Transcript Document

Outline:
Binders (walk through as doing training)
Review contents
Welcome
Purpose: To train the Domain Team leads in the process of conducting team
meetings, first steps, and expected outcomes/timelines
Roles and Responsibilities
Overview of timeline – update on status of pre-requisites
General process overview
Intro to the PHAB standards
What are the Domains
Basic structure of standards
Key elements from documentation guidance document/AC Handbook
Self Assessment Tool (review of original and use of new)
Documentation Basics – PHAB ppt
Preparing documentation –
Documentation selection –
key elements
Assessing documentation
what types should you look for
Core Public Health Programs
Tools to manage the documentation (PHAB spreadsheet)
Accreditation SharePoint site
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Accreditation Team Leads
Training
Traci Berreth and Dan Ward
November 6, 2014
 Purpose
 Train the Domain Team Leads on the roles within your
teams, the process of accreditation document review and
collection, and expected outcomes/timelines
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Accreditation Structure
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Roles and Responsibilities
 Accreditation Coordinator: Traci Berreth
 Oversee accreditation efforts
 Process Manager: Dan Ward
 Oversee processes & manage timelines
 PHAB Nomenclature Team: Traci, Dan, Chris Ball, Katie
Anderson, & Sonja Schriever
 Define the process for documentation collection, establish structure
for managing documentation
 PHAB Management Team: Elke, Traci, Dan, Domain Team
leads
 Participate in and guide major steps, guide completion of prerequisites, work on formalizing QIP and Workforce development
plans; etc.
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Roles and Responsibilities
 Domain Team Leads and Co-Leads:
 Team 1: Dieuwke (Co-lead Elke, Traci)
 Team 2: James (Co-lead Kris S.)
 Team 3: Sonja (Co-lead Mary)
 Team 4: Kathy (Co-lead Chris B.)
 Develop in-depth knowledge of assigned domains and standards
 Convene Domain Team meetings and manage overall process
for the team
 Assess documentation
 Report on progress
 Identify gaps in documentation and assign tasks to address
 Approve the documentation for final review by PHAB MT
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Roles and Responsibilities
 Team Members:
 Develop in-depth knowledge of assigned domains and
standards
 Identify potential documentation for each measure
 Assess documentation to ensure it meets the standard
 Identify gaps in documentation and inform Team Lead
 Assist in completing required documentation elements for
e-PHAB
 Participate in quality improvement initiatives to address
opportunities for improvement within assigned domains
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Seven Steps of AccreditationStep 1
 1. Pre-Application (Division is officially here)
 Preliminary work to assess readiness of the Department
 Assign key roles and responsibilities
 Complete online orientation
 Begin outlining timelines and work plans
 Complete and submit Statement of Intent
 One year prior to submitting Application
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Seven Steps of Accreditation –
Steps 2 & 3
 2. Application
 Submit on-line application via e-PHAB
 AC attends in person training (access given to e-PHAB when
training complete)
 3. Documentation review and selection
 Begin assessing and selecting documents following PHAB
criteria
 Implement process for accessing, reviewing and selecting
documents prior to upload to e-PHAB
 Submit documentation through e-PHAB
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Seven Steps of Accreditation –
Step 4
 4. Site Visit
 PHAB team conducts completeness review of submitted
documents, allows state 30 days to respond to requests for
further clarification or additional information
 2-3 day visit from PHAB Team
 State participants will include: AC, Administrator, DHW Director
and other governance, Domain Team leaders, other key
division/department staff, and Community Partners
 Visit includes: Entrance conference, Department walk-through,
Interviews with key staff, Sampling and collection of additional
information if requested, Exit conference
 Within 2 weeks of visit and report will be issued
 State will have 30 days to respond to factual errors
 No response to corrective action plan at this time
 Recommendation made to Accreditation Committee
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Seven Steps of Accreditation –
Step 5
 5. Accreditation Decision
 PHAB Accreditation Committee convenes and determines
status
 Accredited or Not Accredited
 If Not Accredited: State has 90 days to respond with
“Accreditation Action Plan”
 PHAB reviews and approves (1 year to complete, re-reviewed)
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Seven Steps of Accreditation –
Steps 6 & 7
 6. Annual Reports
 7. Re-accreditation process begins within 1 year
of expiration
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Timeline Overview
 7/1/14:
Submit Statement of Intent
(Completed 8/1/14)
 7/1/15:
Make application to PHAB (commit fees)
 7/1/16:
Documentation submission complete
 12/31/16:
Site visit completed, Division of Public
Health Accredited!
