CLHO Accreditation Webinar Series: Webinar #5: Part I

1. CLHO Accreditation Webinar Series: Webinar #5: Part I Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series Coalition of Local Health Officials

2. Objectives • Accreditation Basics & Benefits • Conducting a Self-Assessment/ Accreditation Prep Plan • Forming an Accreditation Team • Developing a Plan • Quality Improvement 101 • QI in the context of Accreditation

3. Benefits of Accreditation • Credibility, transparency, and accountability • Recognition of high performing health departments • Framework for effective planning • Culture of quality and performance improvement • Access to resources for improvement • Public health services aimed at improving health outcomes

4. Why Now? • Training & TA resources available to counties • Grant opportunities • Potential to become more competitive applicant for other funding opportunities • Potential for a stronger voice at the table in CCO conversations • Important to show what PH does as all these transitions occur. • Important to focus on efficiency and quality improvement in current economic environment.

5. Accreditation & the Work You Are Already Doing • 10 Essential Services of Public Health • Recognition for the work you are already doing • Shows what public health does • Minimum Standards

6. 10 Essential Services & 12 Domains

7. DOMAIN Domain Structure • Standard: required achievement • Measure: level required to meet standard • Documentation: shows the achievement www.phaboard.org

8. PHAB Standard Example

9. Accreditation Prerequisites • Community Health Assessment (CHA) • Community Health Improvement Plan (CHIP) • Agency Strategic Plan (SP)

10. Community Health Assessment (CHA) • Health status of the population, identify areas for health improvement, determine factors that contribute to health issues, and identify assets and resources that can be mobilized to address population health improvement. • Collaborative process of collecting and analyzing data and information for use in educating and mobilizing communities, developing priorities, garnering resources, and planning actions to improve the population’s health.

11. Community Health Improvement Plan (CHIP) • Long-term, systematic plan to address issues identified in the CHA. • Describe how the health department and the community it serves will work together to improve the health of the population of the jurisdiction that the health department serves (more comprehensive than the roles and responsibilities of the health department alone). • Community-driven, participatory planning process, stakeholder involvement.

12. Strategic Plan (SP) • Process for defining and determining an organization’s roles, priorities, and direction over three to five years. • Sets forth what an organization plans to achieve, how it will achieve it, and how it will know if it has achieved it. • Provides a guide for making decisions on allocating resources and on taking action to pursue strategies and priorities. • Focuses on the entire health department. Health department programs may have program-specific strategic plans that complement and support the health department’s organizational strategic plan.

13. 7 Steps to Accreditation

14. Preparing for Accreditation • Consider costs and payment, assign an Accreditation Coordinator, learn about process • Engage leadership and staff, form a team, develop a plan and timeline • Start Prerequisites • Gather documentation and score measures • Identify and Analyze strengths and weaknesses • Prioritize the problems • Implement Quality Improvement (Domain 9) • Institutionalize assessment and CQI processes

15. Step 1: Learning about PHAB • PHAB Online Orientation: http://www.phaboard.org/education-center/phab-online-orientation/ • NACCHO in-person presentations • NACCHO Answers to FAQs • NACCHO webinars: http://www.naccho.org/topics/infrastructure/accreditation/webcasts.cfm • PHAB Readiness Checklist: • http://www.phaboard.org/accreditation-process/accreditation-materials/

16. Assigning an Accreditation Coordinator • Recruit or appoint an Accreditation Coordinator • Coordinator provides leadership as needed while overseeing the self-assessment & accreditation process • Possible for the Health Director to take on this role • Fits somewhere naturally? • Example: Cross-programs, WIC Coordinator • Sample Accreditation Coordinator Duties

17. Plan for Engaging the Staff • Every member of the agency’s staff will be involved at some point in the process • For the process to be successful, not only must the Health Director visibly and actively support the process, but the health departments’ staff at all levels must be committed to the work. • Overview and on-going communication

18. Orienting the Staff • Department-wide orientation • Overview, purpose, time commitment, steps and activities involved in the process, importance of accreditation and how it will impact the agency • NACCHO has ‘ready-made’ training materials including a PPT presentation and presenter’s guide designed to inform LHD staff about accreditation and its importance to the agency. http://www.naccho.org/topics/infrastructure/accreditation/trainings.cfm • Ongoing communication is critical

