Policy for National Military Installation Department of Public Health

Policy for National

Military Installation

Department of

Public Health

Initial Accreditation

Adopted November 2023

“This publication was developed under the direction of the Defense Centers for Public Health–

Aberdeen (DCPH-A), Defense Health Agency (DHA) Public Health, and as a result of collaboration

between DCPH-A and the Public Health Accreditation Board (PHAB), to provide supplemental

guidance to the national PHAB Standards & Measures for Initial Accreditation, Version 2022 to reflect

military terminology, operations, and scope of practice within the installation department of public

health settings that are serving Army locations (Contract # W81K0422D0018). Its contents are solely

the responsibility of the authors and do not necessarily represent the official views of the Department

of Defense, the Defense Health Agency, the Department of the Army, or the U.S. Government. The

mention of any non-Federal entity and/or its products is for informational purposes only, and is not to

be construed or interpreted, in any manner, as federal endorsement of that non-federal entity or its

products.”

TABLE OF

CONTENTS

Introduction

Standards & Measures

Additional

Information

II.

Applicability of this Policy

III.

Eligibility for Accreditation

Military Installation Department

of Public Health

Umbrella organizations

IV.

Overarching Policies

Terms and Conditions

Confidentiality

Fees

Evaluation

Technical Assistance

Roles & Responsibilities

Health Department 9

Health Department Director

Accreditation Coordinator

Appointing

Authority 10

Accreditation

Specialist 10

C. Site Visit Team 10

Conflict of Interest

Accreditation

Committee

Members 11

Conflict of Interest

VI.

Accreditation Process

Step 1: Preparation

Accreditation Education

Resources

Readiness Assessment

Step 2: Application

Step 3: Documentation Selection

and Submission

Step 4: Review (Site Visit)

Pre-site Visit Review

Site

Visit

Site Visit Report

Step 5: Accreditation Decision

Accreditation Decision Process

Accreditation Status

Step 6: Additional Reporting

and Annual Reports

Step 7: Reaccreditation

VII.

Appendices

Appendix 1: Process Map 23

Appendix 2: Military Installation Department

of Public Health Extension Policy

Appendix 3: Accreditation

Appeals Procedures

Appendix 4: Complaint Policy

and Procedures

Policy for National Military Installation Department of Public Health Initial Accreditation

INTRODUCTION

This policy document presents the process for seeking and obtaining initial public health department

accreditation through the Public Health Accreditation Board (PHAB). The process for reaccreditation is presented

in a separate document. For the purposes of this Policy, the term “health department” includes Military

Installation Departments of Public Health.

PHAB is the national accrediting organization for public health departments. PHAB is dedicated to advancing and

transforming public health practice by championing performance improvement, strong infrastructure, and

innovation. PHAB’s vision is a high-performing governmental public health system that supports all people living

their healthiest lives.

With support from the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson

Foundation (RWJF), PHAB has worked with public health practitioners and experts to develop and continually

improve the national accreditation program. Incorporated in May 2007, PHAB works closely with national

organizations that represent the wide variety of public health departments and structures across the country.

These partners include but are not limited to the American Public Health Association (APHA), the Association of

State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials

(NACCHO), the National Association of Local Boards of Health (NALBOH), the National Indian Health Board

(NIHB), the National Network of Public Health Institutes (NNPHI), the Public Health Foundation (PHF), and the de

Beaumont Foundation.

Following the release of the

Standards & Measures for Initial Accreditation, Version 2022

(referred to as “The

Standards” in this document) in September 2022, PHAB engaged with the Defense Centers for Public Health

(DCPH) – Aberdeen (DCPH-A) to develop supplemental guidance tailored to support Military Installation

Departments of Public Health with a current focus on select departments that serve

Army locations. Together,

PHAB and the DCPH-A reviewed The Standards, considering opportunities to further develop clarifying guidance

and examples reflective of public health programs, services, functions, and operations within the context of

Military Installation Departments of Public Health and Army installations. In addition, the supplemental guidance

was informed by site visit reports and experiences compiled from Military Installation Departments of Public

Health serving Army locations that have achieved or are in the process of achieving initial accreditation.

National public health accreditation consists of the adoption of a set of standards, a process to assess

performance against those standards, and recognition for those departments that meet the standards. The

accreditation process and standards are intended to be flexible and inclusive to accommodate many different

configurations of public health departments at all governmental levels, including Military Installation

Departments of Public Health.

Accredited health departments demonstrate accountability to their stakeholders. The goal of the national

accreditation program is to help public health departments assess their current capacity and guide them to

continuously improve that capacity, thus promoting a healthier population.

Policy for National Military Installation Department of Public Health Initial Accreditation

Standards & Measures

Accreditation demonstrates that public health departments, including Military Installation Departments of Public

Health, maintain the capacity to deliver the three Core Functions of public health—assessment, policy

development, and assurance—and the 10 Essential Public Health Services, which provide a fundamental

framework for describing public health activities. Accreditation also demonstrates that public health departments

possess key capabilities as outlined in the Foundational Public Health Services (FPHS). The FPHS framework

outlines the unique responsibilities of governmental public health and defines a minimum set of capabilities and

areas that must be available in every community. The Standards identify “foundational capability” measures,

which are key to ensuring the community’s health and achieving equitable health outcomes. National

accreditation only applies to The Standards and does not address local political or personnel issues.

The Standards were originally developed with input from public health practitioners with wide-ranging public

health expertise, including a Standards Development Workgroup, a Tribal Standards Workgroup, and various

PHAB Think Tanks and expert panels with subject matter expertise to address specific topics. The first version of

The Standards (Version 1.0) was tested through a desk review alpha test, vetting, and an evaluated beta test. The

Standards have been revised since the original Version 1.0 and will be revised in the future as the public health

field advances. All revisions of The Standards are made with input from public health practitioners and experts

and with oversight from the PHAB Accreditation Improvement Committee, comprised of practitioners and PHAB

Board members. All proposed revisions are vetted in the field before they are presented to the PHAB Board of

Directors for adoption.

From 2014 to 2019, PHAB collaborated with U.S. Army public health practitioners under the direction of the U.S.

Army Public Health Center, U.S. Army Medical Command (now known as the Defense Centers for Public Health–

Aberdeen, Defense Health Agency) to develop an adapted version of The Standards, the

Army Public Health

Initial Accreditation, Standards and Measures, Version 1.5,

along with a corresponding

Acronyms & Glossary of

Terms

. These publications were originally adapted for

what were then referred to as

Army Installation

Departments of Public Health.

In 2022, DCPH-A contracted with PHAB to develop supplemental guidance specific to Military Installation

Departments of Public Health, focusing on those departments serving a specific set of Army locations. While the

requirements within The Standards (for initial, reaccreditation, and the Pathways Recognition Program) remain in

force and applicable to all Military Installation Departments of Public Health, the supplement offers guidance

reflective of the structures, functions, and operations of those Military Installation Departments of Public Health

that serve Army locations, as well as guidance pertaining to the array of programs, services, and initiatives

provided to the installation community.

Among the principles that guide the development and revision of The Standards is that the requirements will

describe a moderate level of capacity – not minimum and not maximum standards. PHAB intends for The

Standards to advance collective public health practice. For that reason, The Standards are designed to be feasible

in that they reflect current public health practice, and they also require health departments to improve as they

proceed through the process. PHAB’s Pathways Recognition Program (for health departments not yet ready to

apply for full accreditation) and PHAB’s forthcoming Excellence Recognition Program (to highlight health

departments that excel in particular areas of public health practice) are designed to support public health

advancement for health departments across a spectrum of performance.

Policy for National Military Installation Department of Public Health Initial Accreditation

Additional Information

This document can be found on the PHAB website –

http://www.phaboard.org

. The online

version includes sections entitled “For More Information,” which provide additional resources,

including links to tip sheets, online courses, and additional websites. These resources may be

updated as new information becomes available. Military Installation Department of Public

Health Accreditation Coordinators and other personnel are encouraged to use these resources

in preparation for accreditation.

FOR MORE INFORMATION

For more information on

accreditation

, including benefits, a list of accredited health departments,

frameworks, and more, visit phaboard.org/resources.

II.

APPLICABILITY

THIS

POLICY

PHAB will periodically revise this policy and The Standards. This 2023 version of the policy for

Military Installation Departments of Public Health (the “2023 Policy–Installation”) was adopted by

the PHAB Board on June 9, 2023. It applies to any Military Installation Department of Public Health

serving an Army location that is

applying under the

PHAB Standards & Measures for Initial

Accreditation, Version 2022

The Policy remains in full force and effect until a new version of the

policy is approved by the DCPH-A and the PHAB Board. The version of the policy and The

Standards applicable to a health department at the time it begins the accreditation process

remains applicable throughout the duration of the respective health department’s accreditation

cycle unless the health department, the DCPH-A, and PHAB mutually agree that a different version

will apply. For example, Accreditation Committee Action Requirements (ACAR) and any complaints

and appeals for a particular health department will be governed by the version of the Policy and

The Standards that apply at the time the health department commences its Application for an

accreditation cycle. If PHAB amends any provision in the 2023 Policy, it will take reasonable efforts

to notify the point of contact for each health department registered in PHAB’s electronic system

to which the change in policy pertains.

III.

