHAB ICR UPDATED 121919

This information collection is authorized by Section 301 of the Public Health Service Act (42 U.S.C. 241) (See Attachment A: Public Health Service Act). The Centers for Disease Control and Prevention (CDC) works to protect America from health, safety and security threats, both foreign and in the U.S.¹

The mission of the Public Health Accreditation Board (PHAB) is to improve and protect the health of the public by advancing and transforming the quality and performance of public health agencies in the US and abroad. One of the impetuses for the development of the national voluntary accreditation program was a 2003 Institute of Medicine report, titled The Future of the Public’s Health in the 21^st Century, which suggested that the field consider accreditation as a means to improve performance and accountability of health departments.² This led to the Exploring Accreditation Project, which concluded that such a program would be both desirable and feasible.³ Based on that, PHAB, a nonprofit organization, was founded in 2007. With funding from the CDC and the Robert Wood Johnson Foundation (RWJF) and participation by more than four hundred public health experts and practitioners, PHAB developed a consensus set of standards to assess the capacity of state, Tribal, local, and territorial health departments.⁴

Between February 2013 (when the first health department was accredited) and November 2019, 36 state health departments, 243 local health departments, 3 Tribal health departments, and one integrated system (comprised of 67 local health departments in one centralized state) have been accredited. Accreditation is granted for a five-year period and the first several health departments have successfully completed the reaccreditation process.

Formal efforts to assess the outcomes of the accreditation program began in late 2012 and continues to date. Priorities focus on gathering feedback for program improvement and documenting program outcomes to demonstrate impact and inform decision making about future program direction. Starting in 2012 and running through December 2019, RWJF and the social science research organization NORC at the University of Chicago, have fielded a series of surveys to document the experiences of health departments participating in the program. RWJF provided funding for this assessment and NORC has been responsible for collecting, analyzing, and summarizing the data. While the CDC has used information from this data collection effort to inform its strategies for supporting health departments pursuing accreditation, it did not sponsor the data collection from 2012-2019.

Data from this assessment has resulted in several peer-reviewed journal articles.^5,6 The latest assessment findings indicate that more than 85% of health departments (HDs) that have been accredited for one year agree or strongly agree with the following statements:⁷

Accreditation has stimulated QI and performance improvement opportunities
Accreditation has allowed the HD to better identify its strengths and weaknesses
Accreditation has stimulated greater accountability and transparency within the HD
Accreditation has helped the HD document its capacity to deliver Three Core Functions of Public Health and Ten Essential Public Health Services
Accreditation has stimulated greater collaboration across HD departments/units

As of January 2020, CDC will assume responsibility and sponsorship over the assessment of the accreditation program, and as a result, OMB approval for data collection starting in 2020 is being sought. The purpose of this ICR is to support the continued collection of information from participating health departments through a series of five surveys. The surveys seek to collect longitudinal data on each health department throughout their accreditation process. The surveys will be administered on a quarterly basis and sent to all health departments that reach each milestone summarized in the table below.

Survey	Milestone
Survey 1: Applicant HDs	Register in PHAB’s electronic system
Survey 2: Recently Accredited HDs	Achieve accreditation
Survey 3: HDs Accredited One Year	1 year after achieving accreditation
Survey 4: HDs Approaching Reaccreditation	4 years after achieving accreditation
Survey 5: Reaccredited HDs	Achieve reaccreditation

Past administration of similar surveys reveals that some of the outcomes of accreditation—particularly ones related to efforts to impact population health outcomes—are gradual. Therefore it is helpful to collect data over a series of years to highlight how the work that health departments began when they initially sought accreditation has matured as they first achieve accreditation status, then work to maintain their accreditation and ultimately prepare for reaccreditation. It is important to continue these data collection activities to continue to build this longitudinal dataset. Because health departments typically take between 2-3 years to complete the initial accreditation process, there are relatively few health departments that have 3 or more data points in the current dataset. In addition, the data that have previously been collected focus primarily on the early adopters of accreditation. As more and more health departments pursue accreditation, it will be important to understand if the experience of accreditation is consistent.

Overview of the Data Collection System

The information collection system consists of web-based surveys (see Attachments B through K). Versions of surveys 1-4 have been fielded for more than a year. The survey instruments have been refined and streamlined based on that experience. Based on prior fielding, the estimated time required to complete each survey is no more than 20 minutes. Although Survey 5 is a new data collection instrument, the number and type of questions are similar to those included in surveys 1-4 and thus the time estimate for data collection is also 20 minutes, based on those surveys’ estimates.

