Now We’re Cooking with Gas – Leveling Up a Health Department in a Smaller County Through PHAB Accreditation

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Now We're Cooking with Gas - Leveling Up a Health Department in a Smaller County Through PHAB Accreditation

An interview with Amanda Mehl, R.N., M.P.H., Public Health Administrator of the Boone County Health Department in Illinois

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When the Public Health Accreditation Board (PHAB) launched its accreditation program in 2011, it set out to build a national network of high-performing health departments.¹ Over a decade later, the results are promising, with 42 state and 393 local health departments earning this distinction.² However, health departments in small communities face unique barriers to accreditation.^3,4

This challenge may stem from resource limitations, workforce constraints and unique service demands that can create barriers to achieving PHAB accreditation.⁵ Data about health department performance consistently show that accreditation rates among health departments serving smaller communities is lower than among those serving larger communities.⁶ Increasing the number of accredited health departments in these areas is a tangible step toward addressing disparities and improving outcomes.^7,8 However, this effort demands more than just increasing accreditation numbers; it requires a deeper understanding of how public health leaders from small communities perceive the value of accreditation and what high-performing public health departments look like in resource-limited settings.

To explore these topics, I turned to Amanda Mehl, Public Health Administratorof the Boone County Health Department in Illinois. I first met Amanda at the 2024 Kansas Public Health Association Annual Conference, where she shared her state's ongoing journey through public health transformation. Her passion was infectious, and for good reason: Boone County had just become the smallest PHAB-accredited local health department in Illinois. Energized by her enthusiasm, I set out to learn more about what this milestone meant to her, how it shaped her department's work and what lessons it holds for achieving excellence in public health.

A Snapshot of the Boone County Health Department

Boone County is a county in Illinois with a population of just over 53,000 - about the same size as Saline County in Kansas. Situated between the urban centers of Rockford and Chicago, Boone County was known historically for its agricultural roots but has experienced significant demographic shifts over the past few decades. A growing Latino population now makes up nearly a quarter of its residents, bringing new vibrancy to the community, but also creating new service needs for the health department.

The Boone County Health Department mirrors the county's character: small but resourceful. With a team of fewer than 30 staff members, it provides essential services such as immunizations, maternal and child health programs and initiatives to combat chronic diseases and the opioid epidemic. These priorities reflect the department's adaptability and commitment to addressing the distinct health needs of the county's population.

As Amanda explained, achieving PHAB accreditation has been a game-changer for the department, guiding them to pursue excellence despite limited resources.

The Value of PHAB Accreditation for Small Health Departments

Amanda emphasized several reasons why PHAB accreditation was transformative for the Boone County Health Department. Those reasons include that it serves as a "playbook" for leading the health department, it functions as a catalyst for fostering an innovative organizational culture and it provides a powerful advocacy tool.

"I Have to Have a Playbook" - PHAB Accreditation as a Leadership Tool

When Amanda considered stepping into the administrator role, she quickly realized there was no formal training for running a health department. "There's no manual for this job," Amanda shared. "Talking with other administrators is helpful, but in decentralized states like Illinois or Kansas, every health department operates differently. PHAB accreditation gave me the playbook I needed to modernize our operations and lead effectively."

Amanda transformed the Boone County Health Department using the accreditation process as her foundation. "This health department had never had a strategic plan before," she explained. "We didn't do quality improvement or performance management. PHAB accreditation provided the standards and guidance to bring these practices to life."

Amanda leveraged accreditation to elevate existing staff into new roles and make strategic hires that are better aligned with the department's goals. "When I started, we made some strategic hires as turnover and retirements created openings. I looked for people with the right mindset and skills to modernize the department. For example, I hired a director of departmental operations with a background in accreditation and quality improvement. She became my copilot, helping us navigate the complexities of accreditation while also taking on financial responsibilities."

Accreditation also became a tool to train staff and develop internal capacity. "We've used aspects of accreditation to train people in their roles. Sometimes it's been successful, and sometimes it hasn't worked out, but it's always been an opportunity for growth."

Amanda also used creative funding solutions to bring in specialized expertise. "We used PHIG (public health infrastructure grant) dollars to retain a temporary COVID-19 staff member as our health strategist. This role has been instrumental in maintaining plans, facilitating training and championing our departmental initiatives."

She also emphasized the importance of institutionalizing policies and procedures. A critical component of Amanda's strategy was moving institutional knowledge from individual staff members to documented processes. "This health department had never had a strategic plan, quality improvement, or performance management. Accreditation required us to build these foundational elements, and it got the work out of people's heads and onto paper. Good leadership means creating something that can run without you - because it's not about you."

Using PHAB accreditation as a framework, Amanda transformed the Boone County Health Department into a high-performing organization despite the challenges of limited funding and resources.