19. Forming an Accreditation Team • Staff throughout the LHD need to be involved • Representatives from all levels of management and staff, and all program areas • Typical Team: • 1) Health Director; 2) Accreditation Coordinator; 3) Senior Management; and 4) Program Staff • Considerations: • Size of LHD, organizational structure, manner in which responsibilities are assigned to staff, workload, time it will take to collect evidence and adequately complete the self-assessment, subject matter expertise

21. Developing a Work Plan • Once key players identified, make a work plan • Considerations: • (1) Delegating responsibilities • (2) Training the team • (3) Developing a timeline • During the initial planning phase of the self-study process, the Accreditation Coordinator should consider developing a team charter which is a written document that clarifies the team mission and how to achieve it. • Duffy, G. L., Moran, J.W. (2010). Team Chartering. Access: www.phf.org/resourcestools/Documents/Team_Chartering.pdf

22. Delegating Responsibilities: Model 1 (for Large LHDs) • Team: Accreditation Coordinator, senior management and program staff • Senior management, including division directors, assign specific domains or Standards and Measures to staff in their respective divisions or programs based on area of expertise • These staff members gather documentation for their assignments and score each measure based on their findings • Senior management will then analyze these results and make recommendations

23. Delegating Responsibilities: Model 2 (Small to mid-size LHDs) • Accreditation team is comprised of the Accreditation Coordinator and senior management • Together they divide all the standards and measures amongst themselves and complete the entire process, including gathering documentation, scoring standards, analyzing results, and making recommendations • This model is more typical in mid-sized LHDs

24. Delegating Responsibilities: Model 3 (Small to very small LHDs) • Accreditation Team is comprised of the Accreditation Coordinator and the Health Director • Typically in very small LHDs, the entire self-study process could be successfully implemented with only these two individuals

25. Training Team Members • Accreditation Coordinator provides training to members to ensure consistency • Training: • Purpose of the self-assessment, how the results will be used, detailed description of the process, discussion of relevant, and assignments for the Standards and Measures • Each team member thoroughly reviews the relevant documents prior to the beginning of the self-study process

26. Developing a Timeline • Time will vary greatly from one LHD to another depending on the size of the agency, available staff and resources to devote to the process. • Very important for the Health Director to allow staff to allot time for this process • Leadership support necessary • Target Date Template • Timeline Example • Specific Timeline Example

27. Select & Organize Documentation • Gathering Documentation: • Gather documentation to show conformity to PHAB Standards and Measures • Use this information to score each measure • PHAB Standards and Measures Version 1.0: Focuses on what the HD provides, not how they provide it.

28. Select & Organize Documentation • National Public Health Department Accreditation Documentation Guidance • General guidance for HDs to consider when selecting the specific documentation that will be submitted to PHAB for each documentation requirement

29. Documentation Policies • No draft documents • Documentation must be dated and in effect and in use at the time that they are submitted (see notes in email to list-serve) • Documents must be submitted electronically(a PDF version is preferred) • In many cases, a measure is demonstrated only once(Examples include department-wide policies, procedures, and plans) • Where documentation requires examples, must submit two examples, unless otherwise noted

30. Documents Policies Continued: • Program representation • HDs are encouraged to provide narrative that describes how the submitted document relates to and meets the requirement. • A single document may be relevant for more than one measure and may be used multiple times. • Documentation submitted to demonstrate conformity to a measure does not have to be presented in a single document; pieces of several documents may be required to demonstrate conformity with one requirement.

31. Documentation Policies Continued • Documents must be signed and dated in order for site visitors to be able to evaluate conformity with timeframes. • Many HDs do not provide all public health services directly but have formal agreements, contracts, or partnerships with other organizations or agencies to provide services. • Where documentation contains confidential information, the confidential information must be covered or deleted.

32. Documentation Resources • PHAB Blank Document Tracker • PHAB Standards and Measures Version 1.0 • http://www.phaboard.org/accreditation-process/guide-to-national-public-health-accreditation/ • National Public Health Department Accreditation Documentation Guidance • http://www.naccho.org/topics/infrastructure/accreditation/documentation.cfm

33. Documentation Resources • NACCHO’s Example Documentation for Accreditation: http://www.naccho.org/topics/infrastructure/accreditation/exampledocumentation.cfm • Organize the process: • LHDs will be required to upload the required documentation into e-PHAB. • Internal system to organize the documentation and streamline the process. • http://www.naccho.org/topics/infrastructure/accreditation/documentation.cfm • Blank Document Tracker • Questions to List-Serve • MaiKia and Erin collecting documentation form CLHO, state, FAQs, etc.

