Train-the-trainer (TTT) is a widely acknowledged educational model across a number of disciplines, including public health preparedness. However, many questions arise about its proper use, its efficacy, and its optimal role in preparedness education. After careful consideration of the literature and past anecdotal experiences with this educational model, TTT was selected as the preferred and sustainable method for public health preparedness in Maine. Upon completion of Year 1 of the Maine TTT program, our evaluation results revealed that TTT was successful and well received by participants. It is evident that TTT is potentially a valuable tool in public health preparedness, but it should be noted that there is no clear prescription for implementing TTT. Institutions and communities adopting TTT as an educational model must be flexible and willing to revise the training plan as challenges are encountered. Future research is required to help clarify optimal ways of using TTT to promote public health preparedness in the 21st century.

Our findings support previous research and add the roles of national public health accreditation and emerging issues as factors in agencies' ability to create and sustain a quality improvement culture.

EDIPPP's outreach and education model demonstrated the effectiveness of following a protocol-defined outreach strategy combined with flexibility to reach culturally diverse audiences or initially inaccessible systems. All EDIPPP sites yielded appropriate referrals of youths at risk of psychosis.

Emerging public health standards, performance assessment tools, and accreditation models hold significant promise for defining and standardizing public health practice, yet the lack of empirical research on their relationship to outcomes represents a serious barrier to adoption. Given the growing interest and momentum related to public health agency assessment and accreditation efforts, there is increasing need for evidence that performance standards and associated accreditation programs are effective means for moving public health systems toward the ultimate goal of population and community health improvement. This article provides an overview of accreditation in health and other industries, and its relationship to outcomes. We examine lessons that might have meaningful public health translations, as well as influences in and on public health that pose challenges for research and evaluation in this area. Finally, we propose a logic model framework to help depict the ways in which we can begin to explore the impact accreditation has on various levels of outcomes. This logic model is intended to guide the development of measures and to serve as a tool to help convey the breadth and depth of research needed to link accreditation to health outcomes.