Items of Information to be Collected

During the lifecycle of the accreditation process, health departments will be invited to participate in surveys based on milestones achieved. As health departments reach each milestone, they will be invited to participate in the corresponding data collection. Each health department will be invited to participate in each survey once (for a total of 5 surveys max per health department). Because health departments register for accreditation and are accredited at various points in the year, the surveys are administered quarterly. In that way a health department will receive a survey invitation shortly after they reach the relevant milestone. As illustrative examples, if a health department registers in April, they might receive Survey 1 in June, whereas a health department registering in November might receive Survey 1 in December. Likewise, health departments that are accredited in March might receive Survey 2 in April, whereas health departments accredited in August might receive Survey 2 in September. This ensures that health departments receive each survey relatively close to hitting each milestone and without a long lag time.

Based on lessons learned from the past 8 years of working to accredit health departments, it is reasonable to expect that in a given year, a total of 60 health departments will reach each milestone (see A12). For example, we would expect 60 new health departments to begin the accreditation process. We would expect 60 health departments to reach the milestone of becoming accredited. We would expect 60 health departments to achieve the milestone of being accredited for one year, and so on and so forth. A survey will be distributed after each milestone reached. During the lifecycle of the accreditation process for a particular health department, that health department will be invited to participate in each of the 5 surveys once. However, it is likely that each health department will at most, receive only one survey per year (based on how the accreditation cycle functions).

Survey 1: Applicant HDs

Survey 1 captures the perspectives of health departments that have registered for the accreditation program. It is designed to gather information before their formal engagement with PHAB to better understand any changes their health department has already made to prepare for accreditation. It also collects information about the health departments’ current relationships with key stakeholders and their engagement in quality improvement. These data points will be used for longitudinal analysis to identify changes that occur as health departments are accredited. Surveys will be administered electronically; a link to the survey web site will be provided in the email invitation. The survey contains 17 items, consisting of both closed-ended and open-ended questions. The survey will be administered quarterly.

Survey 2: Recently Accredited HDs

Survey 2 captures the perspectives of health departments shortly after they have been accredited. It contains questions about the Standards and Measures (which can be used to inform revisions). It also asks about the action plan process for health departments that were required to address non-conforming measures before they were accredited. It asks about outcomes of the accreditation process associated with quality improvement, stakeholder relationships, and financial status, among other topics. The survey solicits information about challenges in the process, which can also inform discussions about program improvement. Surveys will be administered electronically; a link to the survey web site will be provided in the email invitation. The survey contains 29 items, consisting of both closed-ended and open-ended questions. The survey will contain logic to direct respondents to relevant questions. The survey will be administered quarterly.

Survey 3: HDs Accredited One Year

Survey 3 captures the perspectives of health departments one year after they have been accredited. It contains questions about health departments’ ongoing accreditation maintenance activities, which can help inform process refinements. The data collection instrument also focuses on outcomes of the accreditation process associated with quality improvement, stakeholder relationships, and financial status, among other topics. Surveys will be administered electronically; a link to the survey web site will be provided in the email invitation. The survey contains 20 items, consisting of both closed-ended and open-ended questions. The survey will be administered quarterly.

Survey 4: HDs Approaching Reaccreditation

Survey 4 captures the perspectives of health departments four years after they have been accredited, as they are preparing for reaccreditation. The data collection instrument focuses on outcomes of the accreditation process associated with quality improvement, stakeholder relationships, and financial status, among other topics. It also asks about plans for reaccreditation, which can help inform improvements related to that step of the process. Surveys will be administered electronically; a link to the survey web site will be provided in the email invitation. The survey contains 20 items, consisting of both closed-ended and open-ended questions. The survey will contain logic to direct respondents to relevant questions. The survey will be administered quarterly.

Survey 5: Reaccredited HDs

Survey 5 captures the perspectives of health departments after they have successfully completed the reaccreditation process. The reaccreditation standards are different from initial accreditation. This survey collects feedback on those standards to inform potential revisions. It also asks questions designed to help identify how the outcomes associated with undergoing this process may differ from those associated with initial accreditation. Surveys will be administered electronically; a link to the survey web site will be provided in the email invitation. The survey contains 22 items, consisting of both closed-ended and open-ended questions. The survey will contain logic to direct respondents to relevant questions. The survey will be administered quarterly.

