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WELCOME Tribal Accreditation Readiness: Self-Assessment Tool June 12, 2013 Support for this project was provided by a grant from the Robert Wood Johnson.

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Presentation on theme: "WELCOME Tribal Accreditation Readiness: Self-Assessment Tool June 12, 2013 Support for this project was provided by a grant from the Robert Wood Johnson."— Presentation transcript:

1 WELCOME Tribal Accreditation Readiness: Self-Assessment Tool June 12, 2013 Support for this project was provided by a grant from the Robert Wood Johnson Foundation

2 TARGET Project: Tribal Accreditation Readiness through Guidance, Education and Technical Assistance Red Star Innovations Inter Tribal Council of Arizona, Inc. California Rural Indian Health Board Tribal Epidemiology Center Institute for Wisconsin’s Health, Inc. Support for this project was provided by a grant from the Robert Wood Johnson Foundation

3 Objectives By the end of the presentation, participants will: Have a basic understanding of accreditation and its benefits Learn an approach to the self-assessment process using a tool based on the Tribal standards Learn how the tool was used in two Tribal communities

4 Recommendations Familiar with public health accreditation – Eligibility requirements – Accreditation Process – PHAB standards and measures If accreditation is new, we recommend you view the PHAB Online Orientation in addition to this webinar at This webinar will be recorded and available online at

5 Overview Overview of public health accreditation, benefits and readiness activities Introduce the self-assessment tool Share an approach to planning, preparing and organizing for self-assessments Discuss ways to use self-assessment results

6 Public Health

7 What is Public Health Accreditation? Measurement of Tribal, state and local health department performance based on a set of national standards Issuance of recognition of achievement by a nationally recognized entity Supports continuous quality improvement in public health performance

8 Public Health Accreditation Board PHAB: Non-profit, non-governmental organization dedicated to advancing continuous quality improvement of Tribal, state, local and territorial public health departments. Accrediting body for national public health accreditation. Vision: a high performing governmental public health system that will make us a healthier nation.

9 Benefits and Opportunities Strengthen self-determination Identify and act upon improvement opportunities High performance and quality improvement Strengthen leadership and employee performance Build stronger partnerships and increase communication and collaboration Recognition, validation and accountability Potential increased access to resources It’s about communities

10 Accreditation Preparation Organizational Readiness Public Health Performance Three Prerequisites For more information about preparation activities see PHAB Readiness Checklists at

11 Self Assessment: Planning Preparation Process

12 TRIBAL PUBLIC HEALTH SYSTEMS Community Health Tribal Government Tribal Health Dept. Federal agencies Private Industry Local/ State Health Dept. Tribal Colleges Community ITCs/Tribal EpiCenters

13 The Essential Public Health Services 1.Monitor health status 2.Diagnose and investigate health problems 3.Inform, educate and empower people 4.Mobilize communities to address health problems 5.Develop policies and plans 6.Enforce laws and regulations 7.Link people to needed health services 8.Assure a competent workforce 9.Evaluate health services 10.Conduct research for new innovations

14 10 Essential Public Health Services (

15 Tribal Public Health Infrastructure Community Health Tribal Gov Tribal Health Dept/Clini c Federal agencies Private Industry Local/ State Health Depart Tribal Colleges Communi ty Leaders ITC’s/Epi Centers

16 PHAB Standards and Measures version 1.0 12 Domains Each domain represents functions of the 10 Essential Public Health Services and Core Functions ( – Plus Administration and Governance Each domain has a set of standards; each standard a set of measures Required documentation for each measure

17 Domain Standards Measures Required documentation

18 Self-Assessment Workbook Created by the Institute for Wisconsin’s Health through Wisconsin’s Public Health Quality Initiative

19 History of Workbook Adapted scoring system used in NACCHO’s Local Health Department Self-Assessment Tool Used PHAB Beta standards initially Users recommended – As initial scan & discussion opportunity – Creating new version for PHAB Version 1.0 PHAB 1.0 LHD and THD completed 2011

20 Features of Workbook Excel file that incorporates PHAB Standards and Measures Version 1.0 Starting point for rating capacity by measure Encourages collaborative process Provides illustration of strengths and areas for improvement by domain Tool for priority setting and quality improvement to prepare for accreditation


22 Preliminary Review Identify possible documentation sources Identify other staff and stakeholders to help identify, update and/or develop documentation Discuss the activities that will be required to meet the standard Discuss the amount of time required to follow up and complete documentation Provide each measure with a score and add notes where needed

