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TRANSCRIPT
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PHAB Documentation – How to Identify and Select the Best
Examples February 11, 2015
Middlesex County Fire Academy, Sayreville
Presented by: Mary L. Kushion, MSA
Welcome and Workshop Overview
* Identify key documentation points of the 3 PHAB pre-‐requisites * Recognize other essential plans required for accreditation * Understand essential elements of good documentation * Select an agency example of appropriate documentation for one measure in Domains 1-‐5 * Select an agency example of appropriate documentation for one measure in Domains 6-‐12
Workshop Objectives
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Key Documentation Points
Measure 1.1.1 L/T * Up to date membership list with names and organizations listed * Meeting minutes; agendas alone will not suffice * Describe the PROCESS used; it doesn’t HAVE to be a national model as long as you describe it.
Community Health Assessment PHAB STANDARD 1.1
1.1.2 L/T * Data – must be qualitative and quantitative * Data – must be primary and secondary data * Demographics * Health issues and health disparities * Local community contributing factors * Description of resources – more than a list! * Opportunity to provide input from community * Plans to monitor and update the assessment
Community Health Assessment PHAB STANDARD 1.1
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1.1.3 A * Sharing of the assessment with partners – how to access it * Sharing of the assessment with community – again, how to access it * These can be in the form of emails, press releases, posted on website, social media
Community Health Assessment PHAB STANDARD 1.1
5.2.1 L * Describe the process used; the work that was done AFTER assessment complete. * Does NOT need to be a national model; you DO have to show the steps taken in your plan * Community/partner participation in the DEVELOPMENT * Issues identified by community and stakeholders * Assets – refined based on issues developed
Community Health Improvement Plan – PHAB 5.2
5.2.2 L * Measureable outcomes/indicators and time-‐framed targets * Can be evidence-‐based, promising OR innovative. However, IF evidence-‐based, must cite the source. * Highlight where POLICY changes have been identified as a strategy * Identification of champions/responsible for strategies * Demonstration of “consideration” of state and national priorities.
Community Health Improvement Plan PHAB 5.2
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5.2.3 A and 5.2.4 A * Tracking plan – process used to show progress made in the implementation of the CHIP * Examples of achievement * Annual report and revisions made * IF plan is less than 1 year old – must describe the process that will be used to monitor, revise and report.
Community Health Improvement Plan PHAB 5.2
5.3.1 A * Document and describe the process used and the steps taken. * Make sure all levels of staff AND board is involved in the process – meeting minutes and sign in sheets important. Membership roster that includes names AND titles.
Department Strategic Plan – PHAB 5.3
5.3.2 A REQUIRED ELEMENTS * Mission, Vision, guiding principles/values * Strategic Priorities * Goals and Objectives with measureable time-‐framed targets * Consideration of key support functions required for efficiency and effectiveness * Identification of external trends, events or factors * Assessment of strengths and weaknesses * Link to the health improvement plan and QI plan
Department Strategic Plan – PHAB 5.3
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5.3.3 A * Progress reports – completed at least annually. Must provide 2. * Progress reports can be from different strategic plans if the current one is less than a year old.
Department Strategic Plan – PHAB 5.3
Let’s take a 15