Public Health Accreditation

PublicHealth

Accreditation

NewHealthOfficerOrientation

November8,2017

Objectives

Describethepublichealthagencyaccreditation

process.

DescribethePublicHealthAccreditationBoard

(PHAB)standards.

DescribetherelationshipbetweenDHS140Review

andthepublichealthagencyaccreditationprocess.

NavigatetheLocalHealthDepartmentChecklist.

Integrateperformancemanagementandquality

improvementintoaccreditationplanning

SettingtheFoundation

CoreFunctionsandEssentialServices

HealthiestWisconsin2020

By2020,allWisconsinhealthdepartmentswillbe

accreditedusinganestablishedstandard.

Proportionoflocalhealthdepartmentsandtribal

healthunitsthathavemeteitherPublicHealth

AccreditationBoardorstate‐adoptedaccreditation

standards.

AccreditationoftheWisconsinDivisionofPublic

HealthusingeitherPublicHealthAccreditationBoard

orstate‐adoptedaccreditationst andards.

PublicHealthAccreditationBoard(PHAB)

PHAB is a non-profit, voluntary accreditation

organization founded in 2007 whose goal is

to advance public health performance by

providing a national framework of

accreditation standards for tribal, state, local,

and territorial health departments.

Located in Alexandria, VA, PHAB is the national

organization charged with administering the public

health accreditation program.

PHAB’sFounders&Partners

WhatisVoluntaryPublicHealth

Accreditation?

Themeasurementofhealthdepartment

performanceagainstasetofnationallyrecognized,

practice‐focusedandevidenced‐basedstandards.

Theissuanceofrecognitionofachievementof

accreditationwithinaspecifiedtimeframebya

nationallyrecognizedentity.

Thecontinualdevelopment,revision,and

distributionofpublichealthstandards.

Whatisthegoal ofVoluntary

Accreditation?

Thegoalofanationalpublichealthdepartment

accreditationistoimproveandprotectthehealth

ofthepublicby…

advancingthequalityand

performance

….oftribal,state,local,andterritorialpublichealth

departments.

ImportanceofAccreditation

Accreditationcanhelpyourhealthdepartment:

 identifysuccessesandopportunitiesforimprovement

usingastandardofmeasure

 promotequalityimprovementinitiatives

 energizetheworkforceanddevelopastrongteam

 Initiatesandimprovespartnerships

 focusthehealthdepartmentoncommongoals

 evaluateyourhealthdepartment’sperformance

 alignyourresourceswithyourstrategicobjectives

 deliverresultsandoutcomesthatimprovethehealthof

yourcommunity

BenefitsofAccreditation

Nationalrecognitionforpublichealthpractice

• Increasedcredibilitytoresidentsandgoverningbody

• Increasedvisibilityandaccountability

Increasestheunderstandingofpublichealth

• Workforceengagementanddevelopment

• Accesstoanetworkofpublichealthexperts

Potentialaccesstonewfundsorpriorityforfunding

Potentialstreamlinedreporting

Opportunitytoleavethehealthdepartmentand

communitybetterthanyoufoundit!

QuickRealityCheck…..

Process takes time, leadership, and money.

Support of the Health Department Board and

Leadership

Involvement of staff throughout the department

After the first official notice from PHAB to “start” –

typically at least a year

If accredited – Annual reports to PHAB and until

5 years until next full process repeated

Every year Health Department responsible

for ongoing QI work post accreditation

ThePHABAccreditationProcess

SevenStepsintheAccreditation

Process

Pre‐Application

Application

DocumentSelectionandSubmission

SiteVisit

AccreditationDecision

Reports

Reaccreditation(5years)



AllapplicantHealthDepartmentsmustdesignatean

AccreditationCoordinator.



TheCoordinatorcannotbetheHealthDirector.



TheCoordinatormusthavethesupportofHealth

DepartmentLeadershipandst aff.



AnAccreditationTeamisstronglyrecommendedto

assisttheAccreditationCoordinatorinhis/herduties.

AccreditationCoordinator

StepsinAccreditationProcess

Step1–Pre‐application Step2– Application

DetermineEligibility

ReadinessChecklists

OnlineOrientation

StatementofIntent(SOI)

Completedonline

Threeprerequisites

documents

Letterofsupportfrom

governingbody

Electronicsignature

Eligibilitytoapply

Completenessreview

Applicanttraining

TheThreePrerequisites

O CommunityHealthAssessment

O HealthImprovementPlan

O DepartmentStrategicPlan

Doyouknowifthesearedoneinyouragency?

Aretheystrongandwell‐useddocuments?

Whatcanyoudotofocusonthese?

Whyarethesedocumentsimportantevenifyou

don’tcareaboutaccreditation?

AccreditationFees

Installment payment plans are available.

Health Department Category

Initial Accreditation Review

Fee

Effective 7/1/16-6/30/18

Annual Accreditation

Services Fee

Effective 7/1/16-6/30/18

Category1

HealthDepartmentswith

populationsof100,000 orfewer

$14,000 $5,600

Category2

HealthDepartmentswith

populationsgreater than100,000to

500,000

$21,000 $8,400

Category3

HealthDepartmentswith

populationsgreater than500,000to

1,000,000

$28,000 $11,200

Category4

HealthDepartmentswith

populationsgreater than1,000,000

to5,000,000

$35,000 $14,000

Category5

HealthDepartmentswith

populationsgreater than5,000,000

$56,000 $22,400

Whatdothefeescover?

O Anassignedaccreditationspecialist

O TheSiteVisit

O Applicanttraining

O Accesstothee‐PHABinformationsystem

O Anetworkofaccreditedhealthdepartments

O Annualsupport

Step3– Documentation

Mustbecompletewithin12months

UseguidanceintheStandards&Measures

document

Allstaffshouldplayarole

PHABconductsareview

Step4–SiteVisit

O Conductedbytrainedpeerreviewers

O Team sof3to4withateamchairwhowillmanage

thesitevisit

O Sitevisitscheduledatapracticalandagreedupon

time

O Lasts2‐3dayswithasetagenda

O Reportdue2weeksaftervisit

Step5– AccreditationDecision

O Writtennotificationtohealthdepartment

O Twopossibledecisions

•

Accredited

•

Notaccredited

O Accreditationlasts5years

O Ifnotaccredited,AccreditationActionPlandue

within90days–thismayeventuallyleadto

accreditation

Step6– Reports Step7– Reaccreditation

Substantialchanges

•

Leadershipchanges

•

Otherchangesthat

affectabilityto

conformtothe

standards

ListshowOpportunities

forImprovementare

beingaddressed

Advancenotice

Mustcompletethefull

accreditationprocess

Mayuseprevious

documentationwith

appropriaterevisions

Willloseaccreditation

statusifnoapplication

hasbeensubmitted

priortoexpirationdate

TheStandards&Measures–

Newlyrevised!

FrameworkoftheStandards

12 Domains

(10 Essential PH Services plus administration & governance)

O Standards

O Measures

O Documentation

TwelveDomains

Conductassessments focusedonpopulationhealth

statusandhealthissuesfacingthecommunity

Investigate healthproblemsandenvironmentalpublic

healthhazardstoprotectthecommunity

Informandeducateaboutpublichealthissuesand

functions

Engagewiththecommunitytoidentifyandsolvehealth

problems

Developpublichealthpoliciesandplans

Enforce publichealthlawsandregulations

TwelveDomains(cont’d)

Promotestrategiestoimproveaccesstohealthcareservices

Maintainacompetentpublichealthworkforce

Evaluateandcontinuouslyimprove processes,programs,

andinterventions

10.

Contributetoandapplytheevidencebase ofpublichealth

11.

Maintainadministrativeandmanagementcapacity

12.

Buildastrongandeffectiverelationshipwithgoverning

entity

SampleStandard

Self‐AssessmentExercise

Do–Pair‐ Share

Reviewthetoolindividually–reflectonyour

agency

Picksomeoftheitemsthatyouknowthe

answerandyouknowyoudoit/haveitatyour

agency.Picksomeitemsthatyouhavenoclue

aboutoryouknowyoudon’tcurrentlyhave/do.

Talktoapartneraboutthese

Sharewithlargegroup

DHS140– WisconsinProcess

RequirementsforallLHDstomeetstatestatuteand

administrativerulesasrequiredinWI.

StatedetermineslocalhealthdepartmentasaLevelI,II,III

UsesDHSelectronicsystemsforevidencecollection.

Every5yearprocess

ToolorganizedbyEssentialPublicHealthService.

IdentifiesstatuteandrulesaddressedbyPHABaccreditation.

ProvidesmethodforPHABaccreditedagenciestoaddress

aboutone‐thirdofevidencerequeststhroughsubmissionof

theirPHABaccreditationreport.

PS….thisoneisNOTvoluntary!!!!

PHABand140

In2013‐2014theStateOPPAteamcomparedWisconsin

StatutesandRulestoPHABDomainsandStandardsto

identify:

EvidencerequestedbybothPHABaccreditationand

theDHS140Review.

EvidencerequestedbytheDHS140Reviewonly.

ThePHABDomainmostcloselyrelatedtoeach

statuteandrulereference.

New140processincorporatesthisintotools.Localsthat

areaccreditedbyPHABhavetoprovideabout2/3rdsof

therequireddocumentsthatnon‐accreditedhealth

departmentshavetoprovide.

DHS140–PHABCrosswalk:

TheEvidence

140Review

Only:

• BOHComposition

• RecordsRetention

• Beach Closures

• DiseaseManual

• CDReporting

• AnnualReport

• HORequirements

• PHNursingProgram

• TBIsolation

• Screening&FollowUp

• OperatingBudget

AccreditationOnly:

• Domain4– Community

Engagement

• Domain9– Quality

Improvement

140&Accreditation:

• BOHEngagement

• CHA

• CHIP

• InformingPublic/Elected

Officials

• CDOutbreakResponse

• CD&InjuryPrevention

• Confidentiality

• PublicHealthPolicy

• HHHOrdinance

BiggiesformostHealth

DepartmentsinWI

Havingthingsinwriting–ifyoudon’thaveit

documentedithasn’thappened

HavingaPerformanceManagementPlan–

thisisorganizationalperformance

HavingaQIculture

Source: Turning Point. From Silos to Systems: Using Performance Management to Improve the Public’s Health, 2003.

RoadmaptoanOrganizational

CultureofQI

1. NO KNOWLEDGE OF QI

2. NOT INVOLVED IN QI

ACTIVITIES

EXITS 1-2

4. SOME FORMAL QI

ACTIVITIES

5. FORMAL AGENCY-

WIDE QI

EXITS 4-5

3. INFORMAL OR AD HOC QI

ACTIVITIES

EXIT 3

6. QI CULTURE

EXIT 6

Source:NACCHOQILearningCommunity

WhatDoesQualityImprovementHaveTo

DoWithAccreditation?

O Qualityimprovementisthebackbone

ofaccreditation

O Qualityimprovementbecomespartof

whatweashealthprofessionalsdo

everyday

O Accreditationisreallyjustonebig

qualityimprovementproject!

ConnectingtheDotsusingStateResources

RegionalOfficeTechnicalassistance

WALHDAB

IWHI

PreventionBlockGrant

Peersthathavemadethejourney!

Trainedsitevisitors

Other………

Graphic from http://4.bp.blogspot.c om/-Vxaoonk8uNQ/UZ4K9x9_yjI/AAAAAAAAANA/ukwcXCyDqHs/ Accessed 11/12/13

PHABResources

www.phaboard.org:Includestheseandmanymoredocuments

•

9 Things Every Health Department Should Know About Public Health

Department Accreditation

•

National Public Health Department Accreditation Readiness Checklists

•

e-PHAB Statement of Intent Information

•

e-PHAB Application Information

•

Considerations for Selecting an Accreditation Coordinator

•

National Public Health Department Accreditation Prerequisites

•

PHAB Accreditation Coordinator Handbook

•

PHAB Acronyms and Glossary of Terms Version 1.5

•

PHAB Presentation for Health Departments

•

Standards & Measures Version 1.5, an Overview

•

Do’s & Don’ts for Preparing Documentation

•

PHAB Standards and Measures Version 1.5 Documentation Selection

Spreadsheet

•

Accepted Program Areas for PHAB Documentation

•

e-PHAB Documentation Submission FAQ

•

Preparing Documentation

TechnicalAssistanceand

OtherResources

O AssociationofStateandTerritorialHealthOfficials

(ASTHO): www.astho.org

O DivisionofPublicHealth(DPH):

www.dhs.wisconsin.gov/r_counties/VoluntaryAccreditation

O InstituteforWisconsin’sHealth,Inc.(IWHI):

www.instituteforwihealth.org

O NationalAssociationofCountyandCityHealthOfficials

(NACCHO): www.naccho.org

O NationalAssociationofLocalBoardsofHealth

(NALBOH): www.nalboh.org

TechnicalAssistanceand

OtherResources(cont’d)

NationalIndianHealthBoard(NIHB): www.nihb.org

NationalNetworkofPublicHealthInstitutes

(NNPHI): www.nnphi.org

PublicHealthAccreditationWisconsin:

https://sites.google.com/a/phawisconsin.com/login

PublicHealthFoundation(PHF): www.phf.org

THANKYOU!

FORADDITIONALQUESTIONSOR

INFORMATION:

LieskeGiese

CindyJohnson