© 2018 Wolters Kluwer Health, Inc. All rights reserved. Objective: To compare local health department (LHD) accreditation readiness (AR) and quality improvement (QI) maturity in 3 states, between LHDs with varying levels of rurality, and across an LHD staffing-level continuum. Design: This was a cross-sectional comparative study that included an online survey administered to LHD directors in Colorado, Kansas, and Nebraska. The survey included 10 questions assessed on a 5-point Likert scale covering 3 QI domains and 13 questions covering 5 AR domains. The median score for both QI maturity and AR was calculated by each state, by the number of full-time equivalent staff employed at the LHD, and by a measure of rurality and population density. Setting and Participants: A total of 156 LHDs from the states of Colorado, Kansas, and Nebraska. Main Outcome Measure(s): QI maturity and AR scores. Results: A majority (59%) of the surveyed LHDs plan to apply or have already applied for Public Health Accreditation Board (PHAB) accreditation. The overall QI maturity and AR scores were highest in Nebraska, as was the intent to seek PHAB accreditation and current use of PHAB standards. Across levels of rurality and staffing, LHD QI maturity scores were similar; however, AR scores improved as LHD staffing levels increased and rurality decreased. Conclusions: Small LHDs and rural LHDs have QI maturity levels that are comparable to larger, less rural LHDs, but their AR is much lower. As accreditation has been found to have positive benefits, it is important that all LHDs have the capacity and resources to meet the performance standards required of accredited LHDs. Small, rural LHDs may need additional resources and support in order to improve their ability to be accredited and/or certain accreditation requirements may need modification to make accreditation more accessible to small LHDs.