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Local Documentation Selection & Review PHAB Domains 1-4. Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series C oalition of Local Health Officials. Agenda. Accreditation Preparation Process Selecting & Reviewing Documentation Domain Team Structure

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local documentation selection review phab domains 1 4

Local Documentation Selection & Review PHAB Domains 1-4

Erin Mowlds, Program Manager for Local Accreditation

Local Accreditation Webinar Series

Coalition of Local Health Officials

  • Accreditation Preparation Process
  • Selecting & Reviewing Documentation
    • Domain Team Structure
    • Documentation Policies & Considerations
  • Domains 1-4
    • NACCHO Summaries
    • Overall Example Tool
    • Checklist Tool
    • Benton County Tool
  • Self Scoring & Improvement Processes
    • Scoring Tool
    • Examples
preparing for accreditation
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
  • Institutionalize assessment and CQI processes

Selecting &

Reviewing Documentation

domain team structure
Domain Team Structure
  • Share documentation domain team methods
  • NACCHO models:
  • Model 1 (large HDs): The accreditation preparation team is comprised of the Accreditation Coordinator, senior management and program staff.
  • Model 2 (mid-size HDs): The accreditation preparation team is comprised of the Accreditation Coordinator and senior management
  • Model 3 (small HDs): The accreditation preparation team is comprised of the Accreditation Coordinator and the Health Director.
documentation policies
Documentation Policies
  • No draft documents
  • Documentation must be dated and in effect and in use at the time that they are submitted
  • 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
  • HDs are encouraged to provide narrative that describes how the submitted document relates to and meets the requirement.
selection of documentation
Selection of Documentation
  • Relevant to the Domain, Standard, and Measure
  • Documentation Specific to “Required Documentation” and “Guidance” in the Standards and Measures Version 1.0
  • Focused Documentation
types of documentation
Types of Documentation
  • Documentation of Policies and Processes
  • Documentation for Reporting Activities, Data, and Decisions
  • Documentation to Demonstrate Distribution of Information, Technical Assistance and Other Activities
program representation in documentation
Program Representation in Documentation
  • HDs are encouraged to utilize documentation from a variety of PH programs
  • Some measures require that both program and administrative examples are provided. Other measures require two program examples. Other measures require that one of the examples is from a particular type of program (e.g., chronic disease program).
  • While some HDs provide mental health, substance abuse, primary care, human, and social services (including domestic violence), these activities are not considered core PH and PHABʼs scope of accreditation authority does not extend to these areas.
reuse of documents
Reuse of Documents
  • A single document may be relevant for more than one measure and may be used multiple times.
  • Or a single page or chapter of a document used for a measure could be used for another measure.
  • The specific section(s) of the document that addresses the measure must be identified.
multiple documents
Multiple Documents
  • 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.
  • For example, a required set of policies may be contained in several policy documents.
  • An explanation must be included that describes how the documents, taken together, demonstrate conformity with the measure.
documentation timeframes
Documentation Timeframes
  • Documentation submitted must be dated within the five years prior to the date of submission to PHAB, unless otherwise noted by PHAB.
  • Timeline Definitions:
    • Annually- within the previous 14 months of documentation submission,
    • Current- within the previous 24 months of documentation submission,
    • Biennially- within each 24 month period, at least, previous to documentation submission,
    • Regular- within a pre-established schedule as determined by the health department.
signing dating documents
Signing & Dating Documents
  • Documents must be signed and dated in order for site visitors to be able to evaluate conformity with timeframes.
  • Where the requirement is for a document to be adopted within a time frame, such as a CHA, it must be dated.
  • Printed documents, such as a CHA or CHIP do not have to be signed if they are official documents adopted by the HD (with the HD logo, which would, in effect be the same as a HD signature).
revising documents
Revising Documents
  • HD can change any documentation until they hit the final "submit" button to submit the materials to PHAB
  • The HD MAY NOT update or revise documentation after it has been submitted to PHAB and before the site visit.
  • If any additional information is submitted to the site visit team, that documentation must have been developed and adopted prior to the date of the HD’s submission of documentation to PHAB
documentation developed by others
Documentation Developed by Others
  • 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.
  • The purpose of documentation review is to confirm that materials exist and are in use in the HD being reviewed regardless of who originated the material.
confidential documentation
Confidential Documentation
  • Where documentation contains confidential information, the confidential information must be covered or deleted.
  • The health department should not submit any documentation that has personal information or identifiers.
  • A template or form used for the collection or presentation of information can be submitted with an explanation that records will be available on site for review by the PHAB site visitors.
documentation resources
Documentation Resources
  • PHAB Blank Document Tracker
  • PHAB Standards and Measures Version 1.0
  • Guide to National Public Health Accreditation
  • National Public Health Department Accreditation Documentation Guidance
  • http://www.naccho.org/topics/infrastructure/accreditation/documentation.cfm

