case study · case study e-phab documentation assessment ... svt member – don frasier measure...

Case Study

e-PHAB

DOCUMENTATION

ASSESSMENT

DISCUSSION GUIDE

Site Visitor Training

NOTE: The documents used during Site Visitor Training are for instructional

purposes only and do not represent actual documentation, nor is it indicative that

similar documentation would be provided by an accreditation applicant or accepted

or rejected by site visitors. This discussion guide does not cover all aspects of

document quality, nor how they would or would not meet PHAB requirements.

PHAB Education Services – Revised October 2014 Page | 2

Participants complete and report out:

1. Read the measure and the documentation requirements.

2. Look at the file descriptions.

3. Look at the measure narrative.

4. Answer the four questions.

- Open & review the documentation submitted

- Make notes & send questions (if desired)

- Assess the measure noting areas of strength & improvement

- Individually review the assigned documents and then discuss your findings with

your ‘team’

5. Write up a conformity statement.

6. Write up areas of excellence and opportunities for improvement, as needed.

SVT Chair – Sandra Willow

Measure 2.1.2 L (T/L) page 6

Measure 12.1.2 A page 20

SVT Member – Larry Magnolia



SVT Member – Don Frasier


o First, open Example 1 and try to find the required elements

o Then open Example 2 & 2a and note the required elements

Measure 9.2.2 page 15


Go over as a group, if needed:

Measure 3.2.2 A

1. Read the measure and the documentation requirements.

2. Look at the file descriptions (scroll the mouse over the document title).

3. Look at the measure narrative (beneath the required documentation).

4. Answer the four questions.

5. Draft a conformity statement.

Measure 3.2.2 A

Domain 3: Inform and educate about public health issues and functions Standard 3.2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences. 3.2.2 A: Establish and maintain communication procedures to provide information outside the health department Required Documentation 1: Written procedures for communications, updated biennially, that include:

a. Disseminating accurate, timely, and appropriate information for different audiences b. Informing and/or coordinating with community partners for the communication of targeted and unified public health messages c. Maintaining a current contact list of media and key stakeholders d. Designating a staff position as the public information officer e. Describing responsibilities and expectations for positions interacting with the news media and the public, including, as appropriate, any governing entity members and any department staff member

Document 1

Title – Acme Media Policy

File – Measure 3.2.2 Acme Media Policy

File Description – Health Department media policy

Document 2

Title – ACHC Crisis Communication Policy

File – Measure 3.2.2 ACHC Crisis Communication Policy


File Description – This document demonstrates the appointment and role of the PIO

Document 3

Title – Acme County Emergency Pub Info Plan

File – Measure 3.2.2 Acme Co Emer Pub Info Plan

File Description – Contains communication procedures. See highlighted list of media contacts on page 24

Required Documentation 2: Dissemination of public health messages outside the health department

Example 1

Document 1

Title – Diabetes Press Release

File – Measure 3.2.2 Diabetes Press Release

File Description – 1st example of disseminated message Part 1

Document 2

Title – Diabetes Advocacy Day Press Release

File – Measure 3.2.2 Diabetes Advocacy Day Press Release

File Description – 1st example of disseminated message Part 2

Example 2

Document 1

Title – Heat Related Illness Press Release

File – Measure 3.2.2 Heat Related Illness Press Release

File Description – 2nd example of disseminated message

Measure Narrative

We submit our Crisis Communications Plan, our Media Policy and our Acme County

Emergency Public Information Plan, as referenced above, as examples of the department’s

ability to establish and maintain communications procedures to distribute timely

information in an appropriate fashion outside the agency.


We also have provided examples related to two programs – diabetes care from adult

health/chronic disease and heat related illness from community health promotion – to

demonstrate the implementation and following of our plans.

Assessment

1. The three documents include two department policies and a county plan. The

documentation listed is only part of what is needed. The attached policies do not

have the required elements. We do know that they have a PIO, so requirement d is

well covered. Some of requirement e is covered also. While there is a list of media

contacts, there is no list of key stakeholders included for requirement c.