Purpose and Use of the Information Collection

The purpose of this ICR is to collect information from health departments throughout the initial accreditation and reaccreditation process to: a) learn about program processes and the accreditation/reaccreditation standards to improve the program’s quality, and b) document program outcomes to demonstrate impact and inform decision making about future program direction. The results of these surveys may be published in peer reviewed journals and/or in non-scientific publications such as practice reports and/or fact sheets.

Use of Improved Information Technology and Burden Reduction

Data will be collected via web-based surveys allowing respondents to complete and submit their responses electronically. This method was chosen to reduce the overall burden on respondents. The information collection instruments were designed to collect the minimum information necessary for the purposes of this project.

Efforts to Identify Duplication and Use of Similar Information

Information concerning health department experiences have been collected from 2012-2019 using non-governmental funding. The purpose of this request is to continue these efforts. As a growing number of health departments are seeking accreditation, it is important to continue to learn about the program process and outcomes to continuously improve quality and demonstrate value to inform program decision making. There is no other national data-collection effort designed to gather in depth information about accreditation outcomes.

Impact on Small Businesses or Other Small Entities

No small businesses will be involved in this information collection.

Consequences of Collecting the Information Less Frequently

There are no legal obstacles to reduce the burden. The consequences of not collecting this information would be:

Failure to systematically collect information to document evidence of the effectiveness, value and impact of PHAB’s accreditation process.
Disruption of a longitudinal dataset that may limit ability to understand how health departments change throughout their accreditation journey.
Limited guidance to the program on how to adjust and strengthen accreditation standards and processes.

Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances with this information collection package. This request fully complies with the regulation 5 CFR 1320.5 and will be voluntary.

Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

A 60-day Federal Register Notice (FRN) was published in the Federal Register on 09/25/2019, vol. 84, No. 186, pp. 50452 - 50453. There were no comments received. There were no efforts to consult outside the agency.

Explanation of Any Payment or Gift to Respondents

CDC will not provide payments or gifts to respondents.

Protection of the Privacy and Confidentiality of Information Provided by Respondents

The Privacy Act does not apply to this data collection. No personal identifying information will be collected and all responses are voluntary. The instruments will be distributed using known contact information for health departments. All identifying information will be kept secure, stored in a password protected file, and will only be accessible to the project team. No identifiable information describing respondents will be included in the analyzed data and aggregate reports. No sensitive information is being collected. This data collection is not research involving human subjects.

Institutional Review Board (IRB) and Justification for Sensitive Questions

No information will be collected that are of personal or sensitive nature. This data collection is not research involving human subjects (Attachment M - Non-Research Determination).

Estimates of Annualized Burden Hours and Costs

Based on previous fielding of the surveys (see Attachment N: PHAB Survey Distribution Table), the estimated time to complete each survey is 20 minutes.

Estimates for the average hourly wage for respondents are based on the US Department of Labor (DOL) National Occupational and Wage Estimates for life, physical, and social science occupations.⁸ Previous administration of the surveys reveals that approximately 60% of respondents were health department directors, and the remaining 40% were staff level (e.g., accreditation coordinator or program manager). Based on the DOL data and respondent type, the average, estimated hourly wage for respondents are:

- HD Directors: $47.95

- Staff: $33.49

Table A-12 shows estimated burden and cost information.

Table A-12: Estimated Annualized Burden Hours and Costs to Respondents

Data Collection Instrument Name	Type of respondent	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Survey 1: Applicant HDs	Directors	36	1	20/60	12	$47.95	$575
Survey 1: Applicant HDs	Staff	24	1	20/60	8	$33.49	$268
Survey 2: Recently Accredited Health Departments	Directors	36	1	20/60	12	$47.95	$575
Survey 2: Recently Accredited Health Departments	Staff	24	1	20/60	8	$33.49	$268
Survey 3: HDs Accredited One Year	Directors	36	1	20/60	12	$47.95	$575
Survey 3: HDs Accredited One Year	Staff	24	1	20/60	8	$33.49	$268
Survey 4: HDs Approaching Reaccreditation	Directors	36	1	20/60	12	$47.95	$575
Survey 4: HDs Approaching Reaccreditation	Staff	24	1	20/60	8	$33.49	$268
Survey 5: Reaccredited HDs	Directors	36	1	20/60	12	$47.95	$575
Survey 5: Reaccredited HDs	Staff	24	1	20/60	8	$33.49	$268
Totals		300			100		$4,217

Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers

There will be no direct costs to the respondents other than their time to participate in each information collection.