23 Rate each measure on a scale 0-4 –0= No Capacity –1= Minimal Capacity –2= Moderate Capacity –3= Significant Capacity –4= Optimal Capacity Rating Criteria: Capacity

24 Rating Criteria: Time Consider your rating by or the amount of time (example time frame) – 0 = More than 18 months – 1 = At least one year or more – 2 = More than 6 months and less than 9 – 3 = More than 3 months and less than 6 – 4 = Measure met or less than 3 months


26 After The Self- Assessment 26 What did we learn about our department and community? What did we learn about our readiness for accreditation? Should accreditation be a strategic goal for our department? Next year? In 5 years? Are there elements we can include as priorities in our strategic plan? Are there measures we can address in our quality improvement plan? What are our next steps?

27 Self Assessment Limitations Self assessment isn’t a one time shot. It is often a process that is repeated.

28 Self Assessment Process Will be dependent on: Size of the Tribal Health Department Organizational structure Knowledge and expertise Roles and responsibilities – As they relate to domains – Collecting and/or developing documentation Time required to self-assess

29 Organizing for Self-Assessment Identify an Accreditation Coordinator(s) Become familiar with PHAB domains and overall content of each Identify domain groupings based on organizational structure Identify who will participate in the self- assessment: – Health Director, Management/Supervisors, Program Staff Provide a department-wide orientation to accreditation and self-assessment process

30 Example: Domain Groupings Identify domain groupings based on organizational structure, programs and people: Domains 1, 2 (data surveillance and public health hazards) Domains 3, 4, 7 (promotion and prevention) Domains 5, 6 (law and policy) Domains 9, 10 (QI, evaluation, research) Domains 8, 11, 12 (governance, administration) THD needs to decide the best groupings and strategy

31 Domain Teams Identify who should be on each Domain Team for conducting the self-assessment – Consider program managers and staff with strong knowledge and expertise – Some individuals may be on more than 1 team; prioritize which team for self-assessment – Identify a team lead for each Domain Team Identify mechanisms for accountability (such as quarterly or monthly meetings) 31

32 Domain Teams Challenges and Strategies THDs may be small and only have 1-3 teams Limited staff with technical expertise to adequately review, assess and score Smaller number of teams means more time will be required to self-assess all domains Strategies: Focus staff time on the domains where they have greatest expertise Use domain groupings to review similar or related functions Self-assessments can be scheduled for completion in sections or individually

33 Self-Assessment Outcomes Identify THD strengths and opportunities for improvement Prioritize opportunities for inclusion in your strategic plan (prerequisite) Use findings to inform the development of a Quality Improvement Plan ( measure 9.2.1 and 9.2.2 ) Update self-assessment tool as improvement activities are completed


35 Forest County Potawatomi PHA Self-Assessment Tool TPHA Readiness Webinar Lorrie Shepard, RN June 12, 2013

36 Introductions:  Lorrie Shepard, RN – CH Department Supervisor Oversee all CH Programming and In-Home Care Program AAAHC, TPHA (Co-Coordinator), Infection Control Committee

37 FCP Community Health Department  Part of the FCP Health & Wellness Center Medical (OBY-GYN, Pediatrics, Podiatry, Radiology, Lab), Dental, Optical, Physical Therapy, Mental Health & AODA Community Health Department Programs & Services Car Seat ProgramMCH/HOCDiabetes Prevention SDPIImmunizationsInfant Nutrition Program WICHPDPHIV/AIDS WWWPGlucose Test & BP ScreeningHead Checks Smoking CessationNutrition CounselingHome Health/Visits

38 Forest County Potawatomi  Checkerboard – Tribal Land Stone Lake, Blackwell, Carter  Population in Forest County 725 Tribal Members  Service All Tribal Members 1,444 Tribal Members

39 Where are We At with PHA? TPHA Committee Est. HWC Admin Approval HAC Approval Logic Model/Timelines PHA Coordinators Assigned Self-Assessment Tool Electronic Filing System CHA Completed CHIP Workgroups Est. Strategic Planning

40 Readiness Self Assessment Approach  TPHA Committee completed the assessment as a group SuccessesChallenges Lessons Learned Opportunity to Review PHAB Requirements Identify Strengths & Weaknesses Prioritize Projects Delegate tasks to staff based on knowledge & expertise Attendance by ALL Committee Members Interpreting Domains, Standards, Measures Overwhelmed Staff Need to review regularly- not a one time thing Don’t do it too Early Easy to delegate, difficult to follow through Review more often at Committee Meetings to ensure progress is being made.

