Understanding local health departments decision to pursue/defer accreditation: A mixed-method systems thinking approach

This study explores factors impacting local health departments (LHDs) decision to pursue accreditation in states with low public health expenditures. With only three accredited LHDs so far and as a state with a low public health expenditure, Indiana serves as an example for exploring possible factors impacting the LHD’s decision to pursue accreditation. We used the systems thinking approach to understand LHDs’ organizational characteristics impacting their decision to pursue accreditation using a mixed-method of quantitative (descriptive statistics/random forests) and qualitative (interviews) approaches. We interviewed 12 local health departments across Indiana, six of which were pursuing accreditation while the others had deferred it. Using the descriptive analysis of the interviews and the random forests variable importance, we identified significant organizational factors that impacted the LHD decision. The variable importance method identified guiding-information measure as the most significant factor for pursuing accreditation. Guiding information shows whether the guidelines provided by the governing entities were clear and coordinated. Another distinguishing factor among the pursuing/deferring LHDs was the implementation measure. Similar to pursuing LHDs, the deferring LHDs had started the quality improvement process for accreditation, but the activities got halted during the implementation phase. The priorities and leadership of the governing entities were the main drivers for the successful implementation of accreditation. Moreover, aligning the tasks required in the accreditation process with the LHDs regular quality improvement activities may facilitate achieving accreditation.

本研究探讨了公共卫生支出较低的州内，影响地方卫生部门（Local Health Departments，LHDs）申请认证的相关因素。作为公共卫生支出水平较低的州，印第安纳州目前仅有3家通过认证的地方卫生部门，因此可作为探讨影响地方卫生部门申请认证相关因素的典型研究案例。本研究采用系统思维方法，结合定量研究（描述性统计、随机森林分析）与定性研究（访谈法）的混合研究设计，剖析影响地方卫生部门申请认证决策的组织特征。研究团队对印第安纳州内的12家地方卫生部门进行了访谈，其中6家正在推进认证申请，其余则暂缓了认证工作。通过对访谈资料的描述性分析以及随机森林变量重要性分析，本研究明确了影响地方卫生部门认证决策的关键组织因素。随机森林变量重要性分析结果显示，指导信息指标是影响地方卫生部门申请认证的最核心因素。指导信息指标用于衡量监管机构发布的相关指南是否清晰明确且协调统一。在推进认证与暂缓认证的地方卫生部门之间，另一显著差异因素为实施指标。与正在推进认证的部门类似，暂缓认证的地方卫生部门也曾启动过认证相关的质量改进流程，但相关活动在实施阶段被迫停滞。监管机构的优先级设定与领导力是认证工作顺利实施的核心驱动力。此外，将认证流程所需的工作任务与地方卫生部门的日常质量改进活动相整合，可有效助力其顺利通过认证。