Local public health agency accreditation programs managed by public health institutes Featuring states participating

1. Local public health agency accreditation programs managed by public health institutesFeaturing states participating in the Multi-State Learning Collaborative for Performance and Capacity Assessment or Accreditation of Public Health Departments

2. NNPHI Involvement in Performance Management NNPHI Programs NPHPSP MLC PHI Involvement 4 of the 5 states selected National Public Health Performance Standards Program -Collaborative effort sponsored by CDC and 6 partners, including NNPHI -Assist states with implementing the state, local and local governance instruments -NNPHI�s role is to: - facilitate user & partner teleconferences - co-host trainings and workshops -provide technical assistance - update matrix describing the status of NPHPSP implementation throughout the country MLC -14 month project that bridges 5 states implementing assessment/accreditation programs with expert consultants and key stakeholders in performance management and accreditation. Member Institutes -Many (11) of the MLC applicants were public health institutes or involved PHIs in their program -PHIs play a fundamental role in 4 of the 5 MLC states National Public Health Performance Standards Program -Collaborative effort sponsored by CDC and 6 partners, including NNPHI -Assist states with implementing the state, local and local governance instruments -NNPHI�s role is to: - facilitate user & partner teleconferences - co-host trainings and workshops -provide technical assistance - update matrix describing the status of NPHPSP implementation throughout the country MLC -14 month project that bridges 5 states implementing assessment/accreditation programs with expert consultants and key stakeholders in performance management and accreditation. Member Institutes -Many (11) of the MLC applicants were public health institutes or involved PHIs in their program -PHIs play a fundamental role in 4 of the 5 MLC states

3. Multi-State Learning Collaborative IOM recommendation in the 2002 report of The Future of the Public�s Health in the 21st Century, �national commission to consider if an accreditation system would be useful in improving and building state and local public health agency capacities...� (Available online at www.nap.edu) Exploring Accreditation Project Opportunity to share best practices and study innovative efforts of states with established assessment and accreditation programs

4. Collaborative Implementation Funded by RWJF Managed by NNPHI and PHLS Panel of Expert Consultants

7. Participating States 23 states expressed interest in the MLC 18 states applied 5 states selected: Illinois, Michigan, Missouri, North Carolina and Washington

8. Common Characteristics: Reliance on self assessment Similar periodicity for review process (3-5 years) Developed state specific standards Referenced other work: Core Functions, APEXPH, NPHPSP, MAPP, TP PMC, Operational Definition

9. Areas to be addressed by MLC States Transition from Certification to Accreditation Accreditation Readiness Instrument Digital Library of Accreditation Documents Social Marketing Campaign Fund for Public Health Improvement Evaluate Standards

10. Presenters Laura Landrum Illinois Public Health Institute Gail Carlson Missouri Institute for Community Health Melody Parker Michigan Public Health Institute Mary Davis North Carolina Institute for Public Health Torney Smith Spokane Regional Health District

11. Illinois Accreditation Development Project American Public Health Association December 13, 2005 Laura B. Landrum Illinois Public Health Institute

12. Purpose of IADP Design an accreditation framework that would transition the IL local public health certification program into a more performance-based program Contribute to the knowledge base and participate in national dialogue through the MLC

13. Requirements for Certification of Illinois Local Health Departments Before and After 1993

14. IL Certification Process LHD conducts IPLAN process IDPH reviews IPLAN submission for substantial compliance with Code LHD submits Certification Application If Certification Application provides self-affirmation of compliance with all practice standards, then IDPH director grants a 5-year certification to the LHD

15. IPLAN�s Essential Elements, a modified APEX-PH model

16. IPLAN Requirements, every five years� LHD or LPHS self-assessment Community participation Assess community health indicators Set at least 3 priority health needs Risk and contributing factor analysis Outcome and impact objectives and intervention strategies Local Board of Health adoption