Requirements a and b have some documentation in the county plan, but they are not

pointed out or highlighted, so the site visitor would have to read thru and pick out

what they think applies.

2. Here two examples are presented and one is a chronic disease - diabetes. The other

is within health promotion (heat safety, injury prevention?). This section is met. An

OFI would be to include the email or fax cover showing that the releases went out.

Pre-Site Visit Assessment: Largely Demonstrated

The main deficiency is within required documentation 1.

Sample Initial Conformity Statement:

The protocols included information on the individual responsible for

communications, but did not describe the process for dissemination nor how the

department works with other partners to distributing health messages.

Stakeholders are not listed and staff responsibilities need development. The two

messages were acceptable, but it was difficult to link to the protocols.


Measure 2.1.2 T/L Domain 2: Investigate health problems and environmental public health hazards to protect the community

Standard 2.1: Conduct Timely Investigations of Health Problems and Environmental

Public Health Hazards

2.1.2 T/L: Demonstrate capacity to conduct an investigation of an infectious or communicable disease Required Documentation1: Audits, programmatic evaluations, case reviews or peer reviews of investigation reports against protocols (2 examples) Example 1

Title – Evaluation of HepA Response

File – Measure 2.1.2 ACHC – Evaluation of HepA Response 03-2012

File Description – None provided. Example 2

Title – Acme OSWW Program Review 2008

File – Measure 2.1.2 Acme OSWW Program Review 2008

File Description – Here is a complete program review of the On-Site Wastewater (OSWW) program in Environmental Health at ACHC. This was conducted by the State OSWW Division and was conducted in February, 2008. The report was dated May 16, 2008 and details the evaluation of the program against protocols.

Title – OSWW Plan of Action 8-10-10

File – Measure 2.1.2 Plan of Action 8-10-10

File Description – Here is the Plan of Action developed by the ACHC in August of 2010. This follows up and is in response to the Program Review of 2008. Note high-lighted text.

Required Documentation 2: Completed After Action Report (AAR)


Title – Acme Shigella Outbreak Report

File – Measure 2.1.2 Acme Shigella Outbreak report-final 1-21-10

File Description – Here is the final report of the November 2009 Shigella Outbreak in the county and the response of ACHC. The report was finalized on 1-21-2010 and forwarded to the State Division of Epidemiology.

Measure Narrative

ACHC has provided two examples of programmatic reviews. One was done by the state for

our On-Site Waste Water program. Another review was an internal review of our response

to a Hepatitis A outbreak. The AAR is from an investigation of a Shigella outbreak that the

ACHC responded to, mitigated and contacted those affected in the outbreak.

Assessment

1. There are two examples provided. The guidance specifies that the examples should

be related to the capacity to respond to outbreaks of infectious or communicable

disease. Also note that the guidance and the measure state that the documentation

should be reviews of investigation reports against protocols. Acme has provided

two examples. The evaluation is for a Hepatitis A outbreak. There is a need to have

the protocol that was used as a part of the evaluation and this should be asked for.

The On-Site Waste Water (OSWW) example is a program review that is nonspecific

to a particular outbreak or disease situation. It could be possibly argued that the

review does contain information of work against protocol, and that improper

disposal of sewage or a system failure can cause an outbreak of disease, but this is a

stretch and does not meet the intent of the measure. This example would not be

appropriate for the measure. There could be a question with a reopen to ask for

another example that has a focus of an infectious or communicable disease. The

OSWW Plan of Action, has nothing to do with the measure and should be ignored.

2. Only one AAR must be provided. The department does provide an AAR of a

communicable disease outbreak and how the HD conducted the response. This is

acceptable evidence for this requirement. The Glossary does provide a definition of

an AAR based on HSEEP requirements. However, the measure does not require this

structure. It can be used as a guide – an overview, summary, analysis of capability

and conclusion. There is one discrepancy in the report that must be questioned.

While the report is dated 2009, there is a section with the dates as 2004. This will

need to be clarified. (Note that this outbreak provides a means for developing

documentation for the other requirement in this measure. The AAR could be


reviewed against the department’s communicable disease response protocols to

determine if the response was handled in the best way possible. However do not ask

for this specific type of evidence. You could mention this in your comments

regarding Opportunities for Improvement.