"Now We're Cooking with Gas" - PHAB Accreditation as a Catalyst for Innovation

For the Boone County Health Department, PHAB accreditation wasn't just a framework for meeting public health standards - it became a catalyst for innovation and cultural transformation. From revamping antiquated processes to embedding continuous quality improvement, accreditation helped the department modernize and build resilience in ways that profoundly shaped its operations.

"When we started working on accreditation, we were really cooking with gas," said Amanda. "From 2017 to 2019, we worked through our first strategic plan, went through the MAPP (Mobilizing for Action Through Planning and Partnerships) process as a community for the first time, and started forming community groups to address health challenges. We were moving and grooving."

The accreditation process provided an opportunity to shift from reactive to proactive public health practices. Boone County implemented policies and plans aligned with PHAB's twelve domains, but the onset of the COVID-19 pandemic in early 2020 tested the department's newfound systems.

"PHAB requires you to do quality improvement projects every year, and during COVID, we saw just how valuable that was," Amanda explained. "Even in the midst of chaos, we employed quality improvement concepts to refine our processes. For example, we cleaned up billing at our mass vaccination clinics when we started accepting insurance reimbursements, helping us balance the costs of running the clinics. We also adjusted contact tracing workflows, finding practical ways to prioritize and streamline."

Accreditation fundamentally changed how the Boone County Health Department approached its plans and operations. "Historically, public health plans were written, shelved and forgotten. Years later, people would ask, 'Did we do any of that?'" Amanda said. "Now, our plans are living documents. Staff are in those documents weekly, using tracking tools to maintain momentum. If something isn't working, we pivot - meet with coalitions, make edits and move forward. It's become part of our operational culture, and we net more progress over time."

This cultural shift also helped the department shed outdated practices and embrace innovation. "Things were being done here that felt old and outdated, but I saw them as growth opportunities," Amanda reflected. "Accreditation gave us a structure to follow, with everything written down - from onboarding and mentoring to managing and even disciplining staff. It cleaned up our approach and got us out of the 1980s and into the 2020s."

Amanda credits accreditation with helping Boone County create resilient and forward-looking systems. "During COVID, we had to prioritize resources and set realistic expectations for what we could do. Accreditation gave us the tools and mindset to make those decisions with clarity and focus."

The result is a department that continues to innovate while staying grounded in its mission. "Accreditation has been more than a stamp of approval for us - it's taught us how to stay relevant, innovative and ready to meet whatever challenges come next," Amanda concluded.

By turning accreditation into an innovation accelerator, Boone County has shown how small health departments can move beyond compliance and create systems that drive sustained progress and adaptability.

Legitimacy and Advocacy: Using PHAB Accreditation as a Strategic Tool

For the Boone County Health Department, PHAB accreditation has proven to be more than just a mark of operational excellence - it has become a powerful tool for advocacy and legitimizing public health efforts. As Amanda explained, accreditation provides a foundation that strengthens credibility with local leaders, funders and the broader community.

"Accreditation is a tool in my toolbox to show that we operate at a national standard," Amanda shared. "It's not just me throwing ideas at the wall - it's a validated framework."

This legitimacy has been particularly impactful in navigating the often-challenging dynamics of local politics. Amanda emphasized that advocating for resources or defending initiatives becomes more effective when she can point to the rigorous standards required by PHAB accreditation.

"On the local level, accreditation gives us a backbone," Amanda said. "When I'm advocating for funding or defending a program, I can demonstrate that our efforts align with nationally recognized public health standards. It shows that we're not just making decisions in a vacuum - there's a proven method behind what we do."

The credibility gained through accreditation also extends to grant applications and partnerships. Boone County has leveraged its status as a PHAB-accredited health department to compete for funding opportunities that might otherwise be out of reach. Amanda highlighted how this recognition has positioned the department as a leader among its peers.

"Being accredited enhances our reputation," she noted. "It's something we can use strategically - not just to secure grants but to build trust with our community and colleagues. It sets us apart and shows that we're committed to excellence."

This emphasis on legitimacy and advocacy underscores one of the often-overlooked benefits of PHAB accreditation. For small health departments like Boone County, where resources can be limited and scrutiny is high, the ability to align with national standards provides a persuasive edge in making the case for sustained investment in public health.

"Accreditation has taught us to operate at a higher level," Amanda concluded. "It's not just about meeting the standards - it's about proving that public health is worth the investment. And for small communities, that's a critical message."

Bridging the Divide: How Public Health Differs in Small and Large Communities

Public health in small communities operates in a uniquely challenging and rewarding environment. Unlike urban areas, where resources and organizations often are plentiful but fragmented, small communities rely heavily on collaboration and adaptability to meet public health needs. Amanda shared her perspective on how public health in small communities differs and the opportunities it presents.

