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P REPARING FOR N ATIONAL A CCREDITATION REVIEW Susan Ramsey, Director Office of Performance and Accountability November 7, 2011.

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Presentation on theme: "P REPARING FOR N ATIONAL A CCREDITATION REVIEW Susan Ramsey, Director Office of Performance and Accountability November 7, 2011."— Presentation transcript:

1 P REPARING FOR N ATIONAL A CCREDITATION REVIEW Susan Ramsey, Director Office of Performance and Accountability November 7, 2011

2 T RAINING A GENDA Topics for today: Overview of the 2011 PHAB version 1.0 Standards How to Interpret the 2011 PHAB version 1.0 Standards and Measures Standards Review Process Organizing for Self-Assessment Mock Review of Selected Standards Pre-requisites: Online Standards Orientation – SmartPH Review 2011 Standards Review Introduction to the Guidelines 2


4 I NTERPRETATION OF PHAB S TANDARDS AND M EASURES Changes from 2010 Beta Test Standards Numbering System (Taxonomy) Scope of Domains Domains/Standards/Measures Quality Improvement Built into Standards 4

5 D EVELOPMENT F RAMEWORK / C ONVENTIONS Structural Taxonomy Example – Measure 5.3.2 S for state health departments Example – Measure 5.3.2 L for local health departments Standards and measures begin with an active verb Focus on core Public Health activities and services, including environmental health 5 Domain1 Standard1.1 Measure1.1.1 Tribal, State, Local or ALL

6 D OMAINS C ROSS ALL P ROGRAMS FamilyPlanningProgram STD andHIV/AIDSPrograms FoodSafetyProgram On-site SepticProgram ImmunizationProgram Communication Domains Use of Quality Improvement Monitor Health Status Programs Community Involvement Health Policy & Plans 6 The 12 Domains apply at the agency level - they cut across programs and activities

7 12 Domains (10 Essential PH Services plus administration & governance) 32 Standards 105 Measures Documentation PHAB S TANDARDS F RAMEWORK 7

8 S COPE OF D OMAIN 1 Domains address specific topics [help avoid redundancy] Domain 1: Health Status and PH Issues data monitoring and reporting Population health data from a variety of sources Current services provided Assessment information on website; press releases, waiting rooms, annual report Samples of emails; SharePoint Sites 4 Standards 8

9 S COPE OF D OMAIN 2 Domain 2: Diagnosis/investigation of health problems and environmental hazards Written protocols that include procedures for conducting investigations of health problems and hazards (Agency CD Plan and Foodborne Outbreak procedures) Completed after action reports of outbreaks which illustrates that the department and its partners have the capacity to conduct investigations for both infectious and non- infectious diseases 4 Standards 9

10 S COPE OF D OMAIN 3 Domain 3: Provide Health Education/Promotion and Communicate PH functions Public presentations/press releases/brochures/flyers/pubic service announcements to promote role of PH and related messages Evidence that target population helped frame message Evidence of unified messaging with community partners Media plan (risk communication plan) 2 Standards 10

11 S COPE OF D OMAIN 4 Domain 4: Engage the Community to Identify & Address Health Problems Current collaborations – Family planning advisory councils – Great Start collaboratives, Flu coalitions, Child-death review teams Does not have to be agency facilitated, but agency must actively participate Engage the community on policy development to promote public health 2 Standards 11

12 S COPE OF D OMAIN 5 Domain 5: Develop & Implement PH Policies and Plans Conduct a process to develop a community/state health improvement plan Maintaining an all-hazards emergency operations plan 4 Standards 12

13 S COPE OF D OMAIN 6 Domain 6: Education and Enforcement of PH Laws Review of public health laws Document how staff have been trained in laws to support public health laws Conduct and monitor enforcement activities Follow up on complaints Food service hearings/compliance plans 3 Standards 13

14 S COPE OF D OMAIN 7 Domain 7: Assess Healthcare Capacity & Access & Implement Strategies to Address Gaps Convene and/or participate in a collaborative process to assess availability of health care services – Provide description of partnership Convene and/or participate in a collaborative process to establish strategies to improve access to health care services 2 Standards 14

15 S COPE OF D OMAIN 8 Domain 8: Competent PH Workforce & Assess Staff Competency & Address Gaps Document relationships that promotes public health as a career Health department workforce development plan Nationally adopted core competencies Curricula and training schedules 2 Standards 15

