Overview of KCMO Accreditation PHAB Site Visit

January 31, 2012

Why KCMO Applied Our Director was and is excited about national public

health accreditation.

We wanted to be in the first group considered for accreditation.

Accredited or conditionally accredited we wanted to use the standards as a QI tool to identify our strengths and OFI’s (opportunities for improvement).

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Importance of Accreditation:

Identify successes and opportunities for improvement

Promote quality initiatives

Energize the workforce and develop a strong team

Focus the health department on common goals

Evaluate your health department’s performance

Align your resources with your strategic objectives

Deliver results

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Fast We collected our documentation and submitted our

application between January 1, and March 20, 2012

Snap Shot in Time We submitted what we had in place at the time of

submission.

Decentralized Assigned a lead person to each Domain, Each Domain Lead

took responsibility for gathering and uploading documentation for their Domain.

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Our Process:

Step 1 – Pre-Application (Sept. 2011)

Step 2 – Application (Nov. 2011)

Step 3 – Documentation Submission (Jan – March 2012)

Step 4 – Site Visit (Nov. 2012)

Step 5 – Accreditation Decision (Feb. or March 2013)

Step 6 – Reports

Step 7 – Reaccreditation

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Accreditation Diagram

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The Site Visit:

1. An Entrance Conference,

2. A Department walk through/tour

3. Domain Interviews with key staff

4. Collection of additional information, requested by the Site Visit

Team, and

5. Interview with community partners

6. Interview with governing entity

7. An Exit Conference to review identified strengths and areas for

improvement.

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Day 18

Day 1 & 29

Identified Area’s of ImprovementPrior to the Site Visit:

Using the PHAB criteria as a QI tool we identified the following areas to focus future improvement efforts on:

1. Public Health Workforce Plan (Domain 8)

2. Performance Management Plan (Domain 9.1)

3. Quality Improvement (Domain & Standard 9.2)

4. Cultural Competency Assessment (Domain 8.2)

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The Site Visit:

Pre Site visit: requested answers to approximately 30 questions

and requested 30+ additional documents.

Arrived on site prepared, having read documentation and

possessing knowledge of the standards.

During the site visit asked targeted questions

Requested additional documentation

3 reviewers kept 20+ staff really busy!

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ReviewerFeedback

Despite ample documentation the overall story of the department remained unclear.

Need to describe our story better

Documentation was overwhelming

Need to document processes and procedures

Use a team v.s. one coordinator

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Post-Site Visit: Area’s of Improvement

Written Documentation: Document & date protocols, processes and policies (Domain 2)

Community capacity building (Domain 4)

Community involvement in the Community Health Assessment process (Domain 1)

Staff engagement in identifying opportunities for improvement (Domain 9)

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Areas for Improvement

Pre-Site Visit

Domain 8: Health Department Workforce Development Plan

Domain 8: Cultural Competency Assessment

Domain 9:

Performance Management Plan

Domain 9: Quality Improvement

Post Site Visit

Domain 1: Community involvement in the Community Health Assessment process

Domain 2: Written Documentation: Document & date protocols, processes and policies

Domain 4: Community capacity building

Domain 9: Staff engagement in identifying opportunities for improvement

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Fast We collected our documentation and submitted our

application between January 1, and March 20, 2012

Snap Shot in Time We submitted what we had in place at the time of

submission.

Decentralized Assigned a lead person to each Domain, Each Domain Lead

took responsibility for gathering and uploading documentation for their Domain.

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Consequence of a FAST Approach:

No time to set up processes & mechanisms to collect, file, and consistently upload documents.

Resulted in a submission that was not Customer friendly for the PHAB Reviewers > We used e-PHAB as our electronic filing system > Documents were scanned and uploaded differently > Created confusion >generated 60+ requests for answers to questions and documentation from reviewers > Which gave the reviewers even more documents to review, adding to the challenge of reviewing everything submitted.

Not enough time to create and implement new policies and procedures.

Regrets regarding what we should have, could have, and or didn’t do and submit.

Organizational stress, I played the last note on the goodwill of my colleagues. Hopefully time will renew the good will!

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Create an internal system for organizing and storing documentation electronically before uploading into e-PHAB:

Develop, and utilize a consistent process to manage hard copy documents that need to be scanned and stored electronically prior to uploading into ePHAB.

Identify a central location to store all electronic and hard copy documents related to accreditation (e.g., designated information systems drive).

Use a consistent file labeling process (i.e., label files with the Standard Number, Document Name, date of the most recent version, and responsible party name) to help organize and identify documentation.

Next Time We Will:17

Make the Site Reviewer’s job easy by clearly identifying in the description which specific parts of document(s) address the documentation requirement, include page numbers to direct the reviewers attention.

Highlight portions of the document that meets the documentation requirement in a consistent manner.

Develop a process for developing and approving contextual notes that describe how a specific document demonstrates conformity with a specific measure.

Work with a neighboring health department to conduct a mock site visit.