Domains 1-4:

NACCHO Considerations for Local Documentation Requirements

domain 1
Domain 1

Conduct and disseminate assessments focused on population health status and public health issues facing the community

Domain 1 focuses on the assessment of the health of the population in the jurisdiction served by the health department. The domain includes: systematic monitoring of health status; collection, analysis, and dissemination of data; use of data to inform public health policies, processes, and interventions; and participation in a process for the development of a shared, comprehensive health assessment of the community.

standard 1 1
Standard 1.1

Participate in or conduct a collaborative process resulting in a comprehensive CHA

    • Participate in or conduct a local partnership for the development of a comprehensive CHA of the population served by the health department
    • Complete a local CHA
    • Ensure that the CHA is accessible to agencies, organizations, and the general public


  • The CHA partnership must meet regularly
  • Several accepted state or national models (including MAPP)
  • Documentation must address health status disparities, health equity and high health-risk populations
standard 1 2
Standard 1.2

Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on health status of the population

  • Maintain a surveillance system for receiving reports 24/7 in order to identify health problems, public health threats, and environmental public health hazards
  • Communicate with surveillance sites at least annually
  • Collect additional primary and secondary data on population health status
  • Provide reports of primary and secondary data to the state health department and Tribal health departments in the state
standard 1 2 continued
Standard 1.2 Continued


  • An LHD must identify the community partners from which it collects surveillance data and must show proof of trainings for or meetings with these partners
  • Surveillance refers to the systematic monitoring of health status; reports of surveillance can be brief and can focus on only one topic
  • The amount of reports published by an LHD can vary greatly depending on the LHD's size and capacity
  • A standardized data collection instrument can refer to a tool that is recognized as a national, state, or local tool or can be one tool used with many respondents
  • Measure 1.2.3 A requires documentation of two reports of aggregated data. Measure 1.2.4 L requires distribution of two reports to state/Tribal health departments. An LHD may use the same reports for both measures, but this is not required
standard 1 3
Standard 1.3

Analyze public health data to identify trends in health problems, environmental public health hazards, and social and economic factors that affect the public's health

  • Analyze and draw conclusions from public health data
  • Provide public health data to the community in the form of reports on a variety of public health issues, at least annually
standard 1 3 continued
Standard 1.3 Continued


  • Reports containing analysis can focus on specific health issues or community health in general
  • Documentation from an agency's CHA can be used to show data analysis
  • For measure 1.3.1 A, reports containing analysis can be for the PH community and therefore do not need to have a specific target audience
  • For measure 1.3.2 L, reports need to be directed at a target audience and distribution should be documented
  • For measure 1.3.2 L, the HD does not need to develop the reports it distributes; reports not produced by the LHD must have a connection to the jurisdiction or population, or contain significant PH information
standard 1 4
Standard 1.4

Provide and use the results of health data analysis to develop recommendations regarding public health policy, processes, programs, or interventions

  • Use data to recommend and inform public health policy, processes, programs, and/or interventions
  • Develop and distribute community health data profiles to support public health improvement planning processes at the local level


  • A health data profile is not a comprehensive health assessment; it can be an overview, summary or synopsis of a particular issue
naccho examples
NACCHO Examples
  • http://www.naccho.org/topics/infrastructure/accreditation/domain-1-examples.cfm
    • 1-1-2-L-community-needs-assessment.pdf
    • 1-2-1-A-24-7-protocol-for-reporting.pdf
    • 1-2-3-A-adult-data-book.pdf
    • 1-4-2-A-healthy-housing-health-profile.pdf
domain 2
Domain 2

Investigate health problems and environmental public health hazards to protect the community

Domain 2 focuses on the investigation of suspected or identified health problems or environmental public health hazards. Included are epidemiologic identification of emerging health problems, monitoring of disease, availability of public health laboratories, containment and mitigation of outbreaks, coordinated response to emergency situations, and communications.

standard 2 1
Standard 2.1

Conduct timely investigations of health problems and environmental public health hazards. 

