At Champ Software’s recent Expert WebinarGretchen Sampson, MPH, RN shared Polk County Health Department’s journey through the accreditation process, including tips and resources for other agencies seeking PHAB accreditation.

Gretchen has been with Polk County Health Department since 1977.


  • Graduated with her BSN in Nursing from the University of Wisconsin – Eau Claire
  • Received her MPH in Health Administration from the University of Minnesota, Twin Cities
  • Became the Director/Health Officer at Polk County in 1996
  • Took her current position as the Community Services Division Director in 2015

Gretchen is understandably a very knowledgeable speaker and we were excited to have her share her experiences and wisdom on how to navigate the accreditation process.

Champ Software thanks Gretchen for sharing the content below.


Polk County is a rural county in northwestern Wisconsin, not far from the Minnesota border or Minneapolis-St. Paul, and the health department has 22 FTEs with a $2.3M budget.

That budget is largely due to Polk County’s aggressive pursuit of grant opportunities; only $910,000 of their budget comes from county tax levies.

The the remainder of the budget is made up of:

  • Grants
  • Fees for services
  • MA/insurance
  • Fiscal agent fees for managing other community collaborative

In Wisconsin, health departments are classified by levels, with Level I health departments providing basic health services to the community, such as:

  • Health promotion
  • Disease prevention
  • Generalized public health nursing

Level III health departments offer a multitude of services and programs, including:

  • Addressing priorities in the Wisconsin state health plan
  • Adhering to the frameworks for the generalized public health nursing program and environmental health programs
  • Submitting a host of reports

Polk County is a Level III health department.

The Current Situation

There is a strong movement towards public health accreditation in the state of Wisconsin, and there are now 13 local health departments in the state who have received accreditation.

The state included accreditation as part of the Healthiest Wisconsin 2020 goals in the state health plan and is one of 16 states who participated in the multi-state learning collaborative.

This “informed and accelerated the development of accreditation for state and local public health departments and helped make quality improvement a key part of public health.”

This participation gave Polk County an awareness of the standards and measures being developed before they ever began the accreditation process.

Polk County was one of the first 14 health departments in the nation to be accredited.

While the County’s original goal was to be the first health department in Wisconsin to be accredited, they were actually the third…  but this doesn’t take the wind out of Gretchen’s sails.

She says, “We don’t think that is too shabby!” Gretchen, a self-proclaimed Achiever, championed Polk County’s move towards accreditation, providing motivation, direction, and administration along the way.

The Preparation

Gretchen simplified how Polk County moved towards accreditation.

Selling it

Accreditation is a lot of work!

A key step in the process is selling the idea of accreditation to staff.


  • Put a positive spin on the project and got staff buy-in on the front side
  • Helped staff understand why you’re seeking accreditation and what it means for the department
  • Communicated the benefits of accreditation to our governing body

Polk County ensured also buy-in from the board of health and the county board by presenting the positive economic impact and the increase in quality services to the public.


We then needed to pull a team together.


  • Made sure the whole team worked well together and got along – you’ll be spending a lot of time with your team!
  • Included subject matter experts as well as people with strengths like:
    • Computer savviness
    • Detail orientation
    • Excellent memory
  • Created a core team to champion and lead the project as well as hold the rest of the team together

Accreditation is time consuming, intense, and very detailed, so getting the right team together was essential.

Strategic Planning

There’s a lot to plan and think about, and everything took time and effort.

Our strategic plan included:

  • Many teams, comprising:
    • Marketing and branding team
    • Workforce development team
    • Performance management/quality improvement team
    • Accreditation team (which has now become the re-accreditation team)
  • Public health partners
  • Leaders/governing bodies, all centered around and working with the core team leaders

The County also planned and mapped out a timeline that was integrated into the strategic plan. This created goals that could be referred to and celebrated when they were reached.

The strategic plan helped keep Polk County on track.

The Process

Year 1 – Self- Assessment and Process Planning

We began the accreditation process in late 2009, starting with assessing where the county was at.

The Polk County Health Department completed NACCHO’s Local Health Department Self-Assessment Tool to help ensure we were ready to begin the accreditation process.

Polk County wanted to ensure they were finished with the “Big 3”: Strategic Plan, CHA, and CHIP, and also used a radar graph to visualize strengths and weaknesses in the essential service domains.

During year 1 we:

  • Spent time identifying major gaps
  • Set up an electronic database to organize and monitor their progress in each domain
  • Trained staff and the board on the domains
  • Created standards and measures

The internal electronic database Polk County created was hosted on the agency network with folders for each domain and sub-folders for standards and measures within each domain.