ELIGIBILITY

FOR

ACCREDITATION

The entity that has the primary statutory or legal responsibility for public health in a Tribe, state,

territory, at the local level, or Military Installation Department of Public Health is eligible to

apply for accreditation. To be eligible for initial accreditation, such entities must operate in a

manner consistent with applicable federal, Tribal, state, territorial, and/or local statutes and

military regulations or their Department of Defense equivalent. PHAB will determine the

applicant’s eligibility to apply for public health department accreditation. A health department

must meet one of the definitions below to be eligible to apply for PHAB accreditation.

Health departments are encouraged to discuss with PHAB any instances where they have

questions about how The Standards or eligibility criteria apply given their organizational

structure.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Military Installation Department of Public Health

For the purposes of PHAB accreditation, the “Military Installation Department of Public Health”

is defined, as the entity responsible for local military installation public health services.

“Military

Installation Department of Public Health” refers to the departments located at the installation (“installation-

level”).

Although most of these entities will use the Installation Department of Public Health

nomenclature, the actual name may vary for some locations due to local considerations and

scope of services (e.g., multiple installations may be included in the department name of the

installation, which may be a Joint base, and the department is named as such). Activities related

to public health services in an operational (deployed) environment are excluded for the purposes

of public health department accreditation.

Further, the activities of Veterinary Services, which have been part of the military public health

enterprise, are not reviewed in PHAB accreditation, although an installation Veterinary Clinic may

partner with a Military Installation Department of Public Health.

Umbrella Organizations

Health departments may apply for accreditation if they are part of an umbrella organization, super

public health agency, or super agency that oversees public health functions in addition to other

governmental functions. However, PHAB will accredit only the public health function of the umbrella

organization. The Military Installation Department of Public Health may be part of a larger

organization with higher chains of command (e.g., medical treatment facility (MTF)) and may utilize

the policies, procedures, or functions of those organizations and commands. For example, the

Military Installation Department of Public Health may utilize the human resources (HR) system of the

organization of which it is a part, such as the MTF, or Civilian Personnel Advisory Center (CPAC), or

that of another identified support agency. In this case, the documentation for “human resource

policy and procedures manual or individual policies” would be the policies and procedures of the

applicable organization or support agency.

If an applicant is part of a broader umbrella organization, the review will focus on the public health

functions, as defined by the 10 Essential Public Health Services. All organizational policies (e.g.,

confidentiality, HR), plans (e.g., strategic plan), and systems (e.g., performance management system)

provided as documentation to PHAB must apply to the division of the organization that carries out

public health functions (e.g., the Military Installation Department of Public Health), regardless of

whether they apply to the entire umbrella organization (e.g., MTF, DHA Market/Network). Because

PHAB’s review is limited to the public health function (i.e., PHAB does not provide a comprehensive

review to ensure that the policies, plans, and systems apply across the umbrella organization as a

whole), the scope of PHAB’s accreditation recognition is limited to the public health function(s), as

defined by the 10 Essential Public Health Services, and does not cover the entire umbrella

organization.

The accountability for meeting the measures rests with the Military Installation Department of Public

Health under accreditation review. The department must provide evidence of meeting the measure,

even if such documentation is produced by an umbrella agency of which the Military Installation

Department of Public Health is a part. In these instances, it is advisable for the department to include

an explanation of how the functions, policies, or procedures of the umbrella organization apply to

and are used by the Military Installation Department of Public Health.

FOR MORE INFORMATION

For more information on

eligibility

, including how to learn more about the applicability of the program in

your jurisdiction, visit phaboard.org/resources.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

IV.

OVERARCHING

POLICIES

Terms and Conditions

A Military Installation Department of Public Health applicant must agree to PHAB’s Terms and

Conditions agreement, which must be electronically signed upon Application submission. As part of

the Terms and Conditions, the Chief/Director or Deputy Chief/Director of the applicant Military

Installation Department of Public Health will attest to the accuracy and validity of, and assume full

responsibility

for, the content of the Application and all documentation and information used by

the applicant throughout the accreditation process, including Annual Reports. The applicant will

acknowledge and

agree that PHAB reserves the right to verify any or all of the information.

Providing false, misleading,

inaccurate, or incomplete information or otherwise violating the rules

governing the accreditation program may constitute grounds for the rejection of the

Application, denial of accreditation, revocation of accreditation status, or other appropriate

disciplinary action.

FOR MORE INFORMATION

To read the

Terms and Conditions

, visit phaboard.org/resources.

Confidentiality

The Military Installation Department of Public Health applicant acknowledges and agrees that

PHAB will undertake reasonable efforts to keep information exchanged throughout the

accreditation review process confidential to the review process, except to the extent that PHAB

might be required by law, statute, rule, or regulation to disclose such information.

Confidential information includes:

•

Any and all of the health department’s documentation.

•

Site Visit Team pre-visit, site visit, and post-visit discussions.

•

Contents of the Site Visit Report.

•

Opinions expressed to the Site Visit Team during interviews and site visit

discussions.

•

Documents viewed and visual observations made as part of the site visit.

•

Membership of the Site Visit Team.

Except as otherwise stated in this policy or prohibited by applicable law, the applicant may make

their own decisions about disclosure of information used for and received during the accreditation

process. They may not, however, disclose to any third party any information regarding the identity

of the Site Visitors.

PHAB will provide the assigned Department of Defense (DoD) Contracting Officer’s Representative

(COR) and the Defense Public Health Accreditation Program Management Team with a list of

decisions (accredited, reaccredited or deferment of decision), including ACAR decisions, for all

Military Installation Departments of Public Health. PHAB will also publish on its website the list of

accredited health departments, including accredited Military Installation Departments of Public

Health. The published list includes basic information such as location, date of accreditation, health

department type, population, and version of The Standards. If a health department had previously

been accredited and is no longer accredited for any reason (e.g., including failure to follow Annual

Reporting requirements, decision not to apply for accreditation, and/or not successfully

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

completing the accreditation process, etc.) the health department’s status as being no longer

accredited will be publicly released.

In addition, to support the evidence base for public health practice, PHAB will make aggregate,

anonymized information gathered through the accreditation process (e.g., assessments of

conformity) available to the public or may share accreditation data with identifiers to researchers

who follow PHAB’s data use agreement process and confidentiality requirements. Information

about data for research purposes is available on the PHAB website. Health departments may also

be able to opt in to sharing additional data with other health departments for the purpose of

shared learning.

Site Visitors are instructed to not discuss the applicant health department or any of its

documentation with others not involved in the health department’s PHAB accreditation process.

At all times, health departments are solely responsible for abiding by all applicable state and

federal laws as well as military regulations or policies regarding personal or sensitive

information. For example, for personnel-related requirements, state or federal law may require

the health department to redact the names of employees. In addition, state or federal laws may

prohibit disclosing personal health information to PHAB (including through PHAB’s electronic

system). PHAB cannot provide advice regarding a health department’s particular obligations

under applicable law. As such, health departments should seek counsel for complying with

applicable privacy laws.

FOR MORE INFORMATION

For more information on the

PHAB Data Portal

Site Visitor Agreement

, and more, visit

phaboard.org/resources.

Fees

As of this document’s publication, fees to apply for initial accreditation are centrally paid for by

the DCPH-A/DHA for Military Installation Departments of Public Health serving select Army

locations. Asterisks (*) indicate specific fee references covered within this Policy.

Evaluation

For PHAB’s continuous quality improvement of the accreditation process, courses, and supporting

guides and documents, PHAB conducts evaluation activities and may contract with an external

evaluator to gather additional feedback. PHAB or its contractor may ask health departments to

complete surveys or participate in interviews or focus groups. It is through evaluations that the

health departments are provided opportunities to submit comments and recommendations

concerning The Standards, the Site Visit Report, the Site Visit Team, the accreditation process,

or any aspect of the accreditation experience. PHAB uses the findings of its evaluations to make

decisions regarding all components of the accreditation process. All applicant health departments

are expected to participate in PHAB’s evaluation process. Findings from the evaluations that are

shared publicly do not identify individuals or organizations. Evaluation content from the health

department

is not shared with the Accreditation Committee, and comments do not affect the

accreditation decision. The DCPH-A may also conduct an evaluation specific to Military

Installation Departments of Public Health experiences or outcomes related to the accreditation

process and designation. These are separate from PHAB’s evaluation activities.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Technical

Assistance

Health departments should direct all questions on the accreditation process and The Standards to

PHAB. PHAB staff is available to provide technical assistance on issues involving the accreditation

process; the e-PHAB information system; required forms; meaning of terms used; and interpretation

of the standards, measures, and documentation guidance. PHAB is responsible for providing

training to applicants on the accreditation process and the selection of documentation that

demonstrates conformity with The Standards.

PHAB has resources and courses available to health departments preparing and applying for

accreditation. PHAB will designate specific courses that are required during the Preparation step

(see Accreditation Process below) and may require additional training at later steps in the process

(e.g., health departments that are required to submit an ACAR also have required training

associated with that process).

FOR MORE INFORMATION

For more information on

technical assistance

, including PHAB’s e-Learning platform, visit

phaboard.org/resources.

ROLES & RESPONSIBILITIES

Health

Department

Department of Public Health Chief or Director

For the purposes of PHAB accreditation at Military Installation Departments of Public Health,

the Health Department Chief/Director may be the department’s senior officer, the installation’s

public health authority, or similar assignment defined as the highest-ranking individual with

administrative and managerial authority at the level of the health department. Throughout this

document, this position will be referred to as the “Health Department Director.”