41 FCP Self- Assessment Workbook

42 Recommendations  Review Domains, Standards and Measures prior to completing the Self-Assessment Tool.  Complete assessment with THPA Committee or key staff involved in the accreditation process.  Review and update workbook regularly.  When selecting Domain Leaders, make sure you assign staff who are engaged in the accreditation process and willing to do the work – otherwise no progress is made.  Regular reminders to Domain Leaders and workgroups to review domains and update assessment tool.  Hold Domain Leaders accountable by having them report back to the TPHA Committee.

43 Thank You!! Forest County Potawatomi Communtiy Health Department Lorrie Shepard, RN: 715-478-4341

44 Tribal Public Health Accreditation Readiness Webinar Apryl Krause, ND May 7, 2013

45 Introduction  Apryl Krause, ND MPH- PY Diabetes Prevention and Treatment Program Manager Oversee the Diabetes Program comprised of Outreach, Fitness, and Recreation See patients as a Naturopathic Doctor in the PY Alternative Medicine Clinic once a week

46 Pascua Yaqui Tribe Reservation in Tucson, AZ. 18,311 enrolled members Approximately 3934 live on the reservation, and another ~4000 live in Yaqui communities in Tucson and Phoenix metro areas. About 10% live in California Aboriginal lands in Sonora, Mexico, and are tightly bound to the communities there. ver.jpg

47 PY Health Department Contract Health Dervices Public Health and Clinical The Pascua Yaqui Tribe is a 638 tribe Its contracted health services provider is El Rio Community Health Centers. El Rio has a primary care clinic and a pharmacy on the PY reservation as well as 11 other locations throughout Tucson. PY took over the administrative responsibility for their healthcare plan in 2010. The Yoeme Health plan serves tribal members living in Pima county who are not eligible for other healthcare coverage. By 2014 PY plans to take over their primary care and the pharmacy. The PYHD has an extensive Behavioral Health Program, a busy Dental clinic, an innovative Alternative Medicine Clinic, and leases space to DeVita to provide hemodialysis. Tribal Health programs and services include: Diabetes Prevention, WIC, HIV/AIDS, CHRs, CHNs, Sewa U’usim (similar to social services), injury prevention, traditional healing, and wound care. PYHD has arranged for specialty care on the reservation including: Rheumatology, Cardiology, & Podiatry

48 Progress with Accreditation Effort Getting approval and forming a team Moving forward PYHD director approved the idea to pursue accreditation and chose a team. Accreditation team attended trainings for Tribal Public Health Accreditation Readiness and Self-Assessment Training and a 3-Prerequisites training in the spring of 2012. Due to conflicting priorities, a new team was formed in the fall and co- coordinators were appointed. The new team started meeting in November 2012. Dr Krause will officially present accreditation details to the council health department oversight committee in June. Unofficial approval has been procured. Co-coordinators and Health director watch accreditation overviews Complete self-assessment (first run) Assign accreditation team members to PHAB domains Arrange for electronic filing system Create timeline Read already existing CHAs as a group. Co-coordinators meet with tribal programs who have recently completed CHAs or who need to conduct one.

49 Self-assessment We chose to go through the self-assessment quickly, ~10 hours, with the understanding that it will be gone through again by domain teams. Benefits Challenges The team became familiar with PHABs Standards and Measures The team now has a very good idea of where PYHD’s strengths and weaknesses lie. The process made the accreditation effort feel concrete- like something that is going to happen. Feeling overwhelmed in light of some of the improvements that need to be made (i.e. writing policies and statutes and then enforcing them) Getting the accreditation team together in one room on a regular basis Need to have more structure, with team being willing to follow that structure.

50 Recommendations Become familiar with the Domains, Standards, and Measures, and review them often. Look for tools for helping organize accreditation efforts from such organizations as NACCHO & PHAB, to name a few. Select accreditation team members, and domain leaders who are self-motivated are interested in the project Don’t bog down in the details. Move on when necessary, and then go back later. Cultivate positive relationships with Departments outside of the Health Department. Don’t be afraid to bug people, especially people who have agreed to participate in the accreditation effort.

51 Thank you! Pascua Yaqui Tribe Health Department Apryl Krause, ND MPH: 520-879-6137

52 Questions/Comments

53 Thank You! Theresa Cariño, MEd Webinar will available at:

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