Transcript Beginning Slides - ASTHO (Association of State and

Saving, Naming, and Describing Documents
Susan Ramsey
Pearls of Wisdom Consulting
[email protected]
253-606-0956
Lia Katz
ASTHO
[email protected]
(202) 371-9090
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Read the statement of the specific measure,
including the “Intent”
Read each requirement carefully. You will need to
validate that each of these requirements are present
in the documentation to receive a score of “Fully
Demonstrates”
Review the guidance section in detail and highlight
every “active” verb statement
Review the PHAB acronyms and glossary and use to
clarify definition of terms and how they are used in
the PHAB Standards
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Domains
Programs
Use of Quality Improvement
Workforce Development
Food Safety
Program
Health Policy & Plans
On-site Septic
Program
Community Involvement
Immunization
Program
Monitor Health Status
Family Planning
Program
STD HIV/AIDS
Programs
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Reflects the work of the health department
Representative of the entire range of
programs and services (sources of
documentation)
Most applicable to what the measure
requires
Talk with peers when stuck
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Written descriptions of process: policies and
procedures, protocols, emergency response plan,
manuals, flowcharts, logic models or other
documentation
Reports: health data summaries, survey data
summaries, data analysis, audit results, meeting
agendas, committee minutes and packets, after-action
evaluations, continuing education, tracking logs, work
plans, financial reports, QI reports or other
documentation
Materials: 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
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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
Standardized footer – name, date
Anyone as long as the document is in use by the
health department (May require proof of the
relationship)
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PHAB Standards Introduction page 5
 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,
prior to documentation submission;
 Regular – within a pre-established schedule, as
determined by the health department; and
 Continuing – activities that have existed for some
time, are currently in existence, and will remain in
the future
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PHAB’s handout, Preparing Documentation, has the details
on:
◦ How to write a good Document Description or Measure
Narrative;
◦ The rules on the types of characters allowed in document
titles;
◦ The rules for character and word length in titles, Document
Descriptions, and Measure Narratives. You must meet
these length rules in order to upload your documents.
 To check character or word count in Word, highlight the
text you want to count; go to the Review tab in Word;
click on Word Count in the left-most box of the menu
ribbon. A box pops up with the info. To check title
length, you have to cut and paste it into a Word
document then check it per above instructions
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Acceptable File Formats
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Documents
◦ Include a title or cover page
◦ Highlight:
 Title
 Date
 Text in the document that meets the measure
 Page of … total pages in document if
extracted
◦ Use only what you need to meet
the standard
Websites
◦ Create screen shots of web sites
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This is a screen shot of a common
drive folder. We have mirrored
PHAB’s Domain, Standard and
Measure structure.
Each measure folder, create a
Doc_x subfolder for each instance
of what PHAB calls required
documentation.
For example, Measure 1.1.1 of the
Standards has three instances of
required documentation, so it
contains three Doc_x folders,
numbered 1,2 and 3.
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Put your documents into the correct Doc_x
folder, along with its document description.
If you create a Measure Narrative, save it in
the Measure folder, not a Doc folder, since
it covers all the documents you submitted
to prove the entire measure
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Use a system that makes sense to you
Use a system so that you will know what is
in a file and what it is for
Use a system so that anyone in your
department who looks at the name will
know what the file contains
Titles and descriptions
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It is likely that someone other than you will upload
documents from your common drive into e-PHAB.
They’ll depend on your document names to put
them in the correct e-PHAB location. If you don’t
follow the naming rules, you’ll be asked to spend
extra time to rename everything you created
Include the date of the document to distinguish
documents from one another, put it here, in this
format
Titles may contain only letters, numbers, periods,
commas and spaces – no underscores or other
special characters
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There are three different ways e-PHAB allows us to
explain how our documentation meets the measures:
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3.
A really descriptive document title
A Document Description (we called this a “read-me”
note) telling the reviewer why the document proves
we meet the measure, and where to look in the
document for the proof. Suggestion: Each of our
documents must have a companion Document
Description
A Measure Narrative telling how multiple documents
submitted for one measure work together to provide
proof. These are optional, but recommended. Be
conservative – do not assume a reviewer will
understand your intentions
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Preparing Document Narratives
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Document title
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Document description
◦ Identify documents
◦ 250 characters limit
◦ Describe document: what it is, what is in it, where
the relevant section is
◦ 150 works limit
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Measure narrative
◦ Explain how documents demonstrate the measure
◦ 10,000 character limit (including spaces,
punctuations)
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E-PHAB Title Box
Use the title boxes to provide a concise name
for the document so the Site Visitors know
what they are about to read
◦ Character Limit: 250 characters
◦ Required
◦ Letters, numbers and spaces
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E-PHAB Description Boxes
Use the description boxes to help provide the
link between the Measure and the uploaded
document for the Site Visitors
◦ Character Limit: 150 words
◦ Optional (recommended)
 Describe how the document demonstrates
conformity
 Identify specific location within the document
 Provide context if upload is part of a larger
document
 Describe the author, if not a health department
document
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E-PHAB Measure Narrative
Use the measure narrative to explain to the
Site Visitor the reason for selecting ALL
documents submitted for the measure
◦ Size Limit: 10,000 characters
◦ Optional (recommended)
 Give context to the evidence
 Describe how all evidence demonstrates conformity
 Explain why the HD is using the documents
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Site reviewers will not be familiar with your HD or
even your state
Provide short summary or note that describes
your processes for the topic addressed by the
measure
Be laser-focused on the specific requirement of
that measure
State page number (or highlight with text box)
where specific information addressing the
measure is located if document more than three
pages long
Provide only the documentation that is needed to
demonstrate performance. More is not better!
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Office
Measure #
How Meets
Standard
Office of Non-Infectious Conditions Epidemiology
Measure 1.1S
Non-Infectious Conditions Epidemiology is responsible for
coordinating the production of The Health of Washington
State report, a comprehensive assessment of trends in
population health status, communicable disease,
environmental health risks, health disparities, and access to
critical health services. A sample of chapters from the 2007
update of The Health of Washington State is included for
documentation of this measure. Additional chapters may be
viewed at: http://www.doh.wa.gov/hws/HWS2007.htm.
Written definitions and descriptions of the data used in The
Health of Washington State are included at the top, righthand corner of each chapter. Additional description of the
data sources is shown in Appendix B of the report.
Where located
in document
Barrier analysis (qualitative data) is incorporated into most
chapters off The Health of Washington State. An additional
example of using qualitative date in assessment is the WIC
Listens Project Report. NICE staff (Amira El-Bastawissi)
provided epidemiological consultation and served as a
project team member for this report.
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