Transcript PHAB Applicant Training Tips

Domain Champion Updates
New Mexico Department of Health
Introductions
 Shannon
Barnes-Accreditation Coordinator
 Anne Barraza-Accreditation Document Librarian
The Seven Steps
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Pre-application
Application
Documentation Selection & Submission
Site Visit
Accreditation Decision
Reports
Reaccreditation
PHAB
Accreditation
Process Map
Documentation Submission:
Measure Page
Uploading a document in EPHAB
Description Box
Description Boxes
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Use the description boxes to help provide the
link between the Measure and the uploaded
document for the Site Visitors
 Character
Limit: 150 words
 Describe how document demonstrates
conformity
 Identify specific location within the document
 Describe the author, if not a HD document
Measure Narrative
Do not enter charts, web links, or
images in the measure narrative
PHAB does not recommend going to 10,000 characters.
If so, the Site Visitors will NOT read the document.
(Read 5 minutes and move on)
Measure Narrative
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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
 Give context to the evidence
 Describe how all evidence demonstrates
conformity
 Explain why the HD is using the documents
Documentation Selection
Consider selection options and programs:
 Best reflects health department operation
 Meets specifics of the required
documentation
 Demonstrates conformity with measure
(Content and intent of M, S, D)
 A variety of programs
General Guidance
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Current and in use when submitted
Draft documents not accepted
No confidential information (Mark Out)
Within past 5 years unless otherwise required
Paperless process
Submit in acceptable file formats
Documentation may be developed:
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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 (ex: Consultant, Academic)
By a partnership (evidence of membership)
More General Stuff
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Use PDF’s when possible
Open uploaded documents to check for
readability (No sideways or upside down PDF
documents)
No blank signature lines
Remember to make the job of the Site
Visitors as easy as possible!
Dates and Signatures
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Review your:
 Policies
 Procedures
 Plans
 Directives
 Public
information
 Protocols
Dates:
Created Date
Revised Date
Reviewed Date
Amended Date
Effective Period
Signatures:
(Evidence of authenticity)
HD Logo
HD Director Signature
HD Abbreviation
HD Email Address
Membership List
Acceptable File Formats
Assessing Documentation
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Four Questions
 What
do I have?
 How does it demonstrate conformity?
 What do I want this to say?
 How would it be assessed?
Don’t think of your documentation as good or bad
What’s the best we can show?
How long will it be from when our
department submits documentation
to when we have our site visit?
Site Visit Process
Pre-Site Visit
Post Site Visit
 Team Chair available
 Review documentation
to Accreditation Committee
 Conference calls
 Request additional
documentation
Site Visit
 Conduct meetings and interviews
 Reach consensus
Site Visit Report
 Team assesses measures and
inputs comments
 Team Chair submits report
Site Visit
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2 days (Usual)
PHAB will set and provide Site Visit agenda to HD prior
to visit
 Organized by Domain
 HD selects staff for participation
 Include specific sessions to meet with:
 Members of governance entity
 Community partners
 HD Director
PHAB Tip to Site Visitors:
Do your best to put the health department at ease
NMDOH is on track…
Updated Timeline Coming Soon!
Major Gaps in Documentation?
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Do you have an action plan?
Do you have a timeline?
How can we support you?
SharePoint Overview
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Questions?
Need assistance?