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Detailed Timeline – First 6 months
Oct-Dec 2014
 Teams convened for first time
 Team members receive initial training and assignments
to review assigned domains.
Jan-Mar 2015
 Training on documentation review and uploading
documents to SharePoint provided to each team
 Teams complete PHAB Self-Assessment v1.5 to identify
gaps
 Team members begin collecting possible documentation
examples that meet required standards of date, evidence
of authenticity, version (draft or final), and criteria
outlined in the Standards and Measures
 Team leads report to PHAB MT
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Overview of Team Process –
Documentation Review and Selection
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
PHAB Standards Introduction
Assessing Documentation
Domain
Standard
Measure
Required Documentation
Guidance
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
PHAB Domains and Standards
Overview
Domain 1. Conduct and disseminate assessments focused on population health status
and public health issues facing the community
1.1
1.2
1.3
Participate in or conduct a collaborative process resulting in a comprehensive
community health assessment
Collect and maintain reliable, comparable, and valid data that provide information
on conditions of public health importance and on the health status of the
population
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
Provide and use the results of health data analysis to develop recommendations
regarding public health policy, processes, programs or interventions
Domain 2. Investigate health problems and environmental public health hazards to
protect the community
Conduct timely investigations of health problems and environmental public health
2.1
hazards
1.4
2.2
Contain/mitigate health problems and environmental public health hazards
2.3
Ensure access to laboratory and epidemiological/environmental public health
expertise and capacity to investigate and contain/mitigate public health problems
and environmental public health hazards
2.4
Maintain a plan with policies and procedures for urgent and non-urgent
communications
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
PHAB Domains and Standards
Overview
Domain 3. Inform and educate about public health issues and functions
3.1
Provide health education and health promotion policies, programs, processes,
and interventions to support Prevention and Wellness
3.2
Provide information on public health issues and public health functions through
multiple methods to a variety of audiences
Domain 4. Engage with the community to identify and address health problems
4.1
Engage with the public health system and the community in identifying and
addressing public health problems through collaborative processes
4.2
Promote the community’s understanding of and support for policies and
strategies that will improve the public’s health
Domain 5. Develop public health policies and plans
5.1
Serve as a primary and expert resource for establishing and maintaining public
health policies, practices, and capacity
5.2
Conduct a comprehensive planning process resulting in a Tribal/state/community
health improvement plan
5.3
Develop and implement a health department organizational strategic plan
5.4
Maintain an all hazards emergency operations plan
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
PHAB Domains and Standards
Overview
Domain 6. Enforce public health laws
6.1
Review existing laws and work with governing entities and elected/appointed officials
to update as needed
6.2
Educate individuals and organizations on the meaning, purpose, and benefit of public
health laws and how to comply
6.3
Conduct and monitor public health enforcement activities and coordinate notification
of violations among appropriate agencies
Domain 7. Promote strategies to improve access to health care services
7.1
Assess health care service capacity and access to health care services
7.2
Identify and implement strategies to improve access to health care services
Domain 8. Maintain a competent public health workforce
8.1
Encourage the development of a sufficient number of qualified public health workers
8.2
Ensure a competent workforce through the assessment of staff competencies, the
provision of individual training and professional development, and the provision of a
supportive work environment
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
PHAB Domains and Standards
Overview
Domain 9. Evaluate and continuously improve health department processes, programs, and
interventions
Use a performance management system to monitor achievement of organizational
9.1
objectives
9.2
Develop and implement quality improvement processes integrated into organizational
practice, programs, processes, and interventions
Domain 10. Contribute to and apply the evidence base of public health
10.1
Identify and use the best available evidence for making informed public health practice
decisions
10.2
Promote understanding and use of the current body of research results, evaluations, and
evidence-based practices with appropriate audiences
Domain 11. Maintain administrative and management capacity
11.1
Develop and maintain an operational infrastructure to support the performance of public
health functions
11.2
Establish effective financial management systems
Domain 12. Maintain capacity to engage the public health governing entity
12.1
12.2
12.3
Maintain current operational definitions and statements of public health roles,
responsibilities, and authorities
Provide information to the governing entity regarding public health and the official
responsibilities of the health department and of the governing entity
Encourage the governing entity’s engagement in the public health department’s overall
obligations and responsibilities
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Standard Structure
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Documentation Selection
 Consider selection options and programs:
 Best reflects health department operation
 Meets specifics of the Required Documentation
 Demonstrates conformity with measure (Context and
intent of M & S & D)
 A variety of programs
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Documentation Selection
 Current & in use when submitted
 Draft documents not accepted
 No confidential information
 2 examples within past 5 years unless
otherwise required (based on submission to PHAB)
 Paperless process
 –“hard copy” submitted electronically in e-PHAB
 Submit in acceptable file formats
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Documentation Selection
 Documents may be used for more than one
measure
 –i.e., Can use same document more than once
 Continuity versus across department
 Several documents may be needed to
demonstrate conformity
 Don’t confuse # of examples with # of
documents
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Evidence of Authenticity
Evidence of Authenticity = Signature
 All documents must show evidence of authenticity.
