Innovation Theory and Local Health Department Accreditation

In this issue of AJPH, Leider et al. (p. 301) describe an innovative approach using latent class analysis to understand how activities and service mix may influence decision-making by small local health departments (LHDs) to apply for accreditation. They also make a compelling case for why this is an important matter to pursue given the current response to the pandemic and the need for a strong public health system. They note that by the end of 2019, only 8% of small LHDs had applied for public health accreditation. The authors explore reasons for the lack of applications, including staff size, per-capita public health spending, and service mix, and offer ways to improve uptake.

DIFFUSION OF INNOVATION AND ACCREDITATION

Diffusion of innovation theory, developed by E. M. Rogers in 1962, provides a useful framework for considering how to increase uptake of public health accreditation among small LHDs in the United States.¹ People or systems that adopt innovations early on are different than those who adopt later or never adopt. Rogers’s theory comprises five categories of adopters:

1. innovators who want to be first,

2. early adopters who tend to be opinion leaders and basically need to know how to implement the innovation but do not require a lot of convincing,

3. early majority who need evidence and success stories,

4. late majority who are skeptical and will only adopt after the innovation has been tried by the majority, and

5. laggards, who are hardest to bring on board and usually need pressure from the adopters.

In the study by Leider et al., the small LHDs fall largely in the late majority and laggards categories.

The reasons for the lack of applications from the small LHDs described in the study by Leider et al. are congruent with the five factors of Rogers’s theory that influence adoption of new innovations, such as public health accreditation. Addressing these factors is necessary to increase the likelihood that small LHDs will eventually adopt the innovation of public health accreditation.

The first factor is whether the innovation offers a relative advantage to the status quo. The fact that few small LHDs from states with state-based accreditation programs applied for national accreditation suggests that these LHDs did not perceive an advantage to receiving national accreditation when they have already been accredited within their state systems. The board of directors of the Public Health Accreditation Board should consider a process whereby smaller health departments from these states could simultaneously prepare for state-specific accreditation and national accreditation, thus reducing the additional time and resources needed to pursue accreditation through separate mechanisms. For small LHDs that are not from states with accreditation programs, greater incentives for achieving accreditation may need to be offered. In their review of incentives for public health accreditation, Thielen et al. highlighted that state health departments and LHDs valued financial incentives, support for infrastructure and quality improvement, and grant application flexibility.²

The second and third factors are compatibility and complexity, or how consistent accreditation is with the values, experiences, needs, and capacities of the LHDs. The authors’ findings that small LHDs did not feel the accreditation requirements matched their agencies’ services and activities reflect poor compatibility between the current accreditation program and the service mix of small LHDs. The authors’ suggestion to develop a set of standards and a process that might better fit smaller LHD capacities would enhance compatibility. A more limited set of requirements would also address the complexity of the innovation. For example, the fact that a strategic plan is required to apply for accreditation makes it difficult to pursue accreditation for small LHDs with nearly half of them stating that their agencies do not have a strategic plan. Helping smaller LHDs meet requirements like the strategic plan may simplify the process and, as the authors suggest, could be done through technical assistance or learning collaboratives, with accredited smaller LHDs providing guidance and support to LHDs that have not yet applied for accreditation.

The fourth factor that has an impact on adoption of an innovation is triability, or the opportunity to test or experiment with the innovation before making a commitment to use. The current accreditation process requires a significant commitment of funding, time, and staff resources up front. The authors’ suggestion to offer an accreditation “light” process for smaller LHDs with limited staff and funding may offer an opportunity for triability that is not currently part of the accreditation program.

The fifth factor is observability, which means the innovation must provide tangible results. Evaluation of the public health accreditation program has demonstrated a range of tangible results.³ However, these results must be linked to a visible, high-priority community need to garner strong political support for accreditation from policymakers and elected officials.⁴ Further research is needed regarding the extent to which local officials and county administrators understand and value having an accredited LHD serving their jurisdictions given competing priorities and strained resources.

RESOURCES NEEDED FOR ACCREDITATION UPTAKE

One limitation of the diffusion of innovation theory is that it does not consider an individual’s or system’s resources to adopt the innovation. In the case of public health accreditation, lack of resources presents a significant barrier to pursuing accreditation even if all the other conditions for adopting accreditation as an innovation are addressed. Similar to other studies, the analysis by Leider et al. found that even among small LHDs, those with larger budgets and staff were more likely to apply for accreditation. Providing additional financial resources to enable smaller LHDs to recruit and retain a competent workforce is one way to build greater equity in public health capacity. Alternatively, cross-jurisdictional or regional approaches to delivering public health services have the potential to enhance the quantity and quality of public health services available at the local level, improve efficient use of resources, and increase accreditation readiness.⁵ It is likely that a mix of strategies will be necessary to observe significant increases in applications for accreditation from small LHDs.