Of the reviews, one evaluated a Hepatitis A response and the other a review of on-

site waste water (OSWW). The OSWW review did not assess capacity toward

infection or communicable disease, but was a general program audit. The report on

a Shigella Outbreak discussed the department’s response but had conflicted dates.


Measure 5.1.3 A

Domain 5: Develop public health policies and plans

Standard 5.1: Serve As a Primary and Expert Resource for Establishing and Maintaining

Public Health Policies, Practices, and Capacity

5.1.3 A: Inform governing entities, elected officials, and/or the public of potential public

health impacts, both intended and unintended, from current and/or proposed policies

Required Documentation 1:

Documentation of the health department informing policy makers and/or the public about

potential public health impacts of policies that are being considered or are in place

Document 1

Title – County Commissioner Agenda Abstract

File – Measure 5.1.3 BOCC Agenda Abstract July 12, 2010

File Description – This document is the abstract of what the Health Director presented to the Board of County Commissioners at their meeting on July 12, 2010.

Document 2

Title – County Commissioner Meeting Minutes

File – Measure 5.1.3 BOCC Minutes - 7-12-10

File Description – This document is a page from the meeting minutes of the Board of County Commissioners held on July 12, 2010. Highlighted is the Health Director’s report on policy changes in the Environmental Health Water Sampling Program.

Document 3

Title – Board of Health Agenda

File – Measure 5.1.3 BOH Agenda Dated August 17, 2010

File Description – This document is the agenda for the Board of Health meeting held on August 17, 2010. On the agenda is discussion of Environmental Health policies.

Document 4

Title – Board of Health Meeting Minutes

File – Measure 5.1.3 BOH Meeting Minutes Dated August 17, 2010


File Description – This document is the meeting minutes of the Board of Health for August 17, 2010. Highlighted are the two policy change discussions.

Document 5

Title – Environmental Health Water Sampling Policy

File – Measure 5.1.3 EH Water Sampling Policy

File Description – This is the Environmental Health water sampling policy discussed at the Board of Health and Board of County Commissioner meetings.

Measure Narrative

The documents for this measure contain two examples of policy change – state

immunization policy and the ACHC Environmental Health water sampling policy.

Presentations to policy makers and processes for public notification are included.

Assessment

In the documentation requirement, “policies” is plural so two examples are needed. All the

documentation (that is, each example) must include two of the items lists in the guidance.

The guidance states …inform policy makers and the public….while the measure uses

and/or. This was an oversight in the guidance and should be and/or.

The documents for this measure contain two examples of policy change - state

immunization policy and the ACHC Environmental Health water sampling policy.

Presentations to policy makers and processes for public notification are included. The

documentation can present one policy presented to two different audiences, two policies

presented to one audience or two policies presented to two audiences.

1. The documentation provided gets at what the measure is assessing but is disjointed.

It appears that the department did inform both the governing entity and elected

officials about the impact of a policy change. We are just unsure what the public

health impact is. There are two issues here – changes in immunizations and changes

to an EH policy. However, the County Commissioner materials are one month out of

date, the examples must have been within the past 24 months, and are not

acceptable. You may ask for another example. Perhaps the documents were within

the timeframes when uploaded, but when submitted, they missed the deadline.


The Board of Health agenda and minutes are uploaded, but the immunization fact

sheet was not. That document is needed to help complete the requirement. The

meeting/presentation would cover item c. The fact sheet would cover item a.

For the EH policy, it is noted that the potential impact was discussed with the Board

of Health, but no detail is recorded. The policy is included but again, we do not

know what the changes are and how it could impact the community from a public

health perspective. Also, the impact was discussed with the Commissioners, but the

materials, comments presented or presentation itself needs to be added.

Questions could be asked to define the impacts from the EH policy. The measure

could be reopened to request the missing documentation.