The Health Department Director is responsible for attesting to the accuracy of the information

submitted to PHAB as demonstrated by authorizing the submission of materials through PHAB’s

electronic information system, e-PHAB. This includes the Application and all documentation

(documentation submission, reopened measures, ACAR, Annual Report).

Accreditation

Coordinator

Health departments pursuing PHAB accreditation are required to appoint one person as an

Accreditation Coordinator. The Accreditation Coordinator cannot be the Health Department

Director; the responsibilities of these two positions are too significant to be handled adequately by

one

person. However, if health department circumstances make it challenging to appoint

someone other than the department director as the Accreditation Coordinator, health

departments may submit a written request to PHAB to appoint the director as the Accreditation

Coordinator.

The Accreditation Coordinator is responsible for coordinating the accreditation process within the

health department and is the primary communication contact between the health department and

PHAB throughout the entire accreditation process. It is the responsibility of the health department

to ensure e-PHAB is updated if any contact information changes.

While the health department must designate the Health Department Director and Accreditation

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Coordinator, the health department can also designate other staff members who will have access

to e-PHAB.

FOR MORE INFORMATION

For more information on

selecting an Accreditation Coordinator

, visit phaboard.org/resources.

Although not required, PHAB strongly encourages health departments to use an Accreditation Team

through the process.

Appointing Authority

The appointing authority is the person with the power to hire the chief or director of the health department.

The term “commander,” as it pertains to the governance of the Military Installation Department of Public

Health, is specific to the commander to whom the chief or director of the Military Installation Department of

Public Health reports (MTF Commander, or other designated Commander, for example), unless otherwise

specified.

The appointing authority is responsible for providing a letter of support to apply for each cycle of PHAB

accreditation.

PHAB Accreditation

Specialist

PHAB Accreditation Specialists will be available to provide technical assistance concerning the

accreditation process and the interpretation and intent of The Standards. Accreditation Specialists

are employed by PHAB and are experienced public health professionals with extensive knowledge

of The Standards and the accreditation process.

A health department will be assigned a PHAB Accreditation Specialist during process steps where

documentation is reviewed for conformity with The Standards. The Accreditation Specialist is

a member of the Site Visit Team. The Accreditation Specialist conducts an initial review of the

applicant health department’s documentation and works to ensure quality assurance, consistency

within and across reviews, rater and inter-rater reliability, and clarity of information in the Site

Visit Report. The Accreditation Specialist works closely with Site Visitors and provides technical

assistance concerning the review process and The Standards. The Accreditation Specialist acts as

the point of contact between the Site Visitors and the health department.

FOR MORE INFORMATION

For more information on how to

contact PHAB Staff

, visit phaboard.org/resources.

PHAB Site Visit Team

PHAB employs a peer review model. PHAB Site Visitors must demonstrate their understanding

of governmental public health services, as spelled out in PHAB’s eligibility requirements. PHAB

will identify Site Visit Team members who have a background and are experienced in military public

health practice or experience working in a Military Installation Department of Public Health. After a

site visitor application is accepted by PHAB, Site Visitors will undergo training designed to

ensure consistency in assessments of The Standards (inter-rater reliability). To remain an active

Site Visitor, individuals may be required to complete additional or refresher trainings as

determined by PHAB.

Site Visitors play a central, substantive, and critical role in the accreditation process. The Site

Visit Team, which is comprised of a peer reviewer(s) and PHAB Accreditation Specialist, reviews

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

documentation submitted by health departments; conducts site visit interviews; and writes the

Site Visit Report.

The Site Visit Team represents PHAB. The team’s responsibility is to learn about the health

department through the review and to contribute to the development of a Site Visit Report that

accurately describes and reflects the health department that they have reviewed. The Site Visit

Team does not decide or recommend the accreditation status of the health department.

The size of the Site Visit Team is determined by the complexity of the review. PHAB appoints a Team

Chair for each health department.

Except during the site visit itself, all communication from the health department will be with the

Accreditation Specialist, rather than with the volunteer Site Visitors.

Conflict of Interest

PHAB strives to ensure that a bias-free decision process is maintained. Anyone who will serve on

a Site Visit Team must identify and disclose actual, potential, or perceived conflicts of interest.

Individuals will not be assigned to a Site Visit Team for a health department with which a valid

conflict of interest exists. The goal is to prevent any negative impact that conflicts of interest may

cause to the accreditation process.

Conflicts of interest may include, but are not limited to —

•

Previous or current employment with the health department;

•

Previous or current consultation or other business arrangement with the health

department;

•

Family relationship with key employees of the health department; or

•

Any other relationship with the health department that would afford the Site

Visit Team member access to information about the health department other

than that which is provided through the PHAB accreditation process.

For a period of

months following the conclusion of a site visit, no Site Visitor may serve as a

consultant to any health department they have reviewed.

Site Visitors sign an agreement form with PHAB that includes conflict of interest provisions inclusive

of the above.

Additionally, to ensure objectivity, individuals that are currently working for a health department

will not be assigned to serve on a Site Visit Team for health departments within that same state.

The health department also has an opportunity to review potential Site Visit Team members for

conflict of interest and request that a change be made in their Team membership, based on that

conflict.

FOR MORE INFORMATION

For

guidance on eligibility

and how to

apply to be a site visitor,

visit phaboard.org/resources.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB Accreditation Committee Members

The PHAB Accreditation Committee determines accreditation status for health departments. The

Accreditation Committee has no fewer than ten members. Members of the PHAB Board of Directors

must comprise a majority of the members. At least 50 percent of the membership must have

recent Tribal, state, territorial, or local health department experience. The PHAB Board appoints

the members of the Accreditation Committee. This delineation was made to ensure a definitive

separation of the accreditation-related decisions made by the Accreditation Committee from the

handling of any appeals or complaints by the remainder of the Board members who do not serve

on the Committee. In keeping with this objective, Board members who are not on the Accreditation

Committee roster may not attend the Accreditation Committee meeting when accreditation

decisions are being considered.

The Accreditation Committee is chaired by a member of the PHAB Board. A Vice Chair is also

appointed. In the event that neither the Chair nor the Vice Chair is available to chair a meeting, a

member of the Accreditation Committee who is also a member of the PHAB Board of Directors is

asked to chair the meeting or affected portion of meeting.

The Accreditation Committee generally meets on a quarterly basis but may meet more frequently,

if required by the workload.

Conflict of Interest

PHAB has an obligation to ensure a bias-free decision-making process. All members of the

Accreditation Committee have an obligation to identify and disclose actual, potential, or

perceived conflicts of interest, and avoid the impact that such conflicts of interest may create in

the accreditation process.

Members of the Accreditation Committee must disclose any conflicts of interest they have with any

health department being reviewed. Committee members could still be able to serve as members

of the Committee but are required to recuse themselves from any review, discussion, deliberation,

or voting related to the respective health department to which the conflict is attached. Recusal

means that the member is blocked from access to the health department’s Site Visit Report and

must leave the room or the conference call when that health department’s accreditation status

decision is being discussed and made.

VI.

ACCREDITATION

PROCESS

The PHAB initial accreditation process consists of seven steps: (1) Preparation, (2) Application, (3)

Documentation Selection and Submission, (4) Review, (5) Accreditation Decision, (6) Additional

Reporting and Annual Reports, and (7) Reaccreditation. Each of these steps includes tasks that

have time limits. (See Appendix 1 for a process map outlining the steps in the process.) A health

department may request an extension from PHAB for extenuating circumstances. (See Appendix 2

for the policy for requesting an extension.) If PHAB approves the extension, then the timeframe

for the step will be adjusted accordingly.

Step

Preparation

A health department’s thorough preparation is critical to its success with the accreditation process.

PHAB has developed resources to help health departments prepare for accreditation, including a series

of courses and required completion of a Readiness Assessment. Health departments will need an

account in e-PHAB, PHAB’s electronic system, to access some of these resources. Registering in e-

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB is non-binding and does not commit a health department to submit an Application. At the time

the account is registered, a health department may be asked to demonstrate that it is a governmental

public health department eligible for accreditation.

Accreditation Education Resources

PHAB maintains a list of available education resources on its website. That list indicates which

courses the Accreditation Coordinator or the Health Department Director is required to complete

before submitting an Application for accreditation. While many of these courses are on-demand,

the Accreditation Coordinator will be required to participate in at least one live learning event

(which may be virtual or in-person) as part of their preparation.

Readiness Assessment

The Readiness Assessment tool aids health departments interested in pursuing PHAB Accreditation

or PHAB Pathways Recognition in determining the best approach based on their current level

of readiness. After the health department submits its assessment to PHAB, it will receive written

feedback about its level of readiness for moving forward in either accreditation or Pathways.

Based on this feedback, the health department decides whether to move forward with

accreditation, Pathways, or not at all. While completion of a Readiness Assessment is a required

step in the process, the health department may decide to move forward, as it sees appropriate,

with Pathways, Initial Accreditation, or neither.

FOR MORE INFORMATION

For more information on

preparing for accreditation

, including required trainings and the Readiness

Assessment, visit phaboard.org/resources.

Step 2: Application

After the health department has submitted its Readiness Assessment to PHAB, determined it

will apply for accreditation, and completed all required training for initial accreditation, it will

submit an Application in e-PHAB. The Application is formal notification to PHAB of a health

department’s official commitment to initiate the public health department accreditation

process. The Application, which includes agreeing to the Terms and Conditions, is a

commitment that the applicant will abide by the current and future rules of PHAB’s

accreditation process to achieve and maintain accreditation status for the 5-year accreditation

period. The accreditation process formally begins once a health department submits a

completed Application.