Annualized Cost to the Government

The government costs include personnel costs for one GS-14 Senior Public Health Advisor involved in project oversight, data collection, analysis, and reporting. Additional costs include a contract with NORC, the nonprofit organization that will administer the survey and analyze the results. Finally, a portion of the funds associated with the cooperative agreement between CDC and PHAB (Cooperative Agreement #5 NU90OT000229-02-00) will be used to help oversee data collection, analysis and reporting. The total cost to the federal government is $93,189.

Table A-14: Estimated Annualized Cost to the Federal Government

Staff	Average Hours per Year	Average Hourly Rate	Average Cost
GS-14, step 10 Senior Public Health Advisor	10	$68.90	$689.00
Cooperative agreement with PHAB (staffing support at PHAB)			$7,500
Contract to NORC (through CDC cooperative agreement with PHAB)			$85,000
Total			$93,189

Explanation for Program Changes or Adjustments

This is a new collection.

Plans for Tabulation and Publication and Project Time Schedule

The following schedule will be followed for each data collection instrument.

Project Time Schedule

A.16 – 1 Project Time Schedule
Activity	Time Schedule
Email invitation sent to respondents	Upon approval and then quarterly in accordance with data collection plan
Data Collection	Upon approval and then quarterly in accordance with data collection plan
Analyses	Twice a year, approximately within 2 months of close of data collection
Report Developed	Two reports will be developed; the first will be approximately one year after the data collection under this ICR begins. The second will be in June 2022.
Publication of Report	The project team will determine if this step is appropriate based on data analysis. If appropriate, finding will be submitted 6 months or more from close of data collection.

Reason(s) Display of OMB Expiration Date is Inappropriate

We are requesting no exemption.

Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification. These activities comply with the requirements in 5 CFR 1320.9.

LIST OF ATTACHMENTS – Section A

Attachment A. Public Health Service Act

Attachment B. Survey 1: Applicant HDs-Word

Attachment C. Survey 1: Applicant HDs-screenshot

Attachment D. Survey 2: Recently Accredited HDs-Word

Attachment E. Survey 2: Recently Accredited HDs-screenshot

Attachment F. Survey 3: HDs Accredited One Year-Word

Attachment G. Survey 3: HDs Accredited One Year-screenshot

Attachment H. Survey 4: HDs Approaching Reaccreditation-Word

Attachment I. Survey 4: HDs Approaching Reaccreditation-screenshot

Attachment J. Survey 5: Reaccredited HDs-Word

Attachment K. Survey 5: Reaccredited HDs-screenshot

Attachment L. Privacy Act Checklist

Attachment M. Non-Research Determination

Attachment N. PHAB Survey Distribution Table

REFERENCE LIST

Centers for Disease Control and Prevention. About CDC: Mission, Role, and Pledge. Accessed 08.02.17; http://www.cdc.gov/about/organization/mission.htm

Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2003.

Final Recommendations for a Voluntary National Accreditation Program for State and Local Public Health Departments. Exploring Accreditation Project Report. Washington, DC: Exploring Accreditation; 2006.

Bender K, Kronstadt J, Wilcox R, Lee TP. Overview of the Public Health Accreditation Board. J Public Health Manag Pract. 2014;20(1):4-6.

Kronstadt J, Meit M, Siegfried A, Nicolaus T, Bender K, Corso L. Evaluating the impact of national public health department accreditation ― United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:803–806.

Siegfried A, Heffernan M, Kennedy M, Meit M. Quality improvement and performance management benefits of public health accreditation: national evaluation findings. Supplement, Impact of Public Health Accreditation. J Public Health Manag Pract. 2018;24(suppl 3):S3-S9.

Evaluation of the Public Health Accreditation Program. https://www.phaboard.org/wp-content/uploads/Evaluation_findings_presentation_March_2019.pdf. Accessed May 24, 2019.

Bureau of Labor Statistics. May 2018 National Occupational Employment and Wage Estimates United States for Life, Physical, and Social Science Occupations. Accessed 04.04.2019; http://www.bls.gov/oes/current/oes_nat.htm

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Statement A PHAB ICR UPDATED 121919