17. State�s role in IPLAN

19. Initial Evaluation Results:Improved Local Effectiveness in IL

20. Certification Program Financing and Incentives PHHS Block Grant for state program - - $250,000 annually since 1993 Local activities to maintain certification status Local sources of funding Local Health Protection Grant (recipients are certified local health departments) Estimated local IPLAN costs = $10,000-$15,000 in 1994

21. Forces of Change in IL Split of a single �SACCHO� into three Northern IL Consortium bill to fund public health by consolidated regions IDPH�s Enrich and Strengthen strategic planning process to revisit basic issues in governmental public health increased interest in use of standards increased interest in accountability, accreditation

22. Evolution of IL Accreditation Components 1984 Roadmap Principles 1990 Project Health 1993 Standards established; IPLAN begins 1994 Certifications granted 1999 2nd Round Certifications 2003 Enrich and Strengthen process 2004 3rd Round Certifications begin 2005 IL Accreditation Project through IL Public Health Institute

23. IL Accreditation Development Project Milestones Convene IL Accreditation Task Force Adopt a set of performance standards Develop enhanced measurement instrument for adopted standards Develop a governance structure/process Design an evaluation/QI plan Develop IL Accreditation Resource Plan Develop an implementation plan

24. Major Issues for IADP Building a new consensus among 3 local public health organizations and IDPH Increasing state capacity to shepherd and sustain new program Revitalizing local and state capacity-building activities Creating a new culture of performance improvement and rigor Balancing capacity, process and outcomes in performance measures

25. IADP Enhancements:From Certification to Accreditation Descriptive metrics Minimal standards Assessment focus State administration Pass/fail criteria Compliance purpose Objective measures Optimal expectations All core functions Possible third party Range/tiered criteria Improvement purpose

26. Michigan Public Health Institute�s Role in Accreditation in Michigan American Public Health Association Session #4105.0 December 13, 2005

27. Michigan�s Partnerships

28. Standards/Measures Current model based on Minimum Program Requirements (MPRs) MPRs are constructed through a formal process (Policy 8000) MPRs must be based in law, rule, department policy or accepted professional standards 221 indicators

29. Programs Reviewed LHD Powers and Duties Clinical Laboratory Food Service Gen. Communicable Disease Hearing Immunization On-Site Sewage Treatment

30. Governance The MDCH is Accreditation�s governing authority The 3 state agencies are the accrediting body The Accreditation Commission is the advisory body

31. Steps to Accreditation Step One: Self Assessment Step Two: On-site Review Step Three: Corrective Plans of Action

32. Accreditation Status Options Accredited with Commendation Accredited Not Accredited

33. MPHI�s Role in Accreditation The Institute provides operational oversight to the process including: Process coordination among partners Tracking system development and administration Reporting system development and administration Accreditation Commission support

34. Enhancing Accreditation Two goals to continued success: Enhance Michigan�s Accreditation Program Objective 1: Assess opportunities for enhancement to current approach Objective 2: Draft voluntary component to enhance current approach Objective 3: Develop tools to enhance reviewer team and local health department interface Objective 4: Develop a model for ongoing awareness, education, and training of local governing entities

35. Enhancing Accreditation Contribute to an interactive learning environment for accreditation Objective 5: Establish an evolving digital library of Michigan accreditation information Objective 6: Develop a model to establish a best practices information exchange

36. Michigan Contacts James A. Butler Public Health Administrator Mich. Dept. of Community Health (517) 335-8032 Email: butlerj@michigan.gov Mary Kushion, M.S.A. Health Officer Central MI District Health Dept. (989) 773-5921 Email: MKushion@cmdhd.org

37. Missouri Institute for Community Health (MICH) Missouri Voluntary Accreditation Program For Local Public Health Agencies NNPHI Session at APHA December 13, 2005

38. 1981-1999 Model standards for LPHAs defined & objectives identified. 2000-2001 Accreditation model established based on core functions & 10 essential services 2001 The self-assessment tool was developed and piloted & guidance document for the model was developed 2002 MICH becomes a 501(c)3 agency & publishes the accreditation standards. Voluntary Accreditation History

39. Goals of the Program

40. Current Model Types of Voluntary Accreditation Primary Accreditation 23 Standards/Criteria Advanced Accreditation 33 Standards/Criteria Comprehensive Accreditation 39 Standards/Criteria

41. Current Model 3 Sections of Standards Performance standards (What do you do?) Workforce core staff requirements, qualifications, & competencies (Who does it?) Physical facilities & administrative services (Where do you do it?)

