Transcript Presentation Title John J. Presenter

California Department of Public Health
Accreditation Readiness Team (ART)
Orientation
Office of Quality Performance and Accreditation
(OQPA)
California Department of Public Health
What is Public Health Accreditation?
Public Health Accreditation Board (PHAB)
• Launched in 2011
• National accrediting body
• Composed of peer public health professionals
Public Health Accreditation is:
• Set of standards developed by peers
• Process to assess performance; identify
strengths and areas for improvement
• Recognizes Departments that meet the standards
California Department of Public Health
What does Accreditation mean to CDPH?
Benefits of Accreditation
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•
•
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High performance and Quality Improvement (QI)
Recognition, validation and accountability
Potential increased access to resources
Busting silos and building bridges across programs
CDPH Employees say Accreditation will:
•
•
•
•
•
Provide introspection
Expand knowledgebase
Improve our visibility
Increase collaboration
Improve morale
California Department of Public Health
Accreditation Steps
1. Pre-application
 Submit a Statement of Intent (SOI)
2. Application
 Application form with pre-requisites
3. Document Selection and Submission
 Applicant selects documentation and submits it to e-PHAB for review
4. Site Visit
 Site visit is conducted by a team of peers and report developed
5. Accreditation Decision
 PHAB Board will award accreditation status for 5 years if successful
6. Reports
 Department submits annual reports to PHAB
7. Reaccreditation
(every 5 years)
Maintain
A
c
h
i
e
v
e
Step 1: Pre-Application
Designate
Accreditation
Coordinator
PHAB Online
Orientation
Accreditation Readiness
Checklist
Submit Statement of Intent (SOI)
Office of Quality Performance and Accreditation
Step 2: Applications
During the Application step of National Public Health Accreditation
the health department submits the application, the pre-requisites and
a letter of support from the governing entity.
Domain 5 - Standard 5.3
Domain 5 - Standard 5.2
Domain 1 - Standard 1.1
The three prerequisites required with the accreditation application:
Office of Quality Performance and Accreditation
Step 3: Documentation Collection and
submission
The process of identifying and uploading documents that demonstrate
the health department’s conformity with the standards and measures is
one of the most important components of the accreditation process.
Standards &
Measures
illustrate
Required
Documents
Domain
Teams will
collect
evidence of
conformity
Domain
Champions
will select
best
examples
Evidence of
conformity
will be
electronically
submitted
through
ePHAB
Office of Quality Performance and Accreditation
Step 4: PHAB Site Visit
Public Health Accreditation Board (PHAB) assigns a Site Visit Team
of 3-4 Public Health Peers to review the Department’s documentation
in relation to the Standards and Measures
CDPH will host a Site Visit (usually lasting 2-3 days) for the Site
Visitors to come to the Department to conduct multiple interviews to
include pre-requisites, domains, community partners and our
governing entity.
During the Site Visit the team will verify the accuracy of documents
submitted, ask for clarity and have peer to peer conversations to
learn more about the work we do.
Site Visitors may reopened measures in order to provide us with a
chance to submit additional documentation.
The Site Visit Team will produce a Site Visit Report with scores (at a
measure level) and summaries of their findings.
Office of Quality Performance and Accreditation
Step 5: Accreditation Decision
Written notification to health department:
Accredited
Not
Accredited
Accreditation
Lasts 5 Years
Accreditation
Action Plan Due
Within 90 Days
Office of Quality Performance and Accreditation
Accreditation Structure
12 Domains
• Group standards pertaining to broad
public health services
32 Standards
• Required level of achievement a health
Department is expected to meet
105 Measures of Quality
• Evaluate if standards are met via
Departmental documentation to
demonstrate evidence of conformity
California Department of Public Health
The 12 Domains of Accreditation
11
California Department of Public Health
Structural Framework and Taxonomy
(example – Domain 5)
(example – Standard 5.3)
(example – Measure 5.3.2)
Domain
Standard
Measure
Required Documentation
(example – Measure 5.3.2.1)
Measure taxonomy indicates who it applies to:
State
Local
Tribal
All
(example – Measure 5.3.2 S for state health depts.)
(example – Measure 5.3.2 L for local health depts.)
(example – Measure 5.3.2 T for Tribal health depts.)
(example – Measure 5.3.2 A for all health departments)
Office of Quality Performance and Accreditation
Standards and Measures
• Each domain contains standards and measures

Standards describe the required level of achievement

Measures provide a way of measuring if the standard is met
• Each measure includes the following information:

Description of the measure’s purpose

The significance of the measure

Listing of the required documentation for the measure

Guidance on the types and forms of documentation appropriate
to demonstrate conformity with the measure
Office of Quality Performance and Accreditation
Example: Domain 1 and
Associated Standards
Office of Quality Performance and Accreditation
Example: Standard 1.1 and
Measure 1.1.1 S
Office of Quality Performance and Accreditation
Accreditation Readiness Components
1. Organizational Commitment
 Engage executive leadership
 Embrace opportunities to build bridges across programs
2. Goals
 Assess needs and allocate resources
 Establish timeline for deliverables
3. Systems
 Create standardized file naming and document storage conventions
 Utilize tracking mechanisms
4. Training and Technical Assistance
 Facilitate reviewer training and Domain Team support
 Consult external resources for qualitative review
5. Communication
 Communicate frequently via meetings and committees
 Foster team culture
California Department of Public Health
Who Are We?
• The Accreditation Readiness Team is a Sub
Committee of the Policy Committee
• ART membership shall consist of members
of the Policy Committee, or the designee for
each Deputy Director
• Any additional representation needed to
achieve our Accreditation efforts will be
determined by the Policy Committee
• Office of Quality Performance and
Accreditation (OQPA) will support
California Department of Public Health
Why Are We Here?
PURPOSE:
• Prepare CDPH to apply for and
receive national accreditation status
from the Public Health Accreditation
Board (PHAB)
• Implement the processes necessary
to maintain accredited status
thereafter
California Department of Public Health
What Are We Responsible For?
•
Assist in the development and completion of the public health
accreditation prerequisites
•
Provide subject matter expertise and general guidance and
support, including:
•

Identifying resources and address organizational
constraints or obstacles to preparing for
accreditation

Providing recommendations on best methods to
accomplish tasks related to achieving accreditation
and present those recommendations to Policy
Committee for review.
Communicate ART activities and accreditation efforts across the
Department
California Department of Public Health
Discussion
Questions and Answers
California Department of Public Health