Pre-Site Visit Assessment: Slightly Demonstrated

Missing documentation, out of date documentation and no cohesive documentation

about the EH policy impact


While documentation was provided on policy issues, there was a lack of discussion

on the impact. While the Board of Health was informed on policy changes to

immunizations and Water Sampling, the evidence did not include the details of the

impacts. One example was outside of required timeframes and cannot be

considered.


Measure 9.2.1

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

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

9.2.1 A: Establish a quality improvement program based on organizational policies and

direction.

The following documentation (2 files) and descriptions have been uploaded into this

measure.


A written quality improvement plan

Example 1

Document 1

Title – ACHC Quality Improvement Plan (Example 1)

File – Measure 9.2.1 Quality Improvement Policy and Plan

File Description – none

Document 2

Title – ACHC Quality Improvement Plan (Example 2)

File – Measure 9.2.1 Quality Improvement Policy and Plan with highlights

File Description – The QI Plan has highlights to note how the plan correlates

to the guidance for the measure.

Document 3

Title – Companion to ACHC QI Plan (Example 2a)

File – Measure 9.2.1 Companion to QI Plan

File Description – This companion document is the key that supplements the

highlights in the QI Plan. This document is color-coordinated to match with

the QI Plan in highlighting the key elements.


Example 2

Title – ACHC Quality Initiatives 2011-12

File – Measure 9.2.1 ACHC QI Initiatives for FY 2011-2012

File Description – This is a work plan for the three initiatives from 2011-2012.

Measure Narrative

The ACHC QI Plan has been adopted to provide the guidance in developing and

implementing a strong QI plan at the health department. The Plan was initially adopted in

2008 and has been used in strategic planning and in programs review. It is reviewed

annually by both the leadership of the ACHC and the Board of Health. A copy is on file in

the County Manager’s Office.

Also included is the worktable of the QI initiatives undertaken at ACHC during the most

recent Fiscal Year (July, 2011 to June 2012).

Assessment

NOTE: The examples are two representations of what could be submitted. The department

would not submit both examples, but either 1 or 2.

The guidance given by the Accreditation Specialist to applicants is that the primary bullets

(far left) are topics that are required in the plan. The indented bullets are examples that

could be used.

For example 1, there is no direction on locating the required elements. It would be

frustrating and time consuming to review. The plan needs to have key elements

highlighted or detailed so the site visitors can easily locate as they review the file. So it is

fine to send a question to the health department asking them to point out the elements in

the plan as listed in the guidance. After about 10 minutes of searching, stop and request

information on where the required elements can be found.

For example 2 & 2a, the plan has highlighted the key elements as listed in the guidance.

This plan is for the most part acceptable, though site visitors may fine some opportunities

for improvement for some areas that need more detail, for example identifying and

selecting projects. There is nothing on communication beyond a sentence, so this is a

question – to please provide documentation on communication activities.


The QI initiatives document is included and meets the guidance bullet asking for the

objectives, timeframes and who is responsible. It is difficult to tell how this relates to the

plan. This could be a question during the domain interview. Also, there are the goals for

the last year, but since a new year has started there should be a new work plan that can be

included. It is fine to ask for this document (it must have been written prior to hitting the

submit button) or offer it as an OFI.

Note: the date uploaded in e-PHAB is not the submitted date.



The plan lacked a clear process to evaluate effectiveness of their QI activities. The

plan also stated that a communications process would be developed, but no

evidence of communication activity was provided. QI initiatives were completed but

the alignment to the plan is unclear.


Measure 9.2.2

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

Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions 9.2.2 A: Implement quality improvement activities The following documentation (3 files) and descriptions have been uploaded into this

measure.

Required Documentation 1: Documentation of quality improvement activities based on the QI plan Document 1

Title – QI Team Notes for Media Relations Initiative

File – Measure 9.2.2 Media Relations 2010

File Description – This document is one of the working records of the QI Team. It demonstrates working through the QI process.

Document 2

Title – Family Planning Storyboard

File – Measure 9.2.2 Acme QI Storyboard

File Description – Storyboard of the ACHC project to decrease Family Planning waiting time – results of the project are demonstrated. See highlighted areas in text to show project participants as well as actions taken and follow-up meeting QI plan guidelines.