That is, the document must have a logo, signature,
email address, or some other evidence that the
document is “authentic” to the applicant health
department. The purpose for this requirement is to
provide PHAB site visitors with evidence that the
documentation does in fact “belong” to the health
department being reviewed.
 Evidence of Authenticity is a best practice
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Evidence of Authenticity
Examples:
 Documentation could be a written policy and include the
signature of a governor, mayor, or health department director.
 With email; the "To" and "From" and the email addresses will
serve as evidence that the document is "official" health
department business.
 A department logo will provide the evidence that the document
is an official health department document.
 A brochure will not have the health department or program director's
signature, but it will include the department's logo.
 Meeting minutes are usually signed but may include the department’s
logo instead, noting that it is an “official” document.
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
All Documents Must be Dated
 All documentation used to demonstrate conformity with
measures must be dated within the timeframe indicated in
the Guidance. The date indicates when the document was
created, adopted, reviewed, revised, etc.
 The specificity of the date on the document will depend on
the documentation requirement and the type of document.
 Emails provide the full date and time
 Policies may include the month, day, and year.
 Reports may include the month and year.
 A brochure may include only the year. In most cases the month
and year will be required
 Dating on documents is a best practice
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Step 1 – Dates and Signatures
Review your existing
documents:
 Policies
 Dates:
 Created date
 Revised date
 Reviewed date
 Procedures
 Amended date
 Plans
 Effective period
 Directives
 Public Information
 Protocols
 Signatures:
 (“Evidence of
authenticity”) HD logo
 HD Director signature
 HD Abbreviation
 HD e-mail address
Division of Public Health
Idaho Department of Health and Welfare
 Membership list
11/6/14
Not Prescriptive
 Look for “What” is in place, not “How” it got there
or “Who” developed it
 Documentation may be developed, e.g.,
 By the health department
 By another level of government (an umbrella agency,
the state or local HD)
 By another governmental agency
 By a community partner, non-profit org
 By a contractor (e.g., consultant, academic)
 By a partnership (evidence of membership)
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Core Public Health Programs
 access to clinical services
 health promotion
 chronic disease prevention
and control
 injury prevention
 communicable disease
 community health
 environmental public
health
 governance
 health education
 management
/administration
 maternal and child health
 public health emergency
preparedness
 public health laboratory
services
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
NOT used for PHAB Accreditation
 mental health
 substance abuse
 primary care and other health care (No individual or
personal health services)
 human services
 social services (including domestic violence)
 health care facilities
 professional licensing programs
 health care financing systems (e.g., Medicaid)
 PHAB’s scope of accreditation authority does not
extend to these areas. Documentation from these
program areas will generally not be accepted for
public health department accreditation.
Division of Public Health
Idaho Department of Health and Welfare
11/6/14
Tools & Resources
 Team Binder
 Accreditation SharePoint site
Domain Team Work Plan
Self-Assessment
 PHAB.org
Division of Public Health
Idaho Department of Health and Welfare
11/6/14