If the Application is not submitted within 12 months of the health department completing its

Readiness Assessment, the health department may need to repeat some of the preparation steps,

and

there

may be fee implications.* The health department must coordinate directly with the

Defense Public Health Accreditation Program Manager to determine if and how such fees will be

paid.

As part of the Application, the health department will be required to upload documentation

that indicates support for accreditation from the appointing authority. The Application will also

require additional information and documentation about the health department, such as the

organizational chart.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB staff will review submitted Applications and required attachments to ensure that—

•

The Readiness Assessment has been submitted, and the health

department has received feedback from PHAB;

•

The Application is complete;

•

Attachments that meet PHAB’s requirements for the Application have

been uploaded; and

•

Necessary trainings have been completed.

PHAB will respond to the applicant, indicating whether the Application has been accepted as

complete. If the Application is not accepted, PHAB will notify the applicant as to what additional or

different information is required to complete the Application.

FOR MORE INFORMATION

For more information on the

accreditation application

, including fees*, visit phaboard.org/resources.

* As of this document’s publication, fees to apply for accreditation are centrally paid for by the DCPH-A/DHA for Military Installation

Departments of Public Health at Army locations.

Step 3: Documentation Selection and Submission

The documentation submitted by the health department to PHAB is critical

. It will be

assessed by a PHAB Site Visit Team to determine the health department’s conformity with The

Standards and to develop the Site Visit Report, which is the basis for the accreditation decision.

After the health department’s Application has been approved, the applicant health department

will be able to begin uploading documentation for each measure in e-PHAB. Health departments

must upload and submit their documentation to PHAB within 12 months of the date of gaining

access to this module in e-PHAB. If a health department does not submit its documentation within

the timeframe, the applicant must begin the process again with required training and Application.

The Standards document includes the specific required documentation needed to demonstrate

conformity with each measure. In addition, the “Requirements for All Documentation” section

of The Standards document sets forth all requirements to which documentation must adhere.

This includes the use of PHAB-provided Documentation Forms to accompany all submitted

documentation. PHAB, in conjunction with the DCPH-A, has developed supplemental guidance to

support Military Installation Departments of Public Health at Army locations in the interpretation

of the requirements outlined in The Standards. The supplemental guidance provides additional

guidance for use by Military Installation Departments of Public Health serving Army locations

and Site Visitors of examples reflective of programs, operations, services, and functions within a

military context with specific focus on those departments serving Army locations. The

supplemental guidance does

not

replace the requirements outlined within The Standards, except

where indicated in

bold red font

in the far left column.

It is the responsibility of the health department to ensure that documentation is

complete, speaks to the intent of the measure, addresses all elements required for

the measure, complies

with all aspects of the “Requirements for All Documentation”

section within The Standards, and

directs the reviewers to the specific parts of the

document that fulfill the requirements.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

There are several circumstances in which health departments may not be required to provide

documentation for specific measures because their performance against those measures has

already been verified:

•

PHAB’s Pathways Recognition program:

If the health department has been

recognized through the Pathways program, the health department is not required

to re-

submit for accreditation the documentation that was previously used for Pathways if

the documentation is within the timelines outlined in the Policy for the Pathways

Recognition program.

•

Project Public Health Ready:

If the applicant is currently recognized as Project

Public Health Ready (PPHR), a criteria-based training and recognition program of

the

CDC and NACCHO, that health department is exempt from submitting documentation

to demonstrate conformity with Standard 2.2 requirements.

•

Defense Public Health Enterprise-wide Documentation:

PHAB will work with the

DCPH-A to identify documents in use among Military Installation Departments of

Public Health serving Army locations to streamline the accreditation process. For

example, if there are documents that would likely be submitted by each applicant

Military Installation Department of Public Health, PHAB could review those

documents once rather than requiring submission and review of each Military

Installation Department of Public Health.

FOR MORE INFORMATION

For more information on

documentation selection

, including the Scope of Authority policy, Standards &

Measures, and Documentation Forms, visit phaboard.org/resources.

Step 4: Review (Site Visit)

After the health department has submitted its documentation for all measures, review of the

documentation begins.

The purpose of the documentation review is to assess the documentation against The

Standards, considering the Initial Accreditation Supplemental Guidance for Military Installation

Departments of Public Health in order to develop a Site Visit Report. The documentation

review will result in an assessment of the health department’s conformity with each measure’s

intent and requirements. Each measure will be assessed using one of four assessment

categories:

Fully Demonstrated:

In the professional judgment of the Site Visit Team, the

submitted documentation is complete, providing evidence of conformity with all

elements of the Required Documentation set forth in The Standards.

Largely Demonstrated:

In the professional judgment of the Site Visit Team, the

submitted documentation demonstrates the elements of the Required

Documentation that are critical to the intent of the measure. That is, the health

department is generally in conformity with the measure and meets its intent but is

missing some elements or parts of the Required Documentation.

Slightly Demonstrated:

In the professional judgment of the Site Visit Team, the

submitted documentation does not demonstrate the intent of the measure. While

some documentation is in conformity with the requirements, the health

department is

missing vital elements of the Required Documentation. The pieces

of the Required

Documentation that are critical to the intent of the measure are not evidenced.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Not Demonstrated:

In the professional judgment of the Site Visit Team, the

submitted documentation provides no evidence of conformity with the Required

Documentation. None of the required elements are demonstrated.

The documentation review is to be conducted in two review phases: a Pre-site Visit Review

and a site visit. The purpose of the Pre-site Visit Review is to review the documentation and

request

additional documentation on any measures initially assessed as Slightly Demonstrated

or Not Demonstrated prior to the site visit. The purpose of the site visit is to provide the

reviewers the opportunity to acquire a more comprehensive review of the health department

through the combination of interviews, meetings with key stakeholders, and any additional

documentation requested of the health department.

Pre-site Visit Review

The PHAB Accreditation Specialist conducts an initial review of all submitted documentation

and will submit all measures initially assessed as Slightly Demonstrated or Not Demonstrated,

as a batch, to the health department. Health departments will be provided the opportunity to

upload additional documentation for those measures, with an accompanying Documentation

Form. The additional documentation could have been created or revised after the health

department’s original documentation submission date.

The health department will have 45 days to provide additional documentation for reopened

measures. If the health department does not respond within the timeframe, the review will proceed

with the originally submitted documentation. The purpose of the opportunity to request additional

documentation during the review is to provide the Site Visit Team with the information it

needs to develop a Site Visit Report that accurately describes how conformity with the

measures was demonstrated, or details what is missing.

Measures initially assessed as Largely Demonstrated or Fully Demonstrated meet the “intent”

of the requirement and typically will not be reopened for additional documentation. After PHAB

receives the health

department’s response to the Pre-site Visit Review, the Accreditation Specialist

will review any additional documentation provided and update the initial assessment.

Peer reviewers will be assigned to the Site Visit Team. A Site Visit Team is comprised of at least

one

PHAB Accreditation Specialist and at least

one

peer reviewer. The peer reviewers will review

the draft Site Visit Report, including assessments and conformity comments, as prepared by

the Accreditation Specialist, as well as contextual information provided in the health

department’s Application. The peer reviewers will also review the documentation for all

measures scored as Slightly Demonstrated or Not Demonstrated and will review

documentation for at least one measure in each Domain. The Site Visit Team will reach

consensus on those assessments and Site Visit Report comments.

Policy for National Military Installation Department of Public Health Initial Accreditation

Site Visit

During the visit, the Site Visit Team focuses on gathering information to (1) validate and verify

the evidence presented in the documentation that was submitted to PHAB; (2) understand the

context in which the documentation is implemented by the health department; and (3) ask for

additional documentation, at their discretion, to supplement what they received prior to the

site visit. The number of days and format (virtual, in-person, or hybrid) of the site visit may

depend on the complexity of the documentation and conditions (e.g., the Site Visit Team’s

ability to travel). As long as conditions allow, site visits for initial accreditation will be conducted

in a hybrid format (for example, the Accreditation Specialist and the Site Visit Team Chair will

visit the health

department in person, and sessions involving the other members of the Site Visit

Team will be conducted

by videoconference). Site visits usually last between 10 and 15 hours.

In addition to discussion about documentation previously submitted to PHAB, time will be allotted

during the site visit to verify any documents that CANNOT be uploaded electronically in a non-

governmental information technology system. Those documents the Military Installation

Department of Public Health might consider using as documentation but have NOT been approved

for inclusion in PHAB’s electronic system are described in the introduction of the supplemental

guidance.

The Site Visit Team will collaboratively prepare for the site visit. The timing and planning of the

site visit are mutually agreed upon among PHAB, the Site Visit Team, and the health department.

PHAB will make every effort to ensure that the site visit is conducted according to the planned

schedule. However, there may be times when the planned site visit must be rescheduled due to

unforeseen circumstances.

The Health Department Chief and Accreditation Coordinator must be available during the

entire site visit and will be required to participate in certain sessions. If the health department

has

designated domain team leaders (responsible for the identification and selection of

documentation

for a particular domain), they should be available for those domain-specific

interviews. The health department determines which department staff participates in each

session during the site visit. The health department must invite community partners and

governance representatives to meet with the Site Visit Team for specific site visit sessions. At its

discretion, the health department may invite others to attend the site visit.