Required Documentation 2: Demonstrate staff participation in quality improvement activities based on the QI plan Document 3

Title – QI Team Minutes for July 2011

File – Measure 9.2.2 QIT Minutes July 2011

File Description – Minutes of the Quality Improvement Team showing actions of the group and the members of the team, thus demonstrating staff participation in QI – see highlighted text.


Measure Narrative

These three documents show how the QI Team at the ACHC are workings to implement the

QI plan and bring meaningful change to the department through the involvement of both

leadership and frontline staff.

Assessment

1. There are two examples provided. The WIC storyboard is using a project from the

clinical standpoint so it is not acceptable. If it were from an acceptable program, it

could be a good example, but needs some narrative to meet the required elements

stated in the guidance. Based on the storyboard alone, site visitors cannot discern

what is asked for in the guidance - what the problem was, what the process was, etc.

Once you see that it is from an unacceptable program, you do not have to continue

with the example. You may ask for another programmatic QI example to be

provided.

The media project certainly has some QI aspects, but seems to focus on workforce

development around specific staff, versus an administrative process. If there is

documentation on how this is a QI project – such as what is the problem regarding

media exposure, how can it be improved, what are the steps, etc. – it may be more

acceptable. Also as a team report, it’s written in a manner that only the HD can

understand and doesn’t clearly answer the questions that the examples must

demonstrate.

Also, the HD is submitting this as an administrative QI project. It doesn’t appear to

apply to an administrative function. One question with a reopen could be to ask for

such a project.

2. The HD has provided a set of minutes with the QI Team members present. Both

projects also list participants. However for the projects, it is not clear who actually

participated in the project. The storyboard list the QI Team, but no project

personnel. Again, the storyboard for the WIC project is not acceptable in the first

place.

Pre-Site Visit Assessment: Slightly Demonstrated (or Not)

Since there is some evidence, slightly demonstrated could be the initial assessment.

Not Demonstrated is acceptable since none of the documentation is acceptable

without some questions being answered.



Of the two examples, one was a clinical issue and is not acceptable and the other

project deals with staff development instead of a process for improvement. While

QI is involved it is not possible to define the issue. Neither example provided

evidence of how the issue was selected, the cause and the process used for

improvement.

One project listed those involved, but neither provided detail on how staff were

involved. Minutes showed staff attending a QI meeting, but did not show

involvement of staff.


Measure 11.1.2

Domain 11: Maintain administrative and management capacity

Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the

Performance of Public Health Functions

11.1.2 A: Maintain written policies regarding confidentiality, including applicable HIPAA requirements Required Documentation 1: Confidentiality Policies

Document 1

Title – HIPAA Manual – Table of Contents File – Measure 11.1.2 ACHC HIPAA Policy Manual Table of Contents Description – This is the Table of Contents from the department’s HIPAA Policy

Manual. The full manual, including all forms used by the ACHC for privacy is

electronic and is available for review upon request or on-site.

Document 2

Title – Maintaining Privacy Policy File – Measure 11.1.2 Maintaining Privacy of Individuals Description – This policy details how the department will maintain privacy of

individuals who are receiving services through the ACHC.


Training content and staff participants Document 1

Title – Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In Description – This is the sign-in roster for the HIPAA training of 04-30-09.


Document 2

Title – Makeup Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In – Makeup Description – This is the sign-in roster for the makeup HIPAA training of 05-12-09.

Document 3

Title – HIPAA Training Agenda File – Measure 11.1.2 HIPAA_Training_Agenda 04-09 Description – Here is the agenda used for the HIPAA training, and makeup session.

This was the last department wide training. HIPAA training is now conducted

individually during orientation for each new staff member.

Required Documentation 3: Signed employee confidentiality forms, as required by policies

Document 1

Title – ACHC Confidentiality Statement File – Measure 11.1.2 Confidentiality Statement Description – This is a copy of the Confidentiality Statement that is signed by every

employee. As noted on the agenda copy, copies are kept in personnel files and

signed copies are available for review on site.