Next Time We Will:18

Consequence of our decentralized Approach:

Our best work was not submitted or considered. We chose to decentralize the process to minimize staff time and

decrease turn around time to gather and upload documentation.

When we made that decision we chose to:

Allowed each Domain Lead to work independently from the other domain leads (they did not meet to vet submissions and many tended to choose examples from their immediate work area)

Allowed each Domain Lead to write their own contextual document descriptions (resulting in different writing styles and formats)

We allowed each Domain Lead and their staff to upload their own documents, 20 + staff had access to upload documents to e-PHAB (too many cooks in the kitchen)

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Next Time:

Establish an Accreditation Team and a meeting schedule.

Set a submission target date a minimum of 12 months out.

The Accreditation Team should review the measure’s Required Documentation and its Guidance within the context of the measure and the “Purpose” statement of the measure. The measure should be considered in the context of the standard and the Domain to ensure that the intent of the measure is being demonstrated by the selected documentation.

As a Team, consider the quantity of documents that the site visitors will be reviewing. Select the documents that best meet the specific requirements of each measure; more is not better.

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Next Time:

Be emphatic that every document created is dated and “signed”, every time!

Documents must be signed, but as we found out that does not necessarily require the presence of a written signature.

Each piece of documentation must include evidence that it has been adopted by the health department. In some cases, documentation will be a written policy and will include the signature of a governor, mayor, or health department director.

In PHAB Accreditation Coordinator Handbook Version 1.0 April 2012 ,Page 12 other cases, documentation may be an email; the "To" and "From" and the email addresses will serve as evidence that the document is "official" health department business.

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In other cases, a department logo will provide the evidence that the document is an official health department document. For example, a brochure will not have the health department or program director's signature, but it will include the department's logo. A health department logo will be acceptable.

Further, a document developed by a partnership or coalition of which the health department is a member, may or may not include the health department's logo. In this case, evidence of the health department's membership or participation in the partnership or coalition will suffice.

Signage: Provide documentation of approvals and date.

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Consequence of taking a Snap Shot in time:

With the exception of 4 items, we submitted what we are doing and what we have done in the past 3-5 years.

We did not read the criteria and then design new process, programs, or interventions except in the following areas:

Workforce development plan Performance management plan Cultural competency policy Policy review policy

We did not have written documentation for all our processes, particularly in Domain 2 (Resulting in the Reviewers identifying several areas as, “Not Demonstrated”

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Next time: As we improve current processes and design new one we

will ensure they are aligned with PHAB standards and measures.

In the mean time we are comfortable with the notion that it’s a win-win. We are either accredited or conditionally accredited. Either way we identify our gaps and OFI and take steps to improve.

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Fast We collected our documentation and submitted our

application between January 1, and March 20, 2012

Snap Shot in Time We submitted what we had in place at the time of

submission.

Decentralized Assigned a lead person to each Domain, Each Domain Lead

took responsibility for gathering and uploading documentation for their Domain.

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Notes from our Environmental Health Director: Don’t assume that reviewers will make the connections to various

documents submitted in an earlier measure;  repeat the placement of all such documents and LEAD the reviewers to the conclusions we intend;   Provide good logistical support (as you did) with computers /projectors in each room;  have staff assigned (as you did) to maintain notes so that interviewees are not obligated to take notes and report findings; they could then concentrate on the conversation and maintain focus;  Emphasize the importance of the Partners Meeting;  a great opportunity for the community to “brag” on the agency; Have a single point of contact for all the writing of explanations/justifications, thereby removing variance between writers, thus, interpretations;  (Remove all other duties for this person during the time of the accreditations document submission timeframe;  they need to devote 100% of their time to this project;   

Pray a lot! 

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Notes from our Communicable Disease Staff: Written protocols (or visual diagrams/flow charts) for EVERY process.

Strong collaboration between Environmental hazards/Food Protection unit and the Epidemiology unit (disease investigators) for outbreak or containment/mitigation procedures.

Make sure you are communicating with the reviewers using the same language, i.e. they kept referring to ‘surge capacity’ in terms of staff only; whereas, that buzzword was not referenced directly in our emergency operation plan; after further clarification, we provided exactly what they were looking for.

Strong partnerships with disease reporters, infection control, medical personnel and consider having at least a few present for the site visit.

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Notes from our Health Education & Health Communications Director:

Not using their terminology in their context lead to a major break-down in “communication” when it came to discussing the communication and marketing components. 

The Reviewers language and experience is so different from ours, and we did not do a very good job of bridging that gap, and getting “over there” in their world, as opposed to staying in our world only.

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Importance of Accreditation:

Identify successes and opportunities for improvement

Promote quality initiatives

Energize the workforce and develop a strong team

Focus the health department on common goals

Evaluate your health department’s performance

Align your resources with your strategic objectives

Deliver results

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END of Presentation

Following slides are background/reference that can be used to field questions info if needed

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Post Site Visit Within two weeks of the close of the site visit, the Site Visit

Team will develop and submit a Site Visit Report to PHAB.