During the site visit, the Site Visit Team may reopen measures and ask that additional

documentation

be uploaded into e-PHAB. For example, if the health department references an

example that could potentially demonstrate conformity with a measure, that measure could be

reopened. Any additional documentation must be submitted by the health department through

e-PHAB within 2 business days of the last session of the site visit. The additional documentation

could have been created or revised after the health department’s original documentation

submission date.

During the site visit, the Site Visit Team Chair leads the work of the Site Visit Team, acts as

spokesperson, and leads meetings involving Site Visit Team members. The Site Visit Team does

not make any comment regarding possible accreditation status at any time. The Site Visit Team

members do not provide advice to the health department or share information about how other

health departments fulfill their public health roles and responsibilities. The role of the Site Visit

Team during the visit is to gather information, not provide feedback or recommendations to

the health department.

The site visit agenda will include an entrance conference; facility tour (in-person or virtual);

interviews with key staff on identified measures; an interview with the

Health Department

Policy for National Military Installation Department of Public Health Initial Accreditation

Chief/Director

;

interviews with a representative(s) of the governing entity and community partners;

and an exit

conference to summarize or highlight overall impressions, greatest strengths, and

opportunities for

improvement. The agenda may be amended to coordinate Site Visit Team

members’ and health

department staff’s needs to attend various sessions. Prior to the site visit, the

Accreditation Specialist will provide a final site visit agenda to the health

department so the

department can ensure the necessary staff members and others are present. A list of measures

about which the Site Visit Team has specific questions will be shared with the health department

in advance of the site visit. The list may not be exhaustive, as discussions during the site visit

could result in additional

measure-, domain-, or theme-related questions.

FOR MORE INFORMATION

For more information on

preparing for the site visit

, visit phaboard.org/resources.

Site Visit Report

The Site Visit Report is the Site Visit Team’s comprehensive and final assessment of the health

department’s conformity with The Standards, taking into account the Supplemental Guidance

for Military Installation Departments of Public Health – Initial Accreditation, based on the

entirety of the information gathered

through the review process. The overall objective of the Site

Visit Report is to accurately describe the

health department’s demonstration of conformity with

the measures, the department’s strengths and opportunities for improvement, and how the

health department functions.

The Site Visit Team develops a Site Visit Report that is submitted to PHAB through e-PHAB.

The Site Visit Report has two audiences: the Accreditation Committee uses the report to make

an accreditation decision, and the health department uses the report for additional work (if

required

by PHAB through the ACAR or Annual Report process), continuous quality improvement,

and Annual

Reports to PHAB.

The Site Visit Team provides an assessment and narrative for each measure. The narrative

provides a summary of how conformity with the measure was demonstrated, and details what

required element(s), if any, was missing. The Team may also describe any areas of excellence

and/or describe any opportunities for improvement that it identifies. Even if a measure is Fully

Demonstrated, the Team may note any identified opportunities for improvement

. These

opportunities

for improvement are not considered in the accreditation decision.

An overall Report summary provides the Team’s appraisal of the health department’s (1) three

greatest strengths, (2) three greatest opportunities for improvement, and (3) overall

impressions of the department as a functioning health department.

The final Site Visit Report is sent to the health department for their information. Health departments

do not have an opportunity to submit comments concerning the Report at this time. Rather,

health departments may submit comments about the report or any part of the accreditation

process as part of PHAB’s evaluation processes.

PHAB does not make Site Visit Reports available to anyone other than the health department, the

DoD COR, the Defense Public Health Accreditation Program Management Team, PHAB

staff, and

the PHAB Accreditation Committee. The health department may share its Site Visit Report with

others at its discretion.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Step 5: Accreditation Decision

Accreditation Decision Process

The PHAB Accreditation Committee is charged with reviewing reports developed by the PHAB

Site Visit Team and determining the accreditation status of health departments. All Site Visit

Reports are available to all members of the Committee to read (unless a conflict of interest has

been identified and recusal warranted).

The Accreditation Committee reviews the health department’s Site Visit Report and determines

accreditation status. The Accreditation Committee makes accreditation decisions based on the

Site Visit Report, including the Site Visit Team’s assessments of conformity with each measure,

conformity comments, and overall Report summary.

If members of the Accreditation Committee have questions about the Report, the Site Visit

Team Chair may be requested to speak with members of the Committee before or during the

meeting. PHAB staff are available to address conformity issues or compliance with the process,

policy, or rules in order to promote consistency in decisions.

PHAB does not accept testimony, letters, phone calls, or other means of communication from

the public about an individual health department while the department’s accreditation process

is in progress.

Applicants are not permitted to attend Accreditation Committee meetings, though PHAB discloses

to the health department when the Committee is reviewing the Site Visit Report. Identifying

information concerning the health department, the Site Visit Report, and the Committee’s

deliberations is confidential and is not shared outside of PHAB.

Accreditation

Status

Following are the three accreditation decisions that the Accreditation Committee can make:

Within 2 weeks of the conclusion of the Accreditation Committee meeting, PHAB will send a

letter through e-PHAB to the Health Department Chief/Director, with a copy to the

Accreditation Coordinator, stating the official PHAB accreditation decision. No verbal feedback

is provided to applicants before the official written decision letter is sent to the applicant

through e-PHAB.

Accredited Health Departments

Accredited health departments receive a certificate, a plaque, and access to online resources

specifically for accredited health departments.

If the health department receives a status of “accredited,” the Accreditation Committee may

provide the health department with a list of measures that are opportunities for improvement. This

is one portion of the Annual Reports to support the department’s continuous quality improvement

efforts. Reporting on specific measures could take one of two forms:

•

If there

are

Foundational Capabilities measures that are assessed as Slightly or Not

Demonstrated, the Accreditation Committee will indicate that an Annual Report with

Accredited

(5 years)

Accreditation

Committee Action

Requirements (ACAR)

Not

accredited

Policy for National Military Installation Department of Public Health Initial Accreditation

Documentation Requirements is needed. In this case, the health department will be

required to provide

documentation

for those measures in the Annual Report the first

year after the accreditation decision. That documentation will be assessed for

conformity with the measure requirements. The health department shall be asked to

provide additional documentation that year or a subsequent year, or be referred to

the Accreditation Committee, if the documentation does not sufficiently demonstrate

improved conformity with the measure.

•

If there are

Foundational Capabilities measures assessed as Slightly or Not

Demonstrated, the health department is required to report in its Annual Reports

progress on other measures designated by the Accreditation Committee.

Each year’s

Annual Report will be reviewed by PHAB staff, and additional reporting

may be required

that year or in subsequent years. If the health department does not report sufficient

progress, the health department shall be referred to the Accreditation Committee.

FOR MORE INFORMATION

For more information, including

communication toolkits

for accredited health departments, visit

phaboard.org/resources.

ACAR

If the Accreditation Committee decides not to confer accreditation status to the health

department based on the Site Visit Report, the Accreditation Committee will issue an Accreditation

Committee Action Requirements (ACAR) to the health department that details specific measures

for which the health department must take further action to satisfy PHAB’s accreditation

criteria. The health department will remain in process until the ACAR is complete.

The health department is required to submit additional documentation for measures identified by

the Accreditation Committee as part of the ACAR within 12 months of the receipt of the

notification that the Accreditation Committee requires additional action. The purpose of the ACAR

is to provide

the health department with an opportunity to improve its performance and develop

documentation

to demonstrate conformity with the measures’ requirements.

The health department must use PHAB’s ACAR Documentation Forms to submit its

documentation for all of the ACAR-required measures and must submit the forms

at one time.

Submitted documents

are reviewed against The Standards and assessed by a Site Visit Team.

PHAB strives to assign the same reviewers that reviewed the entire set of documents

submitted for the accreditation cycle but may assign other PHAB-trained reviewers if the

original Site Visitors are not available.

The Site Visit Team’s assessments are submitted to the Accreditation Committee as an ACAR

Report for the Committee’s determination of accreditation status. The health department will

also receive the ACAR Report.

FOR MORE INFORMATION

For more

information on the ACAR

, including guidance, resources, and Documentation Forms, visit

phaboard.org/resources.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

Not Accredited

The Accreditation Committee’s decision to Not Accredit a health department may be

based on either of the following two sets of criteria: (1) Not Accredited Based on Non-

conformity with The Standards (“Non-conformity Decisions”), and (2) Not Accredited for

Failure to Complete Accreditation Process (“Procedural Decisions”).

Non-conformity Decisions

Non-conformity Decisions may be appealed in accordance with the PHAB Appeals Procedure

set forth in Appendix 3. The Accreditation Committee can issue a Non-conformity Decision at

the following points during the accreditation process:

•

Upon determination that a health department did not adequately fulfill

the requirements of the ACAR Report.

•

Upon a determination that a health department failed to make

sufficient progress on measures designated by the Accreditation

Committee for reporting or documentation in an Annual Report.

•

Upon review of an Annual Report that indicates changes in the health

department or adverse findings that result in the health department no

longer being in conformity with The Standards.

•

Upon an adverse determination pursuant to the PHAB Complaint Policy

and Procedures (see Appendix 4).

Note: The Accreditation Committee does

not

have the option to Not Accredit a health

department

based on the review of the Site Visit Report. At that point in time, the Accreditation

Committee’s only

options are to Accredit or to issue an ACAR.