  • Maintain protocols for investigation process
  • Demonstrate expertise and capacity to conduct investigations and an infectious or communicable disease
  • Demonstrate expertise and capacity to conduct investigations of non-infectious health problems and environmental/occupational public health hazards
  • Work collaboratively through established governmental and community partnerships on investigations of reportable/disease outbreaks and environmental PH issues
  • Monitor timely reporting of notifiable/reportable diseases, lab test results, and investigation results
standard 2 1 continued
Standard 2.1 Continued


  • Agreements and laws must be current, dated, and signed
  • Documents must include clear roles, responsibilities, qualifications, and credentials
  • Rosters must be dated and include list of attendees
  • Investigation reports must include a review and it must be clear that edits were incorporated
  • AARs must be timely (i.e., produced at an appropriate time after an incident)
standard 2 2
Standard 2.2

Contain/mitigate health problems and environmental public health hazards

  • Maintain protocols for containment/mitigation of PH problems and environmental PH hazards, including disease-specific procedures for outbreaks and conducting follow-up documentation and reporting
  • Demonstrate that protocols for containment/mitigation of PH problems and environmental PH hazards include processes determining what triggers implementation of the All Hazards Emergency Operations Plan (AHEOP)
  • Complete an After Action Report (AAR) following communicable disease outbreaks, environmental PH risks, natural disasters, and other events that threaten the health of the people


  • Protocols must be current, address listed elements and be specific.
  • AARs must include all components addressed: what worked well, what issues arose, potential improvements, etc.
standard 2 3
Standard 2.3

Ensure access to laboratory and epidemiologic/environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards

  • Maintain provisions for 24/7 emergency access, including surge capacity, to epidemiological and environmental PH resources capable of providing rapid detection, investigation, and containment/mitigation of public health problems and environmental PH hazards
  • Maintain 24/7 access, including surge capacity, to laboratory resources capable of providing rapid detection, investigation, and containment of health problems and environmental public health hazards
  • Maintain access to other support personnel and infrastructure capable of providing additional surge capacity.
  • Demonstrate that Tribal, state and LHDs work together to build capacity and share resources to address efforts to provide for rapid detection, investigation, and containment of PH problems and environmental hazards
standard 2 3 continued
Standard 2.3 Continued


  • Process for accessing support during emergencies must be clear
  • Call down lists must be current and updated
  • Contracts/MOUs/MOAs/mutual assistance agreements must be  current, signed, and comprehensive
  • Laboratory capacity roles and protocols for handling specimens must be clear and certified
  • Protocol, procedure, or policy documents must be current
  • Staffing list must include detailed contact information and clear assignment of roles
  • Equipment list must be current and comprehensive
  • Training attendance must be dated
  • Records must be dated, current and reviewed
standard 2 4
Standard 2.4

Maintain a plan with policies and procedures for urgent and non-urgent communications

  • Maintain written protocols for urgent 24/7 communications
  • Implement a system to receive and provide health alerts and to coordinate an appropriate public health response
  • Provide timely communication to the general public during public health emergencies
standard 2 4 continued
Standard 2.4 Continued


  • Protocols for communications should be updated at least annually and should include health care providers, response partners, and the media
  • Protocols must include more than one way to contact each partner
  • Method of contacting HD must be current and clear to public and partners
  • Tracking system must be tested at different times, documentation should be dated and results of tests should be clear
  • Media communication should be timely and dated
naccho examples1
NACCHO Examples
  • http://www.naccho.org/topics/infrastructure/accreditation/domain2.cfm
    • 2-1-4-A-MOU-with-ND-for-tanning-inspections.pdf
    • 2-1-4-A-Murine-Typhus-EID-article.pdf
    • 2-1-4-A-Norovirus-Outbreak-Response.pdf
    • 2-2-3-A-Pandemic-Influenza-base-plan.pdf
    • 2-2-3-A-surveillance-guidelines.pdf
    • 2-4-2-A-Emergency-Exercise.pdf
    • 2-4-3-A-1-Swine-flu-and-you.pdf
    • 2-4-3-A-2-Media-statement.pdf
domain 3
Domain 3

Inform and educate about public health issues and functions

Domain 3 focuses on educating the public. This domain assesses the health department's processes for continuing communication as standard operating procedures.

standard 3 1
Standard 3.1

Provide health education and health promotion policies, programs, processes, and interventions to support prevention and wellness

  • Provide information to the public on protecting their health
  • Implement health promotion strategies to protect the population from preventable health conditions
standard 3 1 continued
Standard 3.1 Continued


