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

2. 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

3. 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

4. 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

5. 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

6. The 12 Domains of Accreditation

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

8. 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

9. Example: Domain 1 and Associated Standards

10. Example: Standard 1.1 and Measure 1.1.1 S

11. 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)

12. 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

13. Domain Champion Role

14. Domain Champion Report Out to ART

15. Domain Team Members Role

16. OQPA Liaison Role

17. Domain Team Timeline

18. Documentation Process Overview
Collection
Tracking
Review
Submission
e-PHAB

19. 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

20. 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

21. 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

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

23. 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

24. Do the Documents Satisfy
These Requirements?

25. 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

26. 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

27. 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)

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

29. Discussion
Questions and Answers