16 S COPE OF D OMAIN 9 Domain 9: Program Evaluation & Quality Improvement Plans and activities Evidence of maintaining an agency performance management system Evidence of a written quality improvement plan 2 Standards 16

17 S COPE OF D OMAIN 10 Domain 10: Identify and Use Evidence-based practices and Use of Research Demonstrate and document examples of using evidence-based or promising practices Documentation of availability of expertise (internal or external) for analysis of research 2 Standards 17

18 S COPE OF D OMAIN 11 Domain 11: Operational Infrastructure - IT and Human Resource and Finance Written operational policies – accessible to the staff Organizational chart Regular reviews and updating Audited financial statements Program reports/MOU’s 2 Standards 18

19 S COPE OF D OMAIN 12 Domain 12: Engaging the Public Health Governing Entity Documentation of the statutes, rules, regs. and ordinances for mandated services which gives public health the authority to conduct the programs Examples of communication with governing entity regarding public health issues and/or actions of the health department 3 Standards 19

20 QI IS B UILT INTO THE S TANDARDS : P LAN -D O -S TUDY -A CT -S TANDARD 9.1 20 Plan Act Do Study 9.1.1 : Engage staff at all organizational levels in establishing or updating a performance management system 9.1.3: Use a process to determine and report on achievement of goals, objectives, and measures 9.1.2: Implement a performance management system – self-assessment, committee or team Conduct specific program activities that contribute to achieving goals and performance measures.

21 QI IS B UILT INTO THE S TANDARDS : P LAN -D O -S TUDY -A CT -S TANDARD 9.2 21 Plan Act Do Study 9.2.1: Establish a quality improvement program based on organizational policies and direction 9.2.2: Demonstrate staff participation in quality improvement activities based on the QI plan 9.2.2: Documentation of quality improvement activities based on the QI plan 9.2.2: Implement QI efforts


23 G UIDE T O A CCREDITATION : 23 The 2011 Guide provides seven steps to national public health accreditation process: 1.Pre-application Applicant prepares and assesses readiness checklists, views online orientation to accreditation, and formally informs PHAB of its intent to apply 2.Application Applicant submits application form with pre-requisites, and first fee payment. Applicant attends in-person training (included in fees) 3.Documentation Selection and Submission Applicant selects documentation and submits it to PHAB for review 4.Site Visit Site visit is conducted by a team of peers and report developed 5.Accreditation Decision PHAB board will award accreditation status for 5 years 6.Reports Accredited health department submits annual reports 7.Reaccreditation (5 years later) Accredited health department applies for reaccreditation

24 M AJOR C HANGES IN T HE G UIDE 24 Sequence for in-person training changed Process is paperless Four readiness checklists Statement of Intent Time Frame Waived Application shortened Site visit report changed Scoring scale changed Reports post accreditation changed Appeals procedure included

25 P RE -R EQUISITES 25 Submitted with the application Reviewed by PHAB staff for completeness but not quality and content Reviewed for quality and content by site reviewers Criteria included in Domains 1 and 5

26 G UIDANCE P ROVIDED IN S TANDARDS AND M EASURES 26 The 2011 Guide provides seven steps to national public health accreditation process: Statement of the Standard and individual measure Specific applicability for each measure, Interpretation and explanations of the requirements for each measure Additional examples of documentation for the measure Timeframes stated as part of the explanation of the requirements, and Crosswalk to the 2007 Washington Standards with reference to the Exemplary Practice documentation in each measure

27 U SING THE S TANDARDS AND M EASURES FOR I NTERPRETATION 1. Read the statement of the Standard and of the specific measure 2. Read the “Purpose” of the measure 3. Review the “Significance” 4. Read the specifics in “Required Documentation” 5. If specific documentation is required, read each requirement carefully. You will need to validate that each of these requirements are present in the documentation to score the measure as “Demonstrates” 6. The “Guidance” section provides guidance specific to the required documentation. It states if the documentation is department-wide or if a selection of program’s documentation is required 27

28 What you must submit for proof Guidance specific to the required documentation States if the documentation is department-wide or if a selection of programs’ documentation is required Purpose: describes the public health capacity or activity in which the health department is being assessed Domain Measure Numbers Standard Describes the necessity for the capacity of activity 28