  • Two different program areas must be represented  in health education materials
  • The date and target audience of the distribution of the health education materials must be clear
  • Input from target audience must be applicable to the examples of health education materials submitted
  • Health promotion strategies must address two program areas and one must address a chronic disease
  • Your health promotion strategies should be tied to your health improvement plan
  • Health promotion strategies should have evidence or support for their use
  • Collaboration documentation should include roles and responsibilities of all parties
standard 3 2
Standard 3.2

Provide information on public health issues and public health functions through multiple methods to a variety of audiences

  • Provide information on public health mission, roles, processes, programs, and interventions to improve the public's health
  • Establish and maintain communication procedures to provide information outside the health department
  • Maintain written risk communication plan
  • Provide accessible, accurate, actionable, and current information in culturally sensitive and linguistically appropriate formats for populations served by the health department
standard 3 2 continued
Standard 3.2 Continued


  • Documentation about providing information to the public must describe the purpose of the information and the dates and method of distribution
  • The written communications procedures must include all the information specified in the PHAB standards and measures guidance
  • Documentation of public health messaging must be from two different program areas (one chronic disease)
  • The written risk communication plan can be a part of a larger communications plan or be a part of the emergency operations plan
  • The HD website should be updated regularly and documentation should include links to each page showing the specific requirements delineated by PHAB
naccho examples2
NACCHO Examples
  • http://www.naccho.org/topics/infrastructure/accreditation/domain3examples.cfm
    • 3-1-1-A-H1N1-poster-and-dental-services-brochure.pdf
    • 3-2-3-A-communications-policies.pdf
domain 4
Domain 4

Engage with the community to identify and address health problems

Domain 4 focuses on community engagement. Community members are important partners in identifying and defining public health issues, developing solutions or improvements, developing policies, communicating important information, and implementing public health initiatives. Members of the community offer a unique perspective on how issues are manifested in the community, what community assets can be mobilized, and what interventions will be effective.

standard 4 1
Standard 4.1

Engage with the public health system and the community in identifying and addressing health problems through collaborative processes

  • Establish and/or actively participate in partnerships and/or coalitions to address specific public health issues or populations
  • Link stakeholders and partners to technical assistance regarding models of engaging with community


  • Rosters for collaborations must be current
  • Rosters must list partner organizations (names are not required)
standard 4 2
Standard 4.2

Promote the community's understanding of and support for policies and strategies that will improve the public's health

  • Engage with the community about policies and/or strategies that will promote the public's health
  • Engage with governing entities, advisory boards, and elected officials about policies and/or strategies that will promote the public's health


  • Community or governing entity engagement examples must have happened in last 2 years
naccho examples3
NACCHO Examples
  • http://www.naccho.org/topics/infrastructure/accreditation/domain-4-examples.cfm
    • 4-1-1-A-community-taksforce-documents.pdf
    • 4-1-1-A-poster-pediatric-safety.pdf
    • 4-1-1-A-school-wellness-committee-minutes.pdf
    • 4-1-1-A-screenshot-showing-partnership-participation.pdf
    • 4-2-1-A-News-Release.pdf
    • 4-2-1-A-newspaper-article-public-hearing.pdf
documentation checklist tools
Documentation Checklist Tools
  • Adapted NACCHO Documentation Tool
  • Document Checklist
  • Benton County Example
self scoring documentation
Self-Scoring Documentation
  • Documentation Review Process
  • Scoring Tool

(Adapted from Marni Mason)

analyzing areas for improvement
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.
prioritizing problems
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 Techniques
what is quality improvement
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

why quality improvement
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

qi in the context of accreditation
QI in the context of accreditation

QI is an important component of accreditation and of an effective, efficient HD

Domain 9, interwoven throughout

Prioritized component of accreditation for leadership






Improving the public’s health through continuous Quality Improvement

domain 9 quality improvement
Domain 9: Quality Improvement

Domain 9: Evaluate and continuously improve processes, programs, and interventions

Standard 9.1: Use a Performance Management System to Monitor Achievement of Organizational Objectives

Standard 9.2: Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions

implementing quality improvement
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
institutionalizing the continuous improvements
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
accreditation resources
Accreditation Resources
  • PHAB Resources
    • http://www.phaboard.org/accreditation-process/guide-to-national-public-health-accreditation/
    • http://www.phaboard.org/accreditation-process/public-health-department-standards-and-measures/
  • NACCHO Resources
    • http://www.naccho.org/topics/infrastructure/accreditation/preparing.cfm
    • http://www.naccho.org/topics/infrastructure/accreditation/exampledocumentation.cfm
  • RWJ Resources
    • http://www.rwjf.org/publichealth/accreditation.jsp
thank you
Thank you!

Erin Mowlds