Presentation on theme: "The Local Health Department DHS 140 Review Process"— Presentation transcript:
1The Local Health Department DHS 140 Review Process Tim RinghandDHS – Division of Public HealthNovember 15, 2013The Local Health Department DHS 140 Review ProcessNew Health Officer OrientationNovember 15, 2013Tim Ringhand, Regional DirectorWestern RegionDivision of Public Health
2Statutory and Administrative Rule 140 Review History 1993 Public Health Statutes revised to say:WI statute (1) Rule making. The department shall promulgate rules that specify all of the following:(1) Required services for each of Levels I, II and III local health departments under s (2).(2) Additional required services for Level II and Level III local health departments under s (2) (b) and (c), including services that the department of health services determines appropriately address objectives or services specified in the most recent public health agenda under s (1) (a).
3Statutory and Administrative Rule 140 Review History Chapter DHS REQUIRED SERVICES OF LOCAL HEALTH DEPARTMENTSDHS Designation of level of local health department.(1) Under the authority of s (1), Stats., the department shall direct a process to formally review the operations of all local health departments in a county or municipality at least every 5 years. A review of the operations of a local health department shall result in a written finding issued by the state health officer as to whether the local health department satisfies the requirements for a level I, II or III local health department.(2) In directing the review under sub. (1), the state health officer shall use department personnel and other appropriate local health officials who have expertise in the field of public health and are knowledgeable about the requirements for local health departments.
4140 Review History140 reviews began in 1999 with the 140 review of all city and county health departments (HD).140 review tools were developed that addressed various health department organizational styles:City HDCounty HDCity/County HDHealth and Human Service HD
5140 Review HistoryThe tool also addressed the various Level of health departments.Level I, II, III criteria;andIncorporated Healthier People in Wisconsin – A Public Health Agenda for the Year (HW 2000) as our defining document.
62005 – 140 Review HistoryNext five year 140 review cycle tool place in 2005.Major changes from the review process were:Used Healthiest Wisconsin (not HW 2000) as the standard.Reduced redundancy of similar questions/evidence during the 140 review process.Central Office/Regional Office team reviewed but did not collect evidence.Replaced the three main areas of the 1999 review (Board of Health (BOH), Health Officer (HO), Local Health Department (LHD)) with the “Twelve Essential PH Services” and placed specific questions under the specific Essential Service.
72005 – 140 Review HistoryMajor changes from the review process:Created a separate justification document for Level II and Level III LHDs.Used “Health Priorities” as a means to determine Level II or Level III status.Level II: Seven programs or services that address at least five health priorities of the current state health plan (Healthiest Wisconsin 2010).Level III: Fourteen programs or services that address at least seven health priorities of the current state health plan (Healthiest Wisconsin 2010).
82005 – 140 Review History Level III agency Agent of the state for the Hotel and Restaurant program.Agent of the state for the Tattoo and Body Piercing program.Health Officer with a master’s degree in public health, public administration, or similar field and three years of full time administrative experience in a public health agency or public health work.Bachelor’s of science and sixteen graduate credits toward a degree in public health, public or health administration, and five years of experience in a full time administrative position in a public health agency or public health work.
92009 – 140 Review History2009 was the last major 140 review of all LHDs by DPH.Healthy Wisconsin 2010 still used as the resource.LHDs filled out 140 review electronic survey form.LHDs ed the completed survey form to their respective regional office.
10140 Review History – Lessons Learned 1. Simplify the review process where possible.Combine related statutesEliminate redundant evidence requestsUtilize evidence already provided to DPH2. Use electronic document collection systems when possible.3. Improve DHS 140 on-site visit so that it provides support for LHD operations.4. Include changes in national standards such as the Public Health Accreditation Board (PHAB).
112014 140 Review Guiding Principles Assure LHD statutory compliance with requirements to provide a basic level of services for all citizens;Efficiently collect only evidence essential to meeting statutory requirements;Support PHAB accreditation readiness for non- PHAB accredited LHD’s; andRecognize accreditation evidence used by PHAB accredited LHD’s that is appropriate in meeting DHS 140 required documentation requests.
12DHS 140 – PHAB CrosswalkWisconsin Statutes and Rules used in the DHS 140 ReviewPHAB Domains and StandardsTo 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.