One of the defining characteristics of public health in small communities is the strong spirit of collaboration that arises from limited resources. Amanda emphasized that leaders in small communities often work together in a less confrontational and competitive way compared to their urban counterparts. "Here, where there's limited resources, people are ready to sit around the table and tackle issues together," Amanda shared. "It's a good springboard for collaboration."

This collaborative environment extends beyond public health, encompassing leaders from various sectors, such as the county sheriff, the state's attorney and jail officials. In small communities, these individuals often operate in lower-profile roles compared to urban leaders, which Amanda believes fosters a more cooperative dynamic. "In urban areas, elections and leadership roles can be more competitive and high-profile, which sometimes creates competition and tension," Amanda noted. "In small communities, leaders focus less on prestige and more on problem-solving, which makes collaboration easier."

Another key distinction for public health in small communities is the need to fill critical service gaps that might not align neatly with traditional public health roles. Small health departments frequently take on responsibilities such as home health care, family planning and WIC (Women, Infants, and Children) services - programs that often are undervalued in national public health frameworks.⁹ "In small communities, a lot of health departments provide home health or WIC because they're the only shop in town meeting those needs," Amanda explained. "These services are desperately needed, but they don't always fit into PHAB's 10 Essential Public Health Services."

For Boone County, these programs have become integral to their work, particularly when engaging underserved populations. Amanda described how her department uses WIC and a mobile health unit purchased with COVID-19 funds to gather community feedback and provide services where they are most needed. "We've used feedback from WIC clients and our mobile unit to show that we're responding to community needs," Amanda said. "Even though programs like WIC aren't considered public health services by PHAB, they're critical in our community."

Despite its strengths, public health in small communities faces unique challenges when trying to align with national accreditation standards. Programs like WIC and family planning, while vital, often fall outside the scope of PHAB's accreditation requirements. "PHAB doesn't recognize some of the programs we provide, but they're desperately needed in our community because no one else is doing them," Amanda noted. "That's a tricky dichotomy."

Limited resources also make it harder for health departments serving small communities to meet certain standards, such as conducting research or gathering large datasets. Partnerships with academic institutions, like Boone County's collaboration with the University of Illinois at Chicago (UIC), have been essential in overcoming these barriers. "We flew through Domain 10 because of our partnership with UIC through a learning collaborative grant surrounding precarious work and workers' rights," Amanda shared. "They handled the research, and we got incredible local data for our Community Health Improvement Plan. That kind of collaboration makes a huge difference for small health departments."

As access points to clinical services in small communities across America continue to decline, small health departments often serve as both public health agencies and clinical care providers, a dual role that reflects the unique needs of their communities. Clinical services, such as home health and family planning, often dominate small health department operations. "In many small health departments, clinical services make up more than half of what we do," Amanda said. "Even though they don't fit neatly into the public health framework, they're essential in small areas where sometimes there is no one else to step up."

This adaptability allows health departments serving small communities to bridge gaps in care and build trust with their communities. It also highlights the need for greater flexibility in accreditation standards to reflect the realities of public health in small communities. Despite the challenges, Amanda sees public health in small communities as a rewarding field with unique opportunities. The collaborative spirit, adaptability and deep connection to the community make small health departments an essential component of the public health system.

"Public health is about finding creative ways to solve problems with the resources you have," Amanda concluded. "It's not always easy, but the impact you can make is incredible."

Conclusion

Amanda's journey with PHAB accreditation demonstrates the transformative power of this framework, especially for small health departments facing unique challenges. Boone County's success story is a testament to the adaptability, creativity and resilience required to modernize public health systems in resource-limited settings. From fostering collaboration and filling critical service gaps to using accreditation as a tool for advocacy and innovation, Amanda's experience highlights how accreditation can elevate the operational efficiency of a health department and its impact on the community it serves.

As small health departments across the nation navigate their paths toward accreditation, Amanda's insights offer valuable lessons in leadership, community engagement and the pursuit of excellence. PHAB accreditation is more than a checklist - it's a catalyst for progress, legitimacy and equity in public health, ensuring that even the smallest health departments can deliver big results.

Boone County's story is a powerful reminder that accreditation is not just about meeting standards, it's about building a future where all communities, regardless of size or resources, can thrive.

References

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2. Public Health Accreditation Board (PHAB). (n.d.). Accreditation Activity. Accessed Dec. 3, 2024 from https://phaboard.org/accreditation-recognition/accreditation-activity/
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4. Kovach KA, & Lipnicky A. (2021). An analysis of how characteristics of local health department jurisdictions influence involvement in PHAB accreditation: implications for health equity. Journal of Public Health Management and Practice 27(5):449-458. doi:10.1097/PHH.0000000000001248
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