29 Read the requirements then look at the next slide – does the document meet the measure? 29

30 U SING THE PHAB A CRONYMS AND G LOSSARY 1. Review the PHAB Acronyms and Glossary to clarify definition of terms and how they are used in the Standards 2. Glossary contains a list of acronyms used in the Standards 3. Offers assistance in understanding the Standards and Measures 30

31 T YPES OF D OCUMENTATION TO D EMONSTRATE P ERFORMANCE : Written descriptions of process, such as policies and procedures, protocols, EPRP, manuals, flowcharts, logic models or other documentation. Reports, such as health data summaries, survey data summaries, data analysis, audit results, meeting agendas, committee minutes and packets, after-action evaluations, CE tracking reports, work plans, financial reports, QI reports or other documentation. Materials, such as email, memorandum, letters, dated distribution lists, phone books, health alerts, Fax, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website screen prints, news releases, newsletters, posters, contracts or other documentation. 31

32 D OCUMENTATION R EQUIREMENTS No “wet ink” - documents must be in use, not designed only for the review Documents must show their effective date No draft documents will be allowed If no specific timeframe is cited, all documentation should be from the last five years

33 D OCUMENTATION IN D AILY W ORK Build documentation into regular processes: Use summary formats for regular reporting Minutes of working committees Case write-ups, logs, and progress reports Emphasize conclusions, actions and results 33

34 D OCUMENTATION T IMEFRAMES Some measures state a specific timeframe for the documentation, defined below: Annual - within the last 14 months dating back from 10-10 Current - within the last 24 months prior to 12-09 Biennial - within each 24 month period, at the least, previous to 12-09 Regular – within a pre-established schedule as determined by the health department Continuing – activities that have existed for some time, are currently in existence and will remain in the future 34

35 S CORING Not demonstrated Documentation does not provide evidence that the measure is met or documentation is missing. Slightly Demonstrated Documentation is not provided for one or more of multiple documentation items that are required for a measure, or the department does not meet the measure in one or more areas of the department, or the department provides partial evidence. Largely Demonstrated Fully Demonstrated Documentation is complete and provides evidence that the measure is met. 35




39 S TANDARDS R EVIEW P ROCESS Determine scope of review: required measures Review assignments for Other Program for the program review measures Required to submit all documentation November 1, 2011 Documentation mock review conducted November 7 & 8, 2011 After mock review, reviewers to follow-up with programs for more documentation if review score is not Demonstrates 39

40 T ELL Y OUR S TORY …. Reviewers may not be familiar with your department Provide a short summary or note that describes your processes for the topic being addressed – “Read Me” file Be laser-focused on the specific requirement of that measure Provide only the documentation that is needed to demonstrate performance. More is not better! 40

41 O RGANIZING Y OUR D OCUMENTS Collect and organize all documents for reviewers to review Online document library with folders for each standard and measure Mind Manager submittal tabled for this year State page number (or highlight with text box) where specific information addressing the measure is located if document more than 3 pages long Can use same document for multiple measures--- just indicate all measures that are relevant and page of document 41

42 M ORE D OCUMENTS I S NOT B ETTER !! Be compulsively attentive, “ laser focused” on the specific language used to describe what will meet their requirements Watch “and” vs. “or” language in the required documentation language A single document may serve more than one measure, and conversely, it may take more than one document to prove a measure. Only show what is needed and no more

43 L ABELING & M ARKING D OCUMENTS There must be a title and date on each document Highlight the title and date in yellow Unless it is a brief document and the proof is very obvious, highlight the text that proves the measure. If you are using a hyperlink to our web site for proof, paste it into a Word document and describe it briefly.




47 M OCK R EVIEW I NSTRUCTIONS Teams of 2 people Review Scoring Sheets Individually read each Standard and then the measure that you will be scoring. Identify if there is “Required Documentation” for the measure Determine timeframe for the documentation for the measure Identify if the measure is a “health department level” or “sample of programs” Read documentation and come to consensus on the score for the measure 47

48 M OCK R EVIEW A SSIGNMENTS REVIEWERSDOMAINSNUMBER OF MEASURES Megan Davis Deborah Todd Terry Taylor 1, 2, 639 Diana Ehri Michele Maddox 3, 4, 5, 932 Susan Ramsey Amy Ferris 7, 8, 10, 11, 1234 48


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