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Preparing for National Accreditation review. Susan Ramsey, Director Office of Performance and Accountability November 7, 2011. Training Agenda. Topics for today: Overview of the 2011 PHAB version 1.0 Standards How to Interpret the 2011 PHAB version 1.0 Standards and Measures

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Preparing for national accreditation review

Preparing for National Accreditation review

Susan Ramsey, Director

Office of Performance and Accountability

November 7, 2011

Training agenda
Training Agenda

  • Topics for today:

    • Overview of the 2011 PHAB version 1.0 Standards

    • How to Interpret the 2011 PHAB version 1.0 Standards and Measures

    • Standards Review Process

    • Organizing for Self-Assessment

    • Mock Review of Selected Standards

  • Pre-requisites:

    • Online Standards Orientation – SmartPH

    • Review 2011 Standards

    • Review Introduction to the Guidelines

Interpretation of phab standards and measures
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

Development framework conventions
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

Domains cross all programs
Domains Cross all Programs

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


Family Planning Program


Immunization Program

On-site Septic Program


Health Policy & Plans

Monitor Health Status

Community Involvement

Use of Quality Improvement

Food Safety Program

STD and HIV/AIDS Programs

Phab standards framework
PHAB Standards Framework

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

32 Standards

105 Measures


Scope of domain 1
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 provided

    • Assessment information on website; press releases, waiting rooms, annual report

    • Samples of emails; SharePoint Sites

    • 4 Standards

Scope of domain 2
Scope of Domain 2

  • Domain 2: Diagnosis/investigation of health problems and environmental hazards

    • Written 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

Scope of domain 3
Scope of Domain 3

  • Domain 3: Provide Health Education/Promotion and Communicate PH functions

    • Public 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

Scope of domain 4
Scope of Domain 4

  • Domain 4: Engage the Community to Identify & Address Health Problems

    • Current 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 Standards

Scope of domain 5
Scope of Domain 5

  • Domain 5: Develop & Implement PH Policies and Plans

    • Conduct a process to develop a community/state health improvement plan

    • Maintaining an all-hazards emergency operations plan

    • 4 Standards

Scope of domain 6
Scope of Domain 6

  • Domain 6: Education and Enforcement of PH Laws

    • Review of public health laws

    • Document how staff have been trained in laws to support public health laws

    • Conduct and monitor enforcement activities

    • Follow up on complaints

    • Food service hearings/compliance plans

    • 3 Standards

Scope of domain 7
Scope of Domain 7

  • Domain 7: Assess Healthcare Capacity & Access & Implement Strategies to Address Gaps

    • Convene and/or participate in a collaborative process to assessavailability 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

Scope of domain 8
Scope of Domain 8

  • Domain 8: Competent PH Workforce & Assess Staff Competency & Address Gaps

    • Document relationships that promotes public health as a career

    • Health department workforce development plan

      • Nationally adopted core competencies

      • Curricula and training schedules

    • 2 Standards

Scope of domain 9
Scope of Domain 9

  • Domain 9: Program Evaluation & Quality Improvement Plans and activities

    • Evidence of maintaining an agency performance management system

    • Evidence of a written quality improvement plan

    • 2 Standards

Scope of domain 10
Scope of Domain 10

  • Domain 10: Identify and Use Evidence-based practices and Use of Research

    • Demonstrate and document examples of using evidence-based or promising practices

    • Documentation of availability of expertise (internal or external) for analysis of research

    • 2 Standards

Scope of domain 11
Scope of Domain 11

  • Domain 11: Operational Infrastructure - IT and Human Resource and Finance

    • Written operational policies – accessible to the staff

    • Organizational chart

    • Regular reviews and updating

    • Audited financial statements

    • Program reports/MOU’s

    • 2 Standards

Scope of domain 12
Scope of Domain 12

  • Domain 12: Engaging the Public Health Governing Entity

    • Documentation 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

Qi is built into the standards plan do study act standard 9 1





QI is Built into the Standards:Plan-Do-Study-Act-Standard 9.1

9.1.1 : Engage staff at all organizational levels in establishing or updating a performance management system

Conduct specific program activities that contribute to achieving goals and performance measures.

9.1.2: Implement a performance management system – self-assessment, committee or team

9.1.3: Use a process to determine and report on achievement of goals, objectives, and measures

Qi is built into the standards plan do study act standard 9 2





QI is Built into the Standards:Plan-Do-Study-Act-Standard 9.2

9.2.1: Establish a quality improvement program based on organizational policies and direction

9.2.2: Implement QI efforts

9.2.2: Documentation of quality improvement activities based on the QI plan

9.2.2: Demonstrate staff participation in quality improvement activities based on the QI plan

Guide to accreditation
Guide To Accreditation:

  • The 2011 Guide provides seven steps to national public health accreditation process:

  • Pre-application

    • Applicant prepares and assesses readiness checklists, views online orientation to accreditation, and formally informs PHAB of its intent to apply

  • Application

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

  • Documentation Selection and Submission

  • Applicant selects documentation and submits it to 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

  • Reports

    • Accredited health department submits annual reports

  • Reaccreditation (5 years later)

    • Accredited health department applies for reaccreditation

Major changes in the guide
Major Changes in The Guide

  • 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

  • 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
Guidance Provided in Standards and Measures

  • 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
Using the Standards and Measures for Interpretation

  • Read the statement of the Standard and of the specific measure

  • Read the “Purpose” of the measure

  • Review the “Significance”

  • Read the specifics in “Required Documentation”

  • 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”

  • 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


Purpose: describes the public health capacity or activity in which the health department is being assessed


Describes the necessity for the capacity of activity


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

Using the phab acronyms and glossary
Using the PHAB Acronyms and Glossary the document meet the measure?

  • Review the PHAB Acronyms and Glossary to clarify definition of terms and how they are used in the Standards

  • Glossary contains a list of acronyms used in the Standards

  • Offers assistance in understanding the Standards and Measures

Types of documentation to demonstrate performance
Types of Documentation to Demonstrate Performance: the document meet the measure?

  • 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.

Documentation requirements
Documentation Requirements the document meet the measure?

  • 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
Documentation in Daily Work the document meet the measure?

  • 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

Documentation timeframes
Documentation Timeframes the document meet the measure?

  • Some measures state a specific timeframe for the documentation, defined below:

    • Annual - within the last 14 months dating back from 10-10

    • Current - within the last 24 months prior to 12-09

    • Biennial - 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

Scoring the document meet the measure?

  • Not demonstrated

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

  • Slightly Demonstrated

    • Documentation 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.

  • What questions do you have
    What questions do you have? the document meet the measure?

    Preparing for standards review
    Preparing for Standards Review the document meet the measure?

    Standards review process
    Standards Review Process the document meet the measure?

    • 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

    Tell your story
    Tell Your Story…. the document meet the measure?

    • 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!

    Organizing your documents
    Organizing Your Documents the document meet the measure?

    • 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

    More documents is not better
    More Documents Is NOT Better!! the document meet the measure?

    • 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
    Labeling & Marking Documents the document meet the measure?

    • 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.

    What questions do you have1
    What questions do you have? the document meet the measure?

    Mock review
    Mock Review the document meet the measure?

    Mock review instructions
    Mock Review Instructions the document meet the measure?

    • 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

    Mock review assignments
    Mock Review Assignments the document meet the measure?

    What questions do you have2
    What questions do you have? the document meet the measure?