PHAB may edit the brief narratives contained in the Site Visit Report and may send proposed changes to the Site Visit Team chair for review.

PHAB will provide the applicant health department access to review the report for factual accuracy only. The health department will have 30 days to respond to PHAB through e- PHAB to correct factual errors. Applicants cannot submit additional documentation of corrective action(s) at this time. The only additional documentation that may be accepted is evidence that will correct a factual error in the Site Visit Team report.

Once the final Site Visit report has been completed in e-PHAB, no changes may be made. It is this report that will be submitted to the Accreditation Committee.

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Accreditation Decision

The accreditation decision is made when the PHAB Accreditation Committee determines the accreditation status of a health department based on the Site Visit Report. Applicants will be notified of the date of the Accreditation Committee meeting but are not permitted to attend any Accreditation Committee meetings.

Within two weeks of the conclusion of the Accreditation Committee meeting, PHAB will notify the health department director of the accreditation decision via email and copy the Accreditation Coordinator. A follow-up written letter will be sent by United States Postal Service. No feedback will be provided to applicants before the official written decision letters are sent to applicants.

The health department will receive specific language they are to use to communicate their accreditation status with the public. Health departments must use the PHAB approved language when describing their accreditation status to the general public. Template press releases will also be provided.

When the health department receives a status of “accredited,” the Accreditation Committee will provide the health department with a list of opportunities for improvement from the Site Visit Report. This will support the department’s continuous quality improvement efforts and will be the basis for annual reports to be submitted by the accredited health department to PHAB.

If the health department does not receive a status of “accredited,” a list of opportunities for improvement will support the department’s development of an accreditation action plan. The Accreditation Coordinator will manage the development of an accreditation action plan and its submission to PHAB within 90 days of notification that the health department did not receive the status of “accredited.” The action plan must: Specify the actions and improvements that the health department will implement in order to achieve

“accredited” status, and Specify the amount of time required to implement each action to reach conformity (no more than one

year from the date of PHAB’s approval of the action plan). If the action plan is approved by PHAB, the health department must submit documentation

and description of the completion of the action plan by the date agreed on. If the action plan is not implemented satisfactorily per the Accreditation Committee and accreditation is not achieved within one year from the date of the original accreditation status notification letter from PHAB, the status of the health department will be “not accredited.” The department must then begin the accreditation process again in order to become accredited.

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Reports Submission of annual reports is required for the health

department to maintain their accreditation status for the five year period. The purpose of the annual reports is to describe progress made towards addressing areas of improvement identified by the Accreditation Committee. Annual reports to PHAB will include a description of the improvements made to areas identified as needing improvement and other efforts toward continuous quality improvement. Reports must:

Include a statement that the health department continues to be in conformity with all standards and measures contained in the version under which accreditation was received,

Include leadership changes and other changes that may affect the health department’s ability to be in conformity with the standards and measures,

Describe how the health department has addressed areas of improvement noted by the Accreditation Committee,

Describe how the health department will continue to address areas of improvement identified by the Accreditation Committee and/or by the health department in their accreditation action plan, and

Be signed (authorized through e-PHAB) by the director of the health department.

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Reaccreditation Accreditation is conferred for a five year period. PHAB

will send advanced notice to accredited health departments that their accreditation is expiring. Accreditation Coordinators will lead the submission of a new SOI and Application in the reaccreditation process, and may be required to receive additional training. Procedures for reaccreditation will be developed and published in the future by PHAB.

The version of the standards and measures that was used to award accreditation to a health department will stay in effect for a health department’s five year accreditation period. However, over that period of time, new standards and measures may be adopted by PHAB. In such instances, PHAB will notify all accredited health departments of these changes. It is highly recommended that the Accreditation Coordinators plan how they will address conformity with the standards and measures that will be used in the re-accreditation process

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Site Visit Team Exit Comments:

The Health Department’s substantial influence on community, region, state, national resources, relationships, media management, branding, political management, monitor policy, regulation, legislation… “Art of Public Health”

Data, providing data to partners, they have come to know us (even when they don’t know what data they need, we are there to help them)

Evidence based, publications, model practices

Facilities, for the community, space for community

Staff’s high level of competence, passion, knowledge and commitment

Understanding and application of environmental enforcement and compliance, as noted in Domain 6, is great.

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Quality Improvement

Data Driven Decision MakingManage Change

PDSA CyclesPromote a Learning Environment

PerformanceReporting

Analyze data

Feedback results to managers,

staff, policy makers and

stakeholders

Develop a regular reporting

cycle

PerformanceMeasurement

Collect data

Refine indicators and define

measures

develop/enhance data

systems

Performance Standards

Identify relevant standards

Select Indicators

Set goals and targets

Communicate expectations

KCMO Health DepartmentPerformance Management System

Adopted from Turning Point. "From Silos to Systems: Using Performance Managementto Improve the Public's Health, 2003"

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