13DHS 140 – PHAB CrosswalkDHS 140 Review Statutes, Rules and EvidencePHAB Domains, Standards, Measures and Evidence
152014 – DHS 140 Review Tool Based on 2009 DHS 140 Review Tool. Combines more Statute and Rule references.More evidence available from DPH electronic documentation systems.Arranged by Essential Public Health Service.Identifies statute and rule references 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.
17DHS 140 Review – Getting Started Two to three months prior to DHS 140 Process:DHS 140 letter to HO explaining the DHS 140 Review process.Link to the review tool(s).Proposed timeline for evidence submission to be completed .Proposed date of on-site review.LHD DHS 140 Review Team Recommendations shared with DPH Bureau Directors and staff assigned for DHS 140 review.DHS 140 Review Team convened.Bureau-specific evidence identified in the DHS 140 Review Tool.
18DHS 140 Review – Documentation Submission LHD’s compile required documentation and submit the documentation as requested.The DHS 140 Review Team assigned to the LHD will review required documentation within two weeks of notification that documentation submission is complete.DHS 140 Review Team submits any questions regarding the required documentation back to the LHD. The LHD will respond to DHS 140 Review Team questions about documentation submitted within two weeks.
19140 Review – Documentation Submission - PHAB Accredited For PHAB accredited agencies:Indicate on DHS 140 Review Tool if evidence for PHAB accreditation submitted met the PHAB evidence requirement.Submit PHAB accreditation report.If evidence used for PHAB accreditation does not correspond to DHS 140 required documentation requested, make requested documentation of meeting statute reference available.
20DHS 140 Review – Documentation Submission Evidence types: Do not submit any electronic evidence containing patient confidential information!Web Links: links to documents available on agency or partner websites, e.g. community health assessment, community health improvement plan, annual report, minutes, newsletters, etc.)Electronic documents: load electronic documents on the DHS 140 SharePoint site.Hard copy documents: collect documents that cannot be sent electronically to be viewed during the on-site visit.
22DHS 140 Level II and Level III Survey Review Level II and Level III DHS 140 Review Surveys include:Level II and Level III Health Officer education and experience.Provision of public health programs and services:Level II: seven programs that meet at least five Healthiest Wisconsin 2020 health priorities.Level III: fourteen programs that meet at least seven Healthiest Wisconsin 2020 health priorities.Level III health departments provide the date of their most recent contract with the Division of Public Health for licensing and inspecting food, lodging and recreational facilities.
23DHS 140 – On-Site Review DHS 140 Review Team visits the LHD to: Clarify evidence submitted.Review and hard copy documentation and complete review.Support the health department’s provision of public health services.DHS 140 Review Team determines if the LHD has met statutory requirements.If met, a DPH letter of designation is sent to the LHD, Board of Health Chair, and County Board Chair or other designated representatives; and a local presentation of the leveling certificate is scheduled.If not met, a DPH letter specifying DHS 140 deficiencies and asking for plan of remediation is sent.
26DHS 140 Reviews Due New Local Health Officer Orientation Participants DHS 140 Review completed in 2009DHS 140 Review completed after 2009BurnettDouglasEau ClaireMadison/DaneDe PereShawano-MenomineeMarquetteSt. CroixPortageLafayetteOutagamieWalworthWaukesha
27140 Reviews and Impact on You Agencies with new Health Officers have previously completed 140 reviews.Same documentation required.Same forms required.Face-to-face (LHD/DPH) meeting conducted.Board of Health members invited to participate.
28What’s Happening Next with the DHS 140 Reviews November –December 2013January – March 2014Pilot TestsSharePoint site developmentFinalize DHS 140 Review ProcessTraining DPH staffLHD OrientationBOH educationDHS 140 Reviews expected to begin in earnest the second quarter of 2014
29Benefits of the DHS 140 Review DHS 140 reviews are completed because:Per Wisconsin Statute 250, the Department of Health Services (DHS) requires evaluation of each health department in the state every five years to assure a basic level of services for all citizens.DHS 140 review process provides LHDs an opportunity:To review policies and procedures.To reorganize resource materials and update agreements.For staff and board members to learn from each other about the function and success of the local health department.
30Example of 2009 Certificate of Designation that will be updated for 2014