Measure Narrative

As demonstrated by these documents, the ACHC takes confidentiality of clients and of

information very seriously. Our manuals and training regarding HIPAA and confidentiality

are very thorough and every employee is responsible for following protocol. This is shared

among all staff and leadership. Failure to comply can invoke the disciplinary process.

Better

The HIPAA manual and privacy policy are examples of how ACHC approaches

confidentiality of both medical information and program activities. Policies for HIPAA and

privacy are well-defined and available to all staff. Training begins with orientation and all

new employees are trained on confidentiality of clients in all programs. The training

records are an example of one such training. The confidentiality statement, updated or

reviewed with the employee during the annual evaluation, is kept in every personnel file.


Assessment

1. The HD has provided 2 documents to show their privacy policies. One is the table of

contents for the HIPAA manual. Ask to see that on-site or request it when finished

with the pre-site visit review. The other policy deals with other privacy issues.

These are fine. The department should provide all policies it has – one or multiple.

2. A training roster, along with the make-up, and the training agenda has been

submitted. However, this is only for HIPAA and there is no evidence of training content (if any was available). There is also no training records for the other privacy policy and that needs to be requested. The guidance states there must be training on confidentiality policies. So whatever is provided in required documentation 1 must be present in required documentation 2.

Here you can be specific and asked if there is any evidence of training for the

Maintaining Privacy of Individuals policy.

3. The form has been included. A statement that all have signed the form and the

copies can be seen upon request has been put in the description. This may be a

visual observation when on site – during the tour, you could ask to see where the

statements are kept. Or you could ask to see a couple of signed copies. During the

interview on Domain 11, you could ask during that about their process for signing

and maintaining confidentiality forms.



The department spells out confidentiality for HIPAA and other privacy issues. While

training was provided for the HIPAA policies, there was no evidence that staff were

trained on the other policy, nor was content provided beyond a list of topics. Policy

requires all staff sign a confidentiality form, kept in personnel records.


Measure 12.1.2

Domain 12: Maintain capacity to engage the public health governing entity

Standard 12.1 Maintain Current Operational Definitions and Statements of the Public Health Roles, Responsibilities, and Authorities 12.1.2 A: Maintain current operational definitions and/or statements of the public health governing entity’s roles and responsibilities The following documentation (3 files) and descriptions have been uploaded into this

measure.


Authority of the governing entity

Document 1

Title – General Statutes for the Board of Health

File – Measure 12.1.2 BOH public health statutes - 130A

File Description – This document list the NC statutes that define the makeup and

duties of the local board of health, as well as the appointment of the director (which

is a BOH role).


Description of governing entity

Document 2

Title – Board of Health Operating Procedures

File – Measure 12.1.2 BOH Operating Procedures 9-21-2010

File Description – This document defines the operating guidelines of the Board, such

as officers, meeting times and agendas.

Document 3

Title – Board of Health Overall Operations

File – Measure 12.1.2 BOH Overall Operations Policy 7-17-2009


File Description – Based upon statute, this document details the overall operations,

duties & responsibilities of the BOH including appointments, training, rule-making

authority and policy development.

Measure Narrative

The three attachments for this measure demonstrate that the roles, responsibilities and

authorities of the board are well defined in both statute and in policy. Board Members are

oriented and regularly trained on this content. This evidence shows that the Acme BOH

takes serious its responsibility to represent the county, the department and our residents

in setting and supporting public health policy.

Assessment

Three documents are provided. The statutes provided are about the authority and make-

up of the Board of Health. The document is not dated and we do not know the source of the

material. This could be asked in a question back to the health department. There are two

documents that provide operational guidelines for the Board of Health. The make up the

description of the board of health, though there is some of that in the statutes as well. There

is potential for an OFI to combine the two documents in required documentation 2 into one

operations protocol.

Overall, info is what is needed and is complete.


Based on the lack of a date on the statutes document.

If the Statutes are dated - Fully Demonstrated


The Board of Health’s authority is defined through state statute. There are two

protocols defining the operating procedures and the responsibilities of the board.

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