Presentation on theme: "Public Health Department Accreditation: An Overview Robin Wilcox Chief Program Officer Public Health Accreditation Board August 1, 2012 County Health Executives."— Presentation transcript:
Public Health Department Accreditation: An Overview Robin Wilcox Chief Program Officer Public Health Accreditation Board August 1, 2012 County Health Executives Association of California
Public Health Accreditation
National Public Health Department 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. A platform for continuous quality improvement. The continual development, refinement, and distribution of standards and measures.
PHAB’s Vision 4
Goal of Public Health Department Accreditation The goal of the national public health department accreditation is to improve and protect the health of the public by advancing the continuous quality and performance improvement of state, local, tribal and territorial public health departments.
Public Health Accreditation Board (PHAB)
PHAB is the non-profit public health department accreditation organization founded in PHAB is funded by the Robert Wood Johnson Foundation (RWJF) and by the Centers for Disease Control and Prevention (CDC) but also has accreditation fees associated with the application.. PHAB’s governance structure is a board of directors composed of public health leaders from Tribal, state and local health departments and academia.
PHAB Accreditation Themes Quality Improvement Planning Partnerships Community Engagement Leadership and Governance Customer / Community Focus
Standards and Measures Version 1.0
Principles of Standards and Measures Advance the collective public health practice Moderate level: not minimum, not maximum Be simple, reduce redundancy, minimize burden Apply to all sizes of HDs and all forms of governance structure Establish same standards for Tribal, state and local health departments Build quality improvement into standards
PHAB Domains of Standards Standards Grouped by the Core Functions of Public Health & Ten Essential Public Health Services
Twelve Domains 1.Conduct assessments focused on population health status and health issues facing the community 2.Investigate health problems and environmental public health hazards to protect the community 3.Inform and educate about public health issues and functions 4.Engage with the community to identify and solve health problems 5.Develop public health policies and plans 6.Enforce public health laws and regulations 7.Promote strategies to improve access to healthcare services 8.Maintain a competent public health workforce 9.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
Domains Cross All Programs # 8 Public Health Workforce Family PlanningProgram STD Programs EnvironmentalPH Program MCH Program ImmunizationProgram Sample Domains # 9 Quality Improvement # 3 Educate the Public Programs # 4 Community Engagement# 5 Policy & Plans
Structural Framework Domain Standard Measure Documentation Guidance
The PHAB Accreditation Process
. PHAB’s Electronic Information System Multiple users, different views o Tracks transactions in process o HD SOI and applications o Health departments upload documentation o Site visitors review documentation o Site visitors develop Site Visit Report o Accreditation Committee reviews SVR o Accreditation Committee records decision
Health Department Appoint an Accreditation Coordinator Establish an Accreditation Team Establish a process to select the best documentation for each of PHAB’s measures and requirements for documentation Outreach and involve staff department- wide and partners
Seven Steps 1. Pre-application Applicant prepares and assesses readiness, informs PHAB of its intent to apply (SOI) 2. Application Applicant submits application and pre-requisites and receives training 3. Documentation Selection and Submission Applicant gathers and submits documentation 4. Site Visit Documentation review, site visit and site visit report 5. Accreditation Decisions PHAB Accreditation Committee determines accreditation status: Accredited (5 years) or Not Accredited 6. Reports Annual progress reports 7. Reaccreditation
1. Pre-app: Statement of Intent Submit prior to application Online Designate Accreditation Coordinator Does not commit the health department to applying Submit anytime after online orientation is completed
2. Application Completed online Three prerequisites Letter of support Electronic signature Eligibility to apply Completeness review Forward invoice Applicant training
Three Prerequisites Community Health Assessment Community Health Improvement Plan Health Department Strategic Plan
2. Applicant Training Required for each applicant health department Accreditation Coordinator Another representative at the health department’s cost Must be completed prior to upload of documentation
Accreditation Specialists Each health department is assigned a PHAB Accreditation Specialist –Support HD as they upload documentation –Completeness Review –Communication link between HDs and SVs prior to site visit Questions on documentation Agenda –Attend site visit –Receives the Site Visit Report
