PREPARING FOR NATIONAL ACCREDITATION REVIEWSusan Ramsey, Director

Office of Performance and Accountability

November 7, 2011

TRAINING AGENDA

Topics for today:Overview of the 2011 PHAB version 1.0

StandardsHow to Interpret the 2011 PHAB version

1.0 Standards and MeasuresStandards Review ProcessOrganizing for Self-AssessmentMock Review of Selected Standards

Pre-requisites: Online Standards Orientation – SmartPH Review 2011 Standards Review Introduction to the Guidelines

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OVERVIEW OF PHAB VERSION 1.0 STANDARDS FOR 2011

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INTERPRETATION OF PHAB STANDARDS AND MEASURES

Changes from 2010 Beta Test Standards Numbering System (Taxonomy) Scope of Domains Domains/Standards/Measures Quality Improvement Built into Standards

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DEVELOPMENT FRAMEWORK / CONVENTIONS 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

Domain 1

Standard 1.1

Measure 1.1.1

Tribal, State, Local or ALL

DOMAINS CROSS ALL PROGRAMS

Family Planning Program

STD and HIV/AIDS Programs

Food Safety Program

On-site Septic Program

Immunization Program

Com

mu

nic

atio

n

Domains

Use o

f Qu

ality

Im

pro

vem

en

t

Mon

itor H

ealth

S

tatu

s

Programs C

om

mu

nity

In

volv

em

en

t

Health

Polic

y &

P

lan

s

6

The 12 Domains apply at the agency level - they cut across programs and activities

12 Domains (10 Essential PH Services plus administration & governance)

32 Standards

105 Measures

Documentation

PHAB STANDARDS FRAMEWORK

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SCOPE OF DOMAIN 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 providedAssessment information on website; press

releases, waiting rooms, annual reportSamples of emails; SharePoint Sites4 Standards

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SCOPE OF DOMAIN 2 Domain 2: Diagnosis/investigation of

health problems and environmental hazardsWritten 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

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SCOPE OF DOMAIN 3 Domain 3: Provide Health Education/Promotion

and Communicate PH functionsPublic 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

SCOPE OF DOMAIN 4 Domain 4: Engage the Community to

Identify & Address Health ProblemsCurrent 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 Standards11

SCOPE OF DOMAIN 5 Domain 5: Develop & Implement PH Policies

and PlansConduct a process to develop a

community/state health improvement planMaintaining an all-hazards emergency

operations plan4 Standards

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SCOPE OF DOMAIN 6 Domain 6: Education and Enforcement of

PH LawsReview of public health lawsDocument how staff have been trained in laws

to support public health lawsConduct and monitor enforcement activitiesFollow up on complaintsFood service hearings/compliance plans3 Standards

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SCOPE OF DOMAIN 7 Domain 7: Assess Healthcare Capacity &

Access & Implement Strategies to Address GapsConvene 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

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SCOPE OF DOMAIN 8 Domain 8: Competent PH Workforce &

Assess Staff Competency & Address GapsDocument relationships that promotes

public health as a careerHealth department workforce development

planNationally adopted core competenciesCurricula and training schedules

2 Standards

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SCOPE OF DOMAIN 9 Domain 9: Program Evaluation & Quality

Improvement Plans and activitiesEvidence of maintaining an agency

performance management systemEvidence of a written quality improvement

plan2 Standards

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SCOPE OF DOMAIN 10

Domain 10: Identify and Use Evidence-based practices and Use of ResearchDemonstrate and document examples of using

evidence-based or promising practicesDocumentation of availability of expertise

(internal or external) for analysis of research2 Standards

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SCOPE OF DOMAIN 11 Domain 11: Operational Infrastructure - IT

and Human Resource and Finance Written operational policies – accessible to the

staffOrganizational chartRegular reviews and updatingAudited financial statementsProgram reports/MOU’s2 Standards

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SCOPE OF DOMAIN 12 Domain 12: Engaging the Public Health

Governing EntityDocumentation 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

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QI IS BUILT INTO THE STANDARDS:PLAN-DO-STUDY-ACT-STANDARD 9.1

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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.

QI IS BUILT INTO THE STANDARDS:PLAN-DO-STUDY-ACT-STANDARD 9.2

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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

DOCUMENTATION AND SCORING GUIDANCE

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GUIDE TO ACCREDITATION:

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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.ApplicationApplicant submits application form with pre-requisites, and first fee payment. Applicant attends in-person training (included in fees)

3.Documentation Selection and SubmissionApplicant selects documentation and submits it to PHAB

for review4.Site Visit

Site visit is conducted by a team of peers and report developed

5.Accreditation DecisionPHAB board will award accreditation status for 5 years

6.ReportsAccredited health department submits annual reports

7.Reaccreditation (5 years later)Accredited health department applies for reaccreditation

MAJOR CHANGES IN THE GUIDE

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• 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

PRE-REQUISITES

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• 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

GUIDANCE PROVIDED IN STANDARDS AND MEASURES

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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

USING THE STANDARDS AND MEASURES FOR INTERPRETATION

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

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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

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Read the requirements

then look at the next slide –

does the document meet the measure?

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USING THE PHAB ACRONYMS AND GLOSSARY

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

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TYPES OF DOCUMENTATION TO DEMONSTRATE PERFORMANCE: 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.

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DOCUMENTATION REQUIREMENTS 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

DOCUMENTATION IN DAILY WORK 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

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DOCUMENTATION TIMEFRAMES Some measures state a specific timeframe

for the documentation, defined below: Annual - within the last 14 months dating

back from 10-10Current - within the last 24 months prior

to 12-09Biennial - 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

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SCORING Not demonstrated

Documentation does not provide evidence that the measure is met or documentation is missing.

Slightly DemonstratedDocumentation 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

WHAT QUESTIONS DO YOU HAVE?

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STANDARDS REVIEW PROCESS AND ORGANIZING FOR YOUR REVIEW

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PREPARING FOR STANDARDS REVIEW

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STANDARDS REVIEW PROCESS 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

TELL YOUR STORY…. 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!

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ORGANIZING YOUR DOCUMENTS 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

MORE DOCUMENTS IS NOT BETTER!!

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

LABELING & MARKING DOCUMENTS 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.

EXAMPLE OF DOCUMENTATION - MEASURE 2.4.3 (KITSAP)

WHAT QUESTIONS DO YOU HAVE?

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MOCK REVIEW 46

MOCK REVIEW INSTRUCTIONS 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

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MOCK REVIEW ASSIGNMENTSREVIEWERS DOMAINS NUMBER OF

MEASURES

Megan DavisDeborah ToddTerry Taylor

1, 2, 6 39

Diana EhriMichele Maddox

3, 4, 5, 9 32

Susan RamseyAmy Ferris

7, 8, 10, 11, 12 34

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WHAT QUESTIONS DO YOU HAVE?

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