Working toward accreditation
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Working Toward Accreditation. Joan Ellison, Public Health Director Mary Margaret Stallone, Director Center for Preventive Services Livingston County Department of Health. Conference of Environmental Health Directors / NYSACHO Meeting December 18, 2012. Be A Part Of Achieving Excellence

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Working Toward Accreditation

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Working toward accreditation

Working Toward Accreditation

Joan Ellison, Public Health Director

Mary Margaret Stallone, Director Center for Preventive Services

Livingston County Department of Health

Conference of Environmental Health Directors / NYSACHO Meeting

December 18, 2012

Working toward accreditation

Be A Part Of

Achieving Excellence


Seven steps to accreditation

Seven Steps to Accreditation

  • Pre-application

  • Application

  • Documentation Selection and Submission

  • Site Visit

  • Accreditation Decision

  • Reports

  • Reaccreditation

Steps taken

Steps Taken…

  • Pre-application

    • Online Orientation

    • Assess Readiness

    • Inform PHAB- Statement of Intent to Apply

  • Application

  • Community Health Assessment

  • Community Health Improvement Plan

  • Agency Strategic Plan

Livingston county department of health accreditation timeline

Livingston County Department of Health Accreditation Timeline

Through November 2011

By November 16, 2011

January 2012-May 2012


Documentation Selection and Submission to PHAB

Submit Application to PHAB


Self Assessment

Between June 2012

and November 2012

By February? 2013

Scheduled Site Visit- Could be 1-6 months after submission of all documentation



Steps taken1

Steps Taken…

  • Assemble Accreditation Team

  • Assign Domains to Domain Leader

  • Assemble Domain Teams

Steps taken2

Steps Taken…

  • Documentation Selection and Submission

  • Domain Team Meetings

    • Discussion

    • Gathering of materials/ documents

Steps taken3

Steps Taken…

  • Discussion of materials at Accreditation Team meeting

Steps taken4

Steps Taken…

  • Accreditation Coordinator attended Accreditation Training

    • Shared information with Accreditation Team

    • Discussed revision of process

Steps taken5

Steps Taken…

  • Public Health Director and Accreditation Coordinator met with Domain Leaders

    • Domain Leaders then met with their teams to discuss and revise information as needed

Steps taken6

Steps Taken…

  • Accreditation Team met again to discuss new information to determine if the standards were met

Tracking our achievement

Tracking Our Achievement

Getting ready to push the button

Getting Ready to Push the Button

Pushing the button

Pushing the Button!

Final submission

Final Submission!

Responding to questions

Responding To Questions

  • Two Sets of Questions

  • Related to dates and signatures on documents

  • More information requested from site team

Steps taken7

Steps Taken

  • Site Visit

11/29/12 and 11/30/12

Next steps

Next Steps

  • Accreditation Decision

  • Review Accreditation Site Visit Report- within 14 days of the site visit

  • LCDOH has 30 days to respond

  • Report is sent to the PHAB Board for their review

  • LCDOH to be contacted in approximately two months regarding Board decision

    • If LCDOH does not get accredited, LCDOH has 90 days to take corrective action

Next steps1

Next Steps

  • Accreditation Decision

  • Accreditation- good for five years

    • Site visit team recommends opportunities for improvement

  • Not Accredited

    • Must submit accreditation plan within 90 days

    • Must implement and provide proof of implementation of action plan with 12 months

Next steps2

Next Steps

  • Reports

  • Department reports progress annually

  • Reaccreditation

  • Application for reaccreditation after 5 years



  • Appointing an Accreditation Coordinator

  • Appointing Domain Leaders

  • Include Diverse Group of Staff

  • Ensure Adequate Time to Gather, Revise and Submit Information



  • Staff Awareness and Involvement from the beginning

  • Staff Input – meeting the criteria

  • Creation of Several Policy and Procedures

  • Met Deadlines for Submission

  • Strive to Improve Various Areas

    • Strategic Plan

Working toward accreditation

Lessons Learned Regarding Required Documents

  • Comprehensive meeting minutes

  • Presentations to include date, time, place

  • Documentation of process

  • Proceed with Domain in Numerical Order

What are we doing differently

What Are We Doing Differently?

  • Performance Management

  • Quality Improvement

  • Minutes

    • Documentation of process

  • Tracking systems in place

  • Identify who, what and where presentations are made

Working toward accreditation

Accreditation is the beginning







Improving the public’s health through continuous quality improvement


National Association of County & City Health Officials



Working toward accreditation

Livingston County Department of Health

2 Murray Hill Drive

Mt. Morris, NY 14510


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