34. Identify and Analyze Strengths and Weaknesses • Accreditation Coordinator and preparation team to study, analyze, and process the results • identify the major strengths and weaknesses of the agency • First aggregate the results within each domain and each standard and display it in a way that will allow the team to easily identify strengths and weaknesses • Collectively examine information and make note ofdomains with a large number of standards and measures that have not been met. • This process will assist in gaining insight and developing a plan of action.

35. Self Assessment Tools • NACCHO Local Health Department Self Assessment Tool • APEX Public Health • http://www.naccho.org/topics/infrastructure/APEXPH/index.cfm • Performance Management Self- Assessment Tool from the Turning  Point Performance Management National Excellence Collaborative • http://www.phf.org/resourcestools/Documents/PM_Self_Assess_Tool.pdf • Baldrige Performance Excellence Program • http://www.nist.gov/baldrige/enter/self.cfm • Others?

36. Analyzing Strengths • Drawing upon strengths from one area and applying them to develop and support new strategies in other areas will support an agency’s efforts in CQI. • For instance, similar strengths across multiple Standards and Measures could identify emerging themes • This step highlights positive aspects of the self-assessment and provides an opportunity to celebrate the successes of the agency. • Share these findings with stakeholders including the entire staff, or the community.

37. Analyzing Areas for Improvement • Analyzing areas for improvement uncovered by the self-study is an important step to developing a quality improvement process that will result in solutions.

38. Areas for Improvement • An agency may choose to first define problems at one of the following four levels and identifying areas of analysis for that level: • Individual Measures: weaknesses on individual measures. • Individual Standards: weaknesses among individual standards • Domains: Includes weaknesses among multiple standards and measures within domains • Cross-Domain Clusters: Includes all weaknesses, across all domains that seem to cluster around a common theme

39. Prioritizing Problems • Multiple problem areas that need to be addressed and with limited resources, time, and staff, an agency cannot begin to address all of them at once. • Prioritization Technique: • Multi-voting Technique • Strategy Grids • Nominal Group Technique • The Hanlon Method • Prioritization Matrix • Guide to Prioritization Techniques

40. Prioritization Feasibility/ Ability to Impact Need

41. Implementing Quality Improvement • Likely that many, if not all, high-priority focus areas identified through step 4 can be addressed through QI processes • Form a QI Team • Include front line personnel and staff that are routinely involved with the chosen focus area as the QI cycle is implemented • Develop a team charter to provide the team with a clear and concise plan of action

42. What is Quality Improvement? • QI is the use of a deliberate and defined process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. • It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes and other indicators of quality services or processes which achieve equity and improve the health of the community. Developed by the Accreditation Coalition Workgroup and approved by the Accreditation Coalition in June 2009

43. Why Quality Improvement? • Foundation of Accreditation • Focuses on efficiency and effectiveness • Demonstrates commitment to high quality services • Shows that we are good at what we do and always improving

44. QI in the context of accreditation QI is an important component of accreditation and of an effective, efficient HD Domain 9, interwoven throughout Increased leadership buy-in Re-accreditation improve improve Accreditation improve Improving the public’s health through continuous Quality Improvement

45. Institutionalizing the Continuous Improvements • Reaccreditation process every five years, demonstrating improvement from the previous cycle • Accreditation is a cyclical process of continuous improvement • Goals of the QI project are met for the first selected priority area the agency moves forward with institutionalizing the change • As a next step, the agency can move on to address the next highest priorities using the PDCA cycle and eventually, undergo another agency self-study process • http://www.naccho.org/topics/infrastructure/accreditation/stories.cfm

46. Partnerships & Collaboration • A lot of the accreditation preparation process will involve engaging different groups: • Health Department Leadership • Elected Officials • Staff • Stakeholders • Community Members • Hospitals • NACCHO Resources

47. Plan for Engaging Leadership or Governing Entity • To be eligible for accreditation, an LHD’s local governing entity (LGE) must sign a letter of support. • Additionally, Domain 12 of the PHAB standards relates to engaging the LGE • Essential for LHDs to proactively provide the necessary informationto LGE • http://www.naccho.org/topics/infrastructure/accreditation/lge.cfm

48. Engaging Local Public Health System Partners • Build commitment • Engage participants • Use participants’ time well • Result in a plan that can be implemented successfully

49. Local Public Health System

50. Considerations for Engaging Hospital Partners • They serve the population you serve • They are/ will be conducting CHNAs for IRS requirement • Valuable data and knowledge complementary to public health’s own • Potential coordination of priority setting, plans and actions, costs and effort