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.