42. Current Model The Voluntary Accreditation process has four steps: Application for accreditation LPHA self-assessment MICH review of LPHA MICH accreditation decision

43. Why are we implementing the Accreditation Program?

44. Cause for Celebration!

45. Governance Structure

46. Funding & Support

47. Multi-State Learning Collaborative

48. Multi-State Learning Collaborative

49. I�m speaking on behalf of a large partnership that has worked together for several years to create and implement the NC Local Public Heath Accreditation system. I�ll briefly overview the system and our MLC projects. There is a handout that describes the NC process in detail. I�m speaking on behalf of a large partnership that has worked together for several years to create and implement the NC Local Public Heath Accreditation system. I�ll briefly overview the system and our MLC projects. There is a handout that describes the NC process in detail.

50. NC Public Health System Decentralized: 85 LHDs in districts and single county HDs Operates through Autonomous LHDs Strong health director networking State DPH program monitoring, technical assistance, consultation Accountability through programmatic monitoring

51. Beginning in 2002, NC local health directors began to examine ways to improve public health system accountabilty. Through a series of working groups, the health directors, NC Division of Public Health, and the NCIPH created a framework for a NC LHD accreditation system. In 2003-2004 the Public Health Task convened by the NC DHHS secretary and NC State Health officer recommended a mandatory accreditation process for NC. The Accreditation Committee of this task force developed the initial NC accreditation standards. NC then conducted 2 pilot accreditation projects which were evaluated for feasibility. In Pilot I, 6 of 6 health departments were awarded accreditation. This pilot revealed areas for improvement of the self assessment instrument. In Pilot II, 4 of 4 health departments were awarded accreditation. This pilot revealed the need to address process and policy issues In 2005, the NC legislature passed legislation to create a mandatory, ongoing system with all health departments to go through accreditation process by 2012. Beginning in 2002, NC local health directors began to examine ways to improve public health system accountabilty. Through a series of working groups, the health directors, NC Division of Public Health, and the NCIPH created a framework for a NC LHD accreditation system. In 2003-2004 the Public Health Task convened by the NC DHHS secretary and NC State Health officer recommended a mandatory accreditation process for NC. The Accreditation Committee of this task force developed the initial NC accreditation standards. NC then conducted 2 pilot accreditation projects which were evaluated for feasibility. In Pilot I, 6 of 6 health departments were awarded accreditation. This pilot revealed areas for improvement of the self assessment instrument. In Pilot II, 4 of 4 health departments were awarded accreditation. This pilot revealed the need to address process and policy issues In 2005, the NC legislature passed legislation to create a mandatory, ongoing system with all health departments to go through accreditation process by 2012.