Procedural Decisions

The Accreditation Committee may issue a Procedural Decision to Not Accredit a health

department at the following times:

•

Upon a health department’s failure to submit the requirements for

accreditation (e.g., the health department does not complete

documentation submission) according to the timeframes described in this

document.

•

Upon a health department determining that it will drop out of the

accreditation process at any point after the Site Visit Team has completed

and submitted the Pre-site Visit Review to the health department.

•

Upon a health department’s failure to submit documentation that was

required in an ACAR by the time ACAR documentation is due.

•

Upon a health department’s failure to submit an Annual Report on time.

•

Upon DCPH-A’s/DHA’s failure to pay fees* that are owed to PHAB.

•

Upon a health department’s failure to apply for reaccreditation by the time

the reaccreditation Application is due.

Procedural decisions cannot be appealed.

Upon receiving notice of a Procedural Decision, the health department will have 90 days from

the date of receipt to contact PHAB to request an extension. The granting of an extension is at

PHAB’s sole discretion.

Policy for National Military Installation Department of Public Health Initial Accreditation

Notification of Decision

PHAB will both publish on its website and notify the Military Installation Department of Public

Health, the assigned DoD COR, and the Defense Public Health Accreditation Program

Management Team of any change in status of a health department that was accredited and has

lost its accreditation status. This public notification is part of PHAB’s commitment to

transparency. Because the public record previously indicated that those health departments

were accredited, it is necessary to clarify the health department’s current accreditation status.

If a health department that lost its accreditation status reapplies and becomes accredited, it

will no longer be listed as Not Accredited.

PHAB will not publish the Not Accredited status of health departments that have never been

accredited.

FOR MORE INFORMATION

For more information on

complaints

, visit phaboard.org/resources.

Step 6: Additional Reporting and Annual Reports

The submission of an Annual Report is required of all accredited health departments.

The purpose is to ensure accredited health departments remain in conformity with The Standards

and provide opportunities for additional engagement with PHAB to support advancing quality,

performance, and transformation. This is a vital part of PHAB’s ongoing accreditation process

that continues beyond accreditation notification and helps health departments prepare for

reaccreditation.

The Annual Report must be submitted to PHAB through e-PHAB. Additional guidance, such as

forms, instructions, and staff support will be provided to health departments as they prepare the

Annual

Report.

Process

The Annual Report is due to PHAB on the last day of the calendar year quarter in which the

health department received its most recent accreditation. If the health department needs

additional time, it can request an extension. (See Appendix 2: Extension Policy.)

As part of the Annual Report, health departments are required to report on each of the following if

it applies:

Circumstances that would prevent the health department’s continued

conformity with The Standards;

Progress related to specific measures required by the Accreditation Committee

(as described in the Step 5 section);

Population health outcomes reporting; and

Activities related to continuous improvement as required by PHAB, including

reporting on items identified as part of the Continued Advancement portion of

documentation submission.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB staff will review the Annual Report and may take any or all of the following actions:

Accept the Annual Report and provide feedback to the health department

(feedback will minimally include the specific measures, if any, the health

department is required to continue reporting in the following year);

Engage public health professionals trained and vetted to conduct a review on

behalf of PHAB in reviewing and providing feedback

to the health department;

Refer sections of the Annual report to the Accreditation Committee if the

health department has not demonstrated sufficient progress on measures

required for reporting or has circumstances that may impact the department’s

ability to continue conforming with The Standards

. The Accreditation Committee

may decide to take no action, may ask the health department for additional

information, may require another site visit, or may revoke accreditation.

If a health department does not submit an Annual Report or does not respond to the Committee’s

request for further information,

the Accreditation Committee reviews the health

department’s

accreditation status for a decision concerning the health department’s continued accreditation

status. The Committee may revoke accreditation. If an Annual Report is more than 3 months

past the due date, the health department is referred to the Accreditation Committee for

consideration of revocation of accreditation status.

FOR MORE INFORMATION

For more information on

Annual Reports

, including templates, visit phaboard.org/resources.

Step 7: Reaccreditation

Accreditation status is valid for 5 years from the date that the Accreditation Committee confers

accreditation. To maintain its accreditation status, the health department must apply for

reaccreditation by the deadline. The health department will receive notification from e-PHAB when

the reaccreditation Application is available. Five years after the date of its initial accreditation, the

health department will receive the reaccreditation Application notification via e-PHAB on the

first

calendar day of the calendar year quarter in which PHAB conferred the department’s initial

accreditation. PHAB must receive the Application for reaccreditation from the health department no

later than the

last

calendar day of the calendar year quarter in which the health department

received initial accreditation. (For example, if the health department received initial

accreditation in February 2020, the notification that the reaccreditation Application is available to

the health department will be sent via e-PHAB on January

2025, and the Application will be due

no later than March 31, 2025.)

Health departments applying for subsequent rounds of reaccreditation will follow this same policy.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB

VII.

Appendices

APPENDIX

PROCESS

MAP

7 Step Accreditation Process Initial Accreditation

Key terms: ACM=Accreditation Committee Members; HD=Health Department; SVT=Site Visit Team

PREPARATION

Health Department learns about PHAB.

Health Department creates an account in PHAB’s

electronic systems.

Health Department reviews accreditation education resources.

Health Department attends live learning event (can happen before

or after submitting Readiness Assessment).

Health Department submits Readiness Assessment.

PHAB provides feedback on Readiness Assessment.

Health Department determines whether to apply for accreditation

or Pathways.

Health Department completes required on-demand courses.

APPLICATION

Health Department submits Application.

Within

year of starting

the PHAB Readiness

and Training process

PHAB determines if Application is complete. If not, the Health Department

must resubmit the Application.

DOCUMENTATION

SELECTION

& SUBMISSION

PHAB provides Health Department access to documentation submission

in e-PHAB

Health Department submits

documentation.

Within 1 year of

gaining access in

e-PHAB

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB

SVT

ACM

REVIEW

PHAB conducts Pre-Site Visit Review.

Health Department responds to Pre-site

Visit Review.

Within 45 days

PHAB assigns Site Visitors and schedules the

site visit.

Site Visit Team prepares for site visit.

Health Department and Site Visit Team participate in site visit.

Site Visit Team reopens measures from site visit, as needed.

Health Department submits documentation

for reopened measures from site visit.

Within 2 business days

of end of Site Visit

Site Visit Team finalizes Site Visit Report.

PHAB submits Site Visit Report to Accreditation Committee and

Health Department.

ACCREDITATION

DECISION

Accreditation Committee reviews Site Visit Report and determines if

Health Department is Accredited or if an ACAR is required.

If an ACAR is required, the Health Department

submits ACAR documentation.

Within 1 year

The Site Visit Team reviews documentation and submits the

ACAR Report to the Accreditation Committee for a final decision.

Accreditation Committee determines if Health Department is Accredited

and notifies the Health Department.

REPORTS

Health Department submits four cycles of

Annual Report to PHAB.

Due end of the quarter

each year

Annually, PHAB reviews each Annual Report and accepts it, requires

additional

reporting for the current or future year, or refers the report to

the Accreditation Committee.

REACCREDITATION

PHAB notifies Health Department of reaccreditation eligibility.

SVT

Policy for National Military Installation Department of Public Health Initial Accreditation

APPENDIX

MILITARY INSTALLATION

DEPARTMENT OF PUBLIC HEALTH

EXTENSION

POLICY

Process

If a health department will miss any PHAB deadline, they need to submit a written request for an

extension to their Accreditation Specialist (AS).

If the health department is requesting an extension of

90 days or fewer

it can be submitted via

email. The Health Department Chief/Director must either be the one sending the email or be cc’d

on the email.

If the extension is

greater than 90 days

the health department will need to complete the

application form (posted on the PHAB website) and email it to their Accreditation Specialist.

The Health Department Chief/Director must sign the application to indicate their agreement

with PHAB policies.

If the health department is applying for accreditation or is about to apply for accreditation and

they are requesting a cumulative extension of more than 90 days, there may be additional fees.

Associated fees are handled as part of the DoD contracting process managed by the Defense

Public Health Accreditation Program Management Team. Such extension requests must be

approved by the Defense Public Health Accreditation Program Management Team before being

submitted to PHAB.* Any costs associated with the extension may ultimately be the

responsibility of the requesting health department.

The fees* paid by the Defense Public Health Accreditation Program cover costs associated with maintaining e-

PHAB accounts; providing access to PHAB Accreditation Specialist support, PHAB webinars and educational

offerings; and continuing the accreditation status during the extension timeframe for accredited health

departments. If you have questions about the fees,* please contact the Defense Public Health Accreditation

Program Management Team at dha.apg.pub-health-a.list.ph-improvement-accred[email protected] and PHAB’s

Finance Office at a[email protected] or 703.778.4549 Ext 200.

Health departments can request extensions for accreditation process steps they are currently in or

will begin within 180 days. For a Pre-site Visit Review response, health departments can

request an

extension after their documentation has been submitted. Those extensions will go into effect on

the date the health department receives its reopened measures. Extensions for reaccreditation

Applications will go into effect on the date the Application opens in e-PHAB.

FOR MORE INFORMATION

To access the

extension request

form, visit phaboard.org/resources.

The 90 days addresses the cumulative amount of time the health department is requesting an extension for a given step in the process (e.g.,

application, documentation submission, response to pre-site visit review, ACAR, or Annual Report). In other words, if a health department

already requested and received a 60-day extension for that step in the process, and they would like to request an additional 45-day extension,

the application form is required.

