Date of Completion


Embargo Period



Bonnie McRee, David Gregorio, Karen Spargo

Field of Study

Public Health


Master of Public Health

Open Access

Open Access


Background: Accreditation can benefit local health departments (LHDs) through the promotion of a culture of quality improvement (QI); yet LHDs tend not to perform well on QI-related measures (Domain 9 – Evaluate and Continuously Improve Processes, Programs, and Interventions). Methods: This study evaluated whether small/medium LHDs’ performance on Domain 9 impacts their accreditation results or performance on other domains. The qualitative analysis utilized Normalization Process Theory to reveal factors that guide LHDs in accreditation preparations. Results: Small/medium LHDs not required to submit an action plan scored higher on Domain 9. Performance on four domains exhibited a moderately strong correlation with performance on Domain 9 (.40≤r≤.70). Discussion: LHD staff play a pivotal role in accreditation goals, like the development of a culture of QI. Growth of staff commitment can increase QI comprehension, engagement in QI, stimulated action, and feedback loops that move LHDs towards institutional cultures of QI.

Major Advisor

Bonnie McRee