Those folders were Polk County Health Department’s “virtual home” for the next 8-12 months.

Year 2 – Getting it Done

This year was spent ensuring the “big stuff” was done (Strategic Plan, CHA, and CHIP etc.) as well as documenting the implementation.

Year 3 – Gathering and Uploading Evidence

This was another busy year and we:

  • Gathered and uploaded the evidence for each domain in the database
  • Focused on one domain at a time, scheduling meetings on the calendar each week and month to review their work
  • Assigned key staff members to each domain, and pulled in the health officer who held the process together and provided an agency-wide perspective to the project

The county provided accreditation updates at each board of health meeting in the year leading up to accreditation.

It was important to schedule “sacred” time to devote to gathering and documenting evidence. It also helped to set application and final submission dates and stick to the plan!

“There’s just no getting around it – gathering evidence takes time and effort; all staff need to be involved at some point. Networking with other local health departments doing the same thing is a recipe for maintaining your sanity,” said Gretchen.

Lessons Learned:

Gretchen and Polk County learnt a lot before, during and after accreditation, and shared the main points with us.

  • Leadership from both the organization’s leader as well as the accreditation team leader is critical
    • Throughout the process, staff need:
      • Inspiration
      • Guidance
      • Support
  • Educate and involve every staff member as well as the board
    • Remember, it’s a TEAM effort!
  • Partnerships are key – continue to cultivate those relationships!
    • Polk County’s partner meeting during the site visit was an affirmation of their positive influence and effectiveness in the community
  • Written plans are not enough
    • Plans need to be thoughtfully developed, implemented and evaluated in order to make your life easier
  • Documentation is essential
    • Write the origin date, the review date, and the revision date on everything!
  • Secure a scanner and an email archive program
  • Expect setbacks as there will be times when you realize you didn’t reach the goal you hoped to reach
    • This just shows you where you need to improve for the next time around

The Benefits of Accreditation:

Gretchen and Polk County identified several accreditation benefits as a result of survey and evaluation results from health departments that had just completed their site visit or who had been accredited for more than a year.

Polk County Health Department is now also seeing these benefits.

Gretchen says Accreditation:

  • Identifies strengths and weaknesses (aka areas for improvement)
  • Strengthens your internal and external partnerships
  • Encourages prioritization and address of long-standing concerns
  • Provides the stimulus of quality improvement
  • Improves management processes
  • Increases communication with governing entities
  • Creates accountability to external stakeholders
  • Fosters teamwork and communication within the department

The accreditation process was intense but exciting, and all the staff rose to the challenge during the process and now have an awareness of what strategies in their day-to-day work affect the accreditation status.

The staff has worked extra hard to ensure the work they are doing meets PHAB standards. They also understand how much community partnerships mean to the work of the health department and continue to nurture those community relationships.

Gretchen shared, “There is a feeling of pride to hear our partners articulate how much they appreciated working with us on population health issues.”

“There is a feeling of pride to hear our partners articulate how much they appreciated working with us on population health issues.”

Gretchen Sampson, MPH, RN, Polk County

Tips for Others Considering Accreditation

Unsurprisingly, Gretchen and Polk County have some tips for others considering accreditation.

  • Assess your agency’s readiness- don’t apply too early
  • Achieve staff and administration buy-in
  • Budget the accreditation fees
  • Identify and secure a mentor health department if possible
  • Develop a reasonable timeline
  • Follow a workplan
  • Stay the course!
  • Have fun and don’t take yourselves too seriously

What Role Did Nightingale Notes Play in Polk County’s PHAB Accreditation Process?

Gretchen shared, “We have been a Nightingale Notes user since 2011. We have used [Nightingale Notes] to measure health indicators from some of our Maternal Child Health (MCH) programming, especially our Prenatal Care Coordination (PNCC) program population.

“We’ve created an outcomes tab in Nightingale Notes to document how we’re doing in smoking cessation, depression assessment, safe sleep, and birth weight of babies born to moms in that PNCC program. This can definitely help give you documentation for evidence in Domain 9, which is all about program evaluation and impact.

“Another helpful tool in Nightingale Notes is your KBS ratings scales, because that can also measure the impact of your work with populations. It’s really important that you have methodology to evaluate programs and outcomes of the work that you’re doing.”

Resources and Presentation Recording

To view a video of Gretchen’s full presentation (which includes a section on re-accreditation), download her presentation slide deck, and access all of the various excellent resources she’s provided for agencies working towards accreditation, click below. Time stamps are included for each agenda item in the presentation video so you can easily navigate to the portion of the presentation you want to view.

Access Additional Resources Here