57. PROCEDURAL Peer or professional site visitors Conduct of visit Requests for additional documentation Exit conference Board procedures Appeals process Confidentiality of proceedings and �findings� POLICIES There has been some confusion as to the criteria for meeting a standard, what documentation counts? When can additional documentation be introduced�at the site visit, after the site visit, during Accreditation Board deliberations? How should standards and activities that are in conflict with county policy be treated. Perception that a health department should try to meet all standards and activities. On the one hand pilot health departments wanted to be seen as doing the best possible, they wanted to be viewed well by their peers. On the other hand, they tried to meet all standards to �hedge their bets.� If they missed a few, but covered the rest, they would still be accredited by reaching the 80% threshold. POLITICS 1. Buy in from elected officials: county commissioners have expressed reservations about an accreditation system because there is a cost associated with becoming accredited and there are costs to having an accredited health department. 2. Accreditation might increase the cost of public health service delivery for the health department that may not be supported by the state 3. If the state mandates the system, but most funding comes from local county and state provides no money for accreditation, it becomes an unfunded mandate. PURPOSE What is the goal of accreditation? Performance improvement process Validation process that health department has in place policies and activities to provide essential services Performance improvement implies nobody fails All or nothing allows for failure and remediation, some concerned that this might mean elimination of health departments PROCEDURAL Peer or professional site visitors Conduct of visit Requests for additional documentation Exit conference Board procedures Appeals process Confidentiality of proceedings and �findings� POLICIES There has been some confusion as to the criteria for meeting a standard, what documentation counts? When can additional documentation be introduced�at the site visit, after the site visit, during Accreditation Board deliberations? How should standards and activities that are in conflict with county policy be treated. Perception that a health department should try to meet all standards and activities. On the one hand pilot health departments wanted to be seen as doing the best possible, they wanted to be viewed well by their peers. On the other hand, they tried to meet all standards to �hedge their bets.� If they missed a few, but covered the rest, they would still be accredited by reaching the 80% threshold. POLITICS 1. Buy in from elected officials: county commissioners have expressed reservations about an accreditation system because there is a cost associated with becoming accredited and there are costs to having an accredited health department. 2. Accreditation might increase the cost of public health service delivery for the health department that may not be supported by the state 3. If the state mandates the system, but most funding comes from local county and state provides no money for accreditation, it becomes an unfunded mandate. PURPOSE What is the goal of accreditation? Performance improvement process Validation process that health department has in place policies and activities to provide essential services Performance improvement implies nobody fails All or nothing allows for failure and remediation, some concerned that this might mean elimination of health departments

58. Health Directors Wanted it Sold it Promoted it Support it Political champions Legislators County commissioners Boards of health Partners and stakeholders Involved throughout process Engaged Wrestled with issues Supported process Incentives Tangible�gaining funds that require accreditations�mental health funding example; maintaining funds that might have been lost Intangible�health department staff team building, pride in job, improved appreciation for what public health does Health Directors Wanted it Sold it Promoted it Support it Political champions Legislators County commissioners Boards of health Partners and stakeholders Involved throughout process Engaged Wrestled with issues Supported process Incentives Tangible�gaining funds that require accreditations�mental health funding example; maintaining funds that might have been lost Intangible�health department staff team building, pride in job, improved appreciation for what public health does

63. The Public Health Improvement Plan PHIP 1993 Health Services Act Public Health as a part of Health Reform 1993 43.70.520 - required the plan 1995 43.70. 580 - accepted the first plan and specified future work and an ongoing commitment to improve public health

64. PHIP Requirements Establish performance standards Measure and report on performance Estimate costs to achieve standards statewide Biennially, use the PHIP to evaluate the effectiveness of the public health system Present this work to the legislature

69. The Plan-Do-Check-Act Cycle

70. The Plan-Do-Check-Act Cycle

71. The Plan-Do-Check-Act Cycle

72. Our Vision for Public Health Key health indicators guide investments Performance standards are used statewide Financing is stable, sufficient and equitable Information technology is standardized, secure Workers receive continuous training Access is provided for critical health services Communication about public health is effective Strong alliances support public health

73. Our Goal A predictable level of public health protection throughout the state �What every person has a right to expect.�

74. Why is this difficult in Washington? 35 Separate Local Districts and Boards of Health Wide variation in� Size, Settings, Services, Funding, Philosophy Categorical funding and piecemeal statutes Fear of �Rush to the Floor�

75. Enhancement Project Plan Experience increased efforts in the state Department of Health and four local health jurisdictions Broaden communications and understanding Promote use of the standards for quality improvement across the public health system in Washington state