California Department of Public Health Domain Team Orientation Office of Quality Performance and Accreditation (OQPA)

What is Public Health Accreditation? Public Health Accreditation Board (PHAB) Launched in 2011 National accrediting body Composed of peer public health professionals Public Health Accreditation is: Set of standards developed by peers Process to assess performance; identify strengths and areas for improvement Recognizes Departments that meet the standards

What does Accreditation mean to CDPH? Benefits of Accreditation High performance and Quality Improvement (QI) Recognition, validation and accountability Potential increased access to resources Busting silos and building bridges across programs CDPH Employees say Accreditation will: Provide introspection Expand knowledgebase Improve our visibility Increase collaboration Improve morale

Accreditation Steps A c h i e v e Pre-application Application Submit a Statement of Intent (SOI) Application Application form with pre-requisites Document Selection and Submission Applicant selects documentation and submits it to e-PHAB for review Site Visit Site visit is conducted by a team of peers and report developed Accreditation Decision PHAB Board will award accreditation status for 5 years if successful 6. Reports A c h i e v e Department submits annual reports to PHAB 7. Reaccreditation (every 5 years) Maintain

Accreditation Structure 12 Domains Group standards pertaining to broad public health services 32 Standards Required level of achievement a health Department is expected to meet 105 Measures of Quality Evaluate if standards are met via Departmental documentation to demonstrate evidence of conformity

The 12 Domains of Accreditation

Structural Framework and Taxonomy Domain (example – Domain 5)   Standard (example – Standard 5.3) Measure (example – Measure 5.3.2) Required Documentation (example – Measure 5.3.2.1) Measure taxonomy indicates who it applies to: State (example – Measure 5.3.2 S for state health depts.) Local (example – Measure 5.3.2 L for local health depts.) Tribal (example – Measure 5.3.2 T for Tribal health depts.) All (example – Measure 5.3.2 A for all health departments)

Standards and Measures Each domain contains standards and measures Standards describe the required level of achievement Measures provide a way of measuring if the standard is met Each measure includes the following information: Description of the measure’s purpose The significance of the measure Listing of the required documentation for the measure Guidance on the types and forms of documentation appropriate to demonstrate conformity with the measure

Example: Domain 1 and Associated Standards

Example: Standard 1.1 and Measure 1.1.1 S

Accreditation Readiness Structure Form Accreditation Readiness Team (executive sponsorship) Form Domain Teams (subject matter expertise) Expand Across the Department (collaboration) Centralize Documentation Collection and Organization (coordination)

Documentation Collection Subject Matter Experts Recommend Documentation Executive Lead Domain Team Select Documentation OQPA Guide Accreditation Process Coordinate Documentation Domain Team Liaison Domain Team Domain Champion Silo Busting and Bridge Building Opportunities

Domain Champion Role

Domain Champion Report Out to ART

Domain Team Members Role

OQPA Liaison Role

Domain Team Timeline

Documentation Process Overview Collection Tracking Review Submission e-PHAB

Guidelines for Selecting Documentation Draft Documents will Not be Accepted by PHAB Confidential Information is Not Accepted Confidential info must be covered or deleted Documents Must be Authenticated All Documents must have a CDPH logo or name All Documents must be dated All Documents must be current All Documents with a signature block must be signed

Time Frames for Accreditation Documentation Annually: Within the previous 14 months of documentation submission to PHAB Current: Within the previous 24 months of documentation submission Biennially: Within each 24-month period, at least, prior to documentation submission Regular: Within a pre-established schedule, as determined by CDPH Continuing: Activities that have existed for some time, are currently in existence and will remain in the future

Accreditation Documentation Restrictions Documentation from health care facilities and professional licensing programs cannot be used for public health department accreditation purposes PHAB Scope of Accreditation Authority Does Not Extend to the Following Areas Documentation from these program areas will not be generally accepted for public health department accreditation: Primary Care Dental Clinics Home Health Social Services Domestic Violence Services Mental Health Services Substance Abuse Services

PHAB Scoring Site Visitors will score documentation at a measure level: Fully Demonstrated Largely Demonstrated Slightly Demonstrated Not Demonstrated

Tips for Choosing Documents Study PHAB Guidance for each standard and measure you will be collecting documentation for: Review the Domain Intent Read the guidance of each standard and its specific measure to included the purpose and significance Cleary understand the guidance, time frame and number of examples needed for each individual required documentation Use the PHAB Acronyms and Glossary to clarify definition of terms and how they are used in the PHAB Standards and Measures Do not over-interpret the requirements of the measure Documents only have to demonstrate meeting the requirements Do not carry-over requirements Although the measures may be related, each measure is scored independently

Do the Documents Satisfy These Requirements?

Document Cover Sheet Purpose: Value: Identify and describe documents Indicate document origin and point of contact information Summarize specific document text that addresses the measure Explain document risk points/gaps Value: Standardize method for Domain Teams to submit documentation into shared electronic platform (SharePoint) Memorialize necessary information from subject matter experts

Document Checklist Complete and Review: Purpose: Domain Team and/or OQPA Purpose: Assess the presence of document elements (date, signature, etc.) Identify gaps that may require corrective response or additional information

Documentation Tracking Pre-populated by OQPA Completed by Domain Team Tracking sheet should be updated with identified examples and saved to shared electronic platform (SharePoint)

Storing Your Documents The Department will be utilizing SharePoint as our shared electronic platform. Please review the SharePoint Access Tips Document for further guidance.

Discussion Questions and Answers