As of this document’s publication, fees to apply for initial accreditation are centrally paid for by the DCPH-A/DHA for Military Installation

Departments of Public Health serving identified Army locations.

phaboard.org/resources

Policy for National Military Installation Department of Public Health Initial Accreditation

APPENDIX 3: ACCREDITATION

APPEALS

PROCEDURES

Approved February 2022

Overview

These procedures specify the appeals process available to health departments once an

accreditation decision has been made. A health department may appeal only the following

accreditation decisions made by the Public Health Accreditation Board (PHAB)’s Accreditation

Committee: (1) denial of initial accreditation; (2) denial of reaccreditation; or (3) revocation of

accredited status.

The grounds for appeal are limited to the following:

(a)

The negative decision was the result of the misapplication of

PHAB’s accreditation procedures or standards; or

(b)

The negative decision is not supported by, and is contrary to, the

substantial evidence in the record.

The accreditation status of the health department shall remain unchanged pending the outcome

of a timely, properly filed appeal. These procedures are a formal, administrative process and are

designed to operate without the assistance of attorneys. However, any party may be represented

by an attorney with respect to an appeals procedure.

Initiating the Appeal

When a denial of accreditation/reaccreditation or a revocation of accreditation is communicated

to the health department as part of a Non-conformity Decision,

the letter of transmittal shall

advise the health department that the decision is appealable, and that the health department has

thirty (30) calendar days

to appeal. The letter of transmittal is both emailed and physically mailed

“receipt requested” to the Health Department Chief/Director. The thirty-day timeline for

responding begins on the date the letter of transmittal is received by the health department. If

the health department fails to initiate its appeal within thirty (30) days, the decision becomes

final and public. If the health department initiates the appeal process within the prescribed thirty

(30) days, the health department’s accreditation status remains as it was prior to the action

taken by the Accreditation Committee that is under appeal, pending disposition of the appeal.

The health department’s appeal must be made in writing and filed both electronically via email and

by physical mail to the attention of the President and Chief Executive Officer of PHAB and a copy

also submitted to the Defense Public Health Accreditation Program Manager. The appeal must

detail the grounds upon which it is based and identify relevant information in the health

department’s records already submitted to PHAB that supports its appeal. The health department

may not rely on any information or documentation unless that information and documentation

was submitted to PHAB as part of its initial accreditation/reaccreditation review or revocation

review, as applicable. No new information or documentation may be submitted through the appeal

process. The health department should include a specific reference to where the information or

documentation was previously provided in the accreditation process or revocation review.

Procedural decisions (i.e., determination of Not Accredited status because a health department failed to complete a step in t he process)

are not subject to appeal.

Unless otherwise specified, all days will be measured in calendar days not business days.

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB

Procedures

Upon receipt of the written appeal, PHAB’s President and CEO will notify the Chair of the PHAB Board

of Directors. Within five (5) business days, the Chair will then appoint an Appeals Panel made up

of three members of the Board, as well as two non-Board members. If the Chair of the PHAB Board

has a relationship with the health department making the appeal that might constitute a real or

perceived conflict of interest as defined by PHAB’s conflict of interest policy, the Chair will present

the potential conflict to the President and CEO who will decide whether a conflict of interest exists.

If the President and CEO determines that the Chair has a real or potential conflict of interest, the

Vice Chair of the PHAB Board of Directors will appoint the Appeals Panel.

Each panel member will be notified by the PHAB President and CEO that they have been appointed

to the Appeals Panel and asked to affirm that they have no conflict of interest with the appellant

health department as defined by the PHAB conflict of interest Policy.

Within five (5) business days of the final composition of the Appeals Panel, the PHAB President and

CEO shall provide the appellant health department with the following information:

•

The written appeals and hearing procedures;

•

The names and bios of the Panel members;

•

A list of at least three (3) potential dates for the appeal hearing that will be

conducted by the panel. The potential hearing dates shall be no fewer than

thirty (30) and no more than ninety (90) days from the date the information

is shared with the appellant health department;

•

The location of the appeals hearing and/or whether it will be conducted by

videoconference (to be determined in the sole discretion of the Appeals

Panel); and

•

Notification of the appeals fee. *

The PHAB President and CEO will request that the appellant health department:

•

Review the list of Appeals Panel members and declare whether the health

department reasonably perceives any conflicts of interest with any member

of the Panel;

•

Identify the names and roles of the health department’s staff who will attend

and participate in the appeals hearing, including whether the department

will be represented by legal counsel; and

•

Identify which of the proposed hearing dates are preferred by the health

department.

The appellant health department shall respond within five (5) business days to the PHAB President

and CEO.

If a conflict of interest is identified by either a member of the Appeals Panel or by the appellant

health department and such determination is reasonable as determined by those members of

the Appeals Panel not identified as having a conflict of interest, the member of the Appeals Panel

so identified will not participate in the appeal process, and a new Appeals Panel member will

be selected by the Chair of the PHAB Board of Directors and reviewed by the appellant health

department in an expeditious manner.

As of this document’s publication, fees to apply for accreditation are centrally paid for by the DCPH-A/DHA for Military Installation

Departments of Public Health serving Army locations.

Policy for National Military Installation Department of Public Health Initial Accreditation

The appellant health department shall pay a reasonable appeals fee as determined by the PHAB

Board of Directors and published in its fee schedule. Payment of half of the fee is expected at the

time the hearing is set, with final payment occurring at the close of the hearing process. The

fees for an appeal are not currently included in the DoD contract and should not be assumed to

be covered by the Defense Public Health Accreditation Program. The appellant health

department must coordinate directly with the Defense Public Health Accreditation Program

Manager to determine if and how appeals fees will be paid. The expense may ultimately be the

responsibility of the appellant health department.

Conducting the Appeal Hearing

The appeal hearing is an administrative hearing and is not conducted as a legal proceeding.

General rules of conduct are as follows:

The hearing shall occur no later than ninety-five (95) days from the Appeals

Panel’s final composition, after conflicts of interest have been addressed.

Notification of the hearing date will be made to all parties concerned at least

thirty (30) days prior to the date of the hearing. The appellant health department

may amend its original written appeal statement submitted when it notified the

PHAB President and CEO of its appeal. If the department elects to provide an

amended statement, it must be provided to the Appeals Panel at least fifteen

(15) business days prior to the appeal hearing.

The health department may request that the record considered by the

Accreditation Committee in reaching its decision be made available. The record

shall include, but is not necessarily limited to:

Accreditation Committee Operational Procedures Manual applicable

at the time the negative decision was made by the Accreditation

Committee;

Standards & Measures applicable at the time the negative decision

was made by the Accreditation Committee;

Excerpts from the minutes of the Accreditation Committee meeting(s)

relevant to the decision being appealed by the health department;

Relevant accreditation reports made by PHAB staff and peer reviewers

and responses to those reports by the health department; and

Relevant written communications to and from PHAB staff and peer

reviewers and the health department regarding the Accreditation

Committee’s review, including any prior decision letters as applicable.

Opportunity to appear before the Appeals Panel will be extended to three

representatives of the health department and its counsel. The health department

will have sixty (60) minutes to orally present its position. Thereafter, the Appeals

Panel will direct questions to and hear responses from the health department.

The health department will also be permitted to make a closing statement. A

written transcript will be made of the hearing.

Policy for National Military Installation Department of Public Health Initial Accreditation

Any additional rules of conduct for the hearing that are established by

the Appeals Panel Chair shall be provided to the health department and, as

appropriate, its counsel at least fifteen (15) business days prior to the appeal

hearing. If the health department has questions about or objects to any

additional rule(s) for the conduct of the hearing, it should make their questions

or objections known to the PHAB President and CEO immediately. The PHAB

President and CEO will seek to clarify and/or resolve all questions or objections

in an expeditious manner before the appeal hearing.

Appeals Panel Processes

As soon as practical after being appointed, the Appeals Panel members

will convene and elect a Chair from among its members. The Appeals Panel

will be staffed by the PHAB President and CEO with additional staff as deemed

appropriate by the President and CEO.

All sessions in which the Appeals Panel meets to organize its work, as well as

all deliberations of the Appeals Panel, will be conducted in executive session.

The Appeals Panel may interview the Site Visit Team Chair, any PHAB staff, or

members of the Accreditation Committee, as they may deem appropriate, to

understand the background and process undertaken that led to the decision of

the Accreditation Committee being appealed.

In reaching its decision, the Appeals Panel will consider the record before

the Accreditation Committee at the time it made its decision to deny or

revoke accredited status as applicable, the health department’s written

appeal statement, information gathered by the Appeals Panel itself, such as

interviews with Accreditation Committee members or PHAB staff members, any

presentation made by the health department at the hearing, and the health

department’s responses to questions asked by the Appeals Panel members

during the hearing.

The Appeals Panel, on a majority vote, either affirms, amends, remands, or

reverses the Accreditation Committee decision being appealed. The Appeals

Panel shall issue a written decision including: a summary of relevant portions of

the Accreditation Committee’s decision; a summary of any relevant procedural

or factual findings made by the Appeals Panel; the Appeals Panel’s rulings and

decisions with respect to the matters under appeal; and the outcome and

resolution of the appeal. This written decision will be provided to the appellant

health department within ten (10) business days of the appeal hearing conducted

by the Appeals Panel.

If the Appeals Panel affirms the decision, the original Accreditation Committee decision becomes

final at that time.

If the Appeals Panel amends, reverses, or remands the decision, it shall provide written direction to

the President and CEO of its recommendations for implementation. PHAB staff will then implement

the Appeals Panel’s decision in a manner consistent with the directions of the Appeals Panel.

Implementation includes the ability to define the length of an accreditation term and any required

reporting or other conditions.

Policy for National Military Installation Department of Public Health Initial Accreditation

In the case of a decision to remand the matter to the Accreditation Committee for reconsideration,

the Appeals Panel will provide written recommendations to the Accreditation Committee and

shall discuss its findings with the Accreditation Committee. The Accreditation Committee shall

review the findings and recommendations of the Appeals Panel and reconsider the Accreditation

Committee’s initial decision taking into account the factors leading to the remand.

PHAB Procedures Post Appeal

The Chair of the Appeals Panel will provide a written and verbal report on the

appeal and its resolution to the Accreditation Committee and to the Board of

Directors at their next, regularly scheduled meetings following the conclusion of

the appeals process.

All decisions of the Appeals Panel are final and binding.

If the Appeals Panel upholds denial of reaccreditation or revocation of

accreditation, the name of the health department will be removed from the

list of accredited health departments and notification of the removal will

appear on PHAB’s website. Additionally, PHAB staff will follow all other standard

communications protocols regarding accreditation decisions, such as

notification to the DoD COR and Defense Public Health Accreditation Program

Manager.

PHAB will not release the details of the appeals hearing and relevant

documentation to any entity other than the appellate health department, unless

legally required.

PHAB reserves the right to utilize de-identified data from an appeal for its

organizational quality improvement purposes.

Policy for National Military Installation Department of Public Health Initial Accreditation

APPENDIX 4: COMPLAINT POLICY

AND

PROCEDURES

Approved February 2022

Background

To maintain the overall credibility of the national public health accreditation process, the Public

Health Accreditation Board (PHAB) uses information from various sources to monitor the sustained

capacity and quality of the health departments that it accredits. Therefore, PHAB has established

policies and procedures for receiving and addressing written complaints about an accredited

health department.

Policy

PHAB accepts only written complaints about an accredited health department that are specific to

a possible lack of conformity with PHAB Standards & Measures under which the health department

was accredited or reaccredited. PHAB does not address complaints or disputes between individuals

and health departments; environmental conditions or hazards; professional licensing or practice;

or any state, local, DoD or Tribal regulations. PHAB does not mediate disputes between the

accredited health department and any party.

Procedures

Complaints must be made by either email or U.S. mail addressed to PHAB’s President & CEO. Before

filing a complaint with PHAB, the person or persons intending to file a complaint (the Complainant)

must use and exhaust the administrative procedures available to them through the accredited

health department. A complaint must be filed in writing on the PHAB complaint form, available

at https://phaboard.org/complaints/. The Complainant must specify the health department (the

Respondent) and the accreditation measure(s) with which the Respondent is purportedly out

of conformity. The Complainant should provide a brief narrative explaining the background and

context of the complaint. In addition to the complaint form and brief narrative, the Complainant

must provide evidence (copies of letters or emails) substantiating that administrative remedies

made available by the Respondent to address complaints have been pursued and exhausted.

Once PHAB receives a properly filed complaint, the following procedures will be followed.

Within five (5) business days, the PHAB President & CEO, or their designated

representative, will respond in writing to the Complainant to acknowledge

receiving the complaint. In the acknowledgement communication, the President

& CEO, or their designated representative, may request more information from

the Complainant; dismiss the complaint as being outside of PHAB’s complaint

policy; or accept the complaint for further review and adjudication.

Within five (5) business days of accepting the complaint for further review

and adjudication, PHAB’s President & CEO, or their designated representative,

will notify in writing the Health Department Chief/Director and the

Accreditation

Coordinator of the Respondent that the Respondent is the subject

of a complaint.

A copy of the complaint and supporting documentation will be

shared with the

Respondent, the

DoD COR, and Defense Public Health

Accreditation Program Manager. The Respondent must respond in writing to the

Policy for National Military Installation Department of Public Health Initial Accreditation

PHAB President & CEO

and address the substance of the complaint within

twenty (20) business days

of receiving notice and a copy of the complaint and

supporting documentation.

Concurrent with notifying the Respondent, the President & CEO, or their

designated representative, will notify the PHAB Board Chair that a complaint has

been received and provide to the Chair a copy of the complaint and supporting

documentation. The Board Chair and the President & CEO will confer and select

up to two (2) additional members of the PHAB Board that have no conflicts of

interest with the Respondent or the Complainant to serve with them as an ad

hoc panel to review the complaint with them.

Within ten (10) business days of the receipt of the health department’s written

response, the Board Chair will convene the ad hoc panel to review the complaint.

The ad hoc panel will review all the materials provided both by the Complainant

and the Respondent and take one or more of the following actions:

•

Dismiss the complaint based on the evidence received. Dismissal will

result in no change to the Respondent’s accreditation status.

•

Determine that further investigation of the complaint is warranted.

If the ad hoc panel makes this determination, trained PHAB peer

reviewers (the Peer Reviewers) who, if possible, have previously

reviewed the Respondent for its initial or reaccreditation application(s)

will be requested to review the Respondent for conformity with the

specific standard(s) and measure(s) cited in the complaint. The Peer

Reviewers will conduct their review in a timely fashion so that it is

completed within sixty (60) days of the ad hoc panel’s request. The

Peer Reviewers will be assisted by PHAB’s Director of Accreditation and

may request additional documentation and/or conduct necessary

interviews with the Respondent’s relevant personnel and/or the

Complainant, either in person or by videoconference, to adequately

assess the Respondent’s conformity with the specific standard(s)

and measure(s) cited in the complaint. The Peer Reviewers will

summarize their findings in a written report to the ad hoc panel and

may be requested to discuss their findings with the ad hoc panel at

the discretion of the PHAB Board Chair and/or President & CEO.

Within five (5) business days of receiving the written report from the Peer

Reviewers, the ad hoc panel will convene and take one of the following actions:

•

Dismiss the complaint based on the evidence received and the peer

review. This will result in no change to the Respondent’s accreditation

status.

•

Conduct additional interviews with the Respondent’s relevant personnel

and/or the Complainant through convening a hearing via video

conference. If the ad hoc panel chooses this option, it must notify the

Complainant and the Respondent of its decision to do so in writing.

Policy for National Military Installation Department of Public Health Initial Accreditation

The ad hoc panel shall explain that the hearing is not an adversarial

proceeding but one that is seeking additional information or

clarification of information received through the Peer Reviewers. The

hearing must be conducted within twenty (20) business days of the

notification being provided to the Complainant and the Respondent.

If the Respondent does not provide a written response (step 2) or participate

in any required further investigation (step 4 or 5), the ad hoc panel will document

the Respondent’s lack of cooperation in its report (step 7). The Respondent may

request an extension of up to fifteen (15) business days from the ad hoc panel

to respond to the ad hoc panel’s request(s) if the Respondent is dealing with

a public health emergency or other significant event outside of its control that

directly impacts its ability to provide a written response to the complaint in a

timely manner. The PHAB Board Chair and/or President & CEO shall grant or deny

the extension request in their sole discretion.

At the conclusion of its fact-finding process (outlined in steps 4 and 5 above),

the ad hoc panel will summarize its findings in a written report along with either

its dismissal of the complaint or its recommendations for further actions. The

report will be addressed to the PHAB Accreditation Committee in a timely fashion

so the Accreditation Committee can deliberate and act on the report at its next

regularly scheduled meeting.

Final Resolution of the Complaint:

The report from the ad hoc panel will be reviewed and deliberated upon by the Accreditation

Committee at its next regularly scheduled meeting. The Accreditation Committee shall be the final

decision-making body for all complaints. Based on the Accreditation Committee’s deliberations,

the following actions may be taken:

Continue the accreditation status of the Respondent without change;

Continue the accreditation status of the Respondent but require the Respondent

in its

next annual report(s) to detail its remediation efforts and compliance with the

specific standard(s) and measure(s) identified by the Accreditation

Committee as

being deficient to maintain the Respondent’s accreditation status,

or, in the case of a

Respondent in its fourth year of an accreditation status, in the Respondent’s

application for reaccreditation;

Place the Respondent on probation for a period not to exceed twelve (12) months

during which time specific follow-up actions, such as regular reporting or a repeat

peer review will be required, and the Respondent’s probationary status will be noted

on the PHAB website during the probationary period; or

Revoke the Respondent’s accreditation.

The Complainant and the Respondent will be advised of the Accreditation Committee’s decision

on the complaint, a summary of the process taken to investigate the complaint, and a summary

of the findings of the investigation within ten (10) business days of the Accreditation Committee’s

decision. No other materials related to the complaint will be provided to the Complainant.

Policy for National Military Installation Department of Public Health Initial Accreditation

All complaints that result in the naming of an ad hoc panel for investigation, and their associated

outcomes, will be reported to the full Board of Directors quarterly.

Complaints, and all associated documentation, will be maintained in PHAB records associated

with the Respondent for the remainder of that Respondent’s accreditation cycle, or no longer than

five years.

PHAB will not publicly release the complaints received nor the results of the complaint assessments

except as they may be compelled to do so by legal process. De-identified complaint data may

be used by PHAB to inform its efforts to improve its services and those of accredited health

departments.

Policy for

National

Military Installation

Department of Public

Health Initial

Accreditation