3. Documentation Selection and Submission 12 months to complete the upload When finished, PHAB will conduct a completeness review Checks that documentation is complete Does not check for conformity with the Standards and Measures PHAB staff will follow-up for missing documentation
3. Documentation Selection Consider variety of options and programs: Best reflects health department operation Meets specifics of the Required Documentation Demonstrates conformity with measure (Context and intent of M & S) Changes may be made until final submission
4. Site Visit After pre-site visit review of documentation Usually 2 day visit Interview staff; verify documentation implementation Meet with community partners and governance May ask for additional documentation Visual observations
4. Site Visitors Peer reviewers Matched to HD Trained by PHAB 3 or 4 team members Conflicts of interest determined
4. Site Visit Report Submitted online Due 2 weeks after completion of site visit Health department will review and may submit any information to correct a factual error
Final Process Steps 5.Accreditation Decision is by the Board’s Accreditation Committee 6.Annual Reports must be provided each year during your accreditation 7.Reaccreditation will occur after 5 years and advanced notice will be sent by PHAB
Multijurisdictional Applications Apply as a single entity o Two or more HDs o PHAB will accredit each HD o All HDs or none accredited o PHAB can limit number of HDs One lead HD One lead AC Geographically contiguous preferred Shared documentation assessed once
Multijurisdictional Applications Established & defined working relationship –MOU –Deliver services/perform functions over combined jurisdiction High degree of interdependence –Each HD could not fulfill role –Half of Domains, majority of Measures
What can you do NOW to begin to prepare?
Readiness Checklists Assists with health department preparation for accreditation Optional, but recommended prior to submitting a Statement of Intent The checklists are not submitted to PHAB
Three Prerequisites Community Health Assessment Standard 1.1 Community Health Improvement Plan Standard 5.2 Health Department Strategic Plan Standard 5.3 Submitted with the application for accreditation Criteria included in Domains 1 and 5 One page “tip sheet” on prerequisites available
Health Department Appoint an Accreditation Coordinator Establish an Accreditation Team Review your documentation for each of PHAB’s measures and requirements for documentation Outreach and involve staff department- wide and partners
Dates and Signatures Review your HD’s: Policies Procedures Plans Directives Public Information Etc. Dates: Created date Revised date Reviewed date Amended date Effective period Signatures: (Evidence of “authenticity”) HD logo HD Director signature HD Abbreviation
Online Orientation 4 Modules –Introduction –Process –Accreditation Coordinator –Standards and Measures 2 hours –About 30 minutes each
Fees Support Assigned Accreditation Specialist In-person training for the HD’s AC Subscription to e-PHAB Easier & cost effective to participate Peer review and Site Visit Site Visit Report with identified opportunities for improvement and areas of excellence Annual QI guidance
Costs of Seeking Accreditation The cost of doing business The cost of CQI – doing better things better The cost of planning and prioritizing The cost of team building and strategic alignment of staff The cost of building partnerships and sharing responsibilities with others in the public health system & community The cost of maintaining a good working relationship with governing entity.
Benefits of Accreditation Recognition and credibility Identifies successes and opportunities for improvement Access to public health experts Platform for culture of continuous quality improvement Means for accountability Energizes the staff Increases the understanding of public health Improves communication with governance Initiates and advances partnerships and community involvement Encourages linkages among levels of health departments
Beta Test Feedback “...had a positive effect on those staff involved by providing opportunities to learn about the department in-depth and how much we do for the people who live and visit our state.” Beta Test Health Department
Beta Test Feedback “The standards and measures can be viewed as an operating manual on how to run a good health department. The basics and fundamentals in management are there, so as new leaders come in they don’t have to reinvent the wheel—the standards and measures can provide a consistent roadmap.” Beta Test Health Department
Technical Assistance PHAB Accreditation Process, Standards and Measures Interpretation, e-PHAB, fees, and accreditation requirements NACCHO, PHF, PH Institutes, each other Preparation of processes, programs, interventions, materials, and documents
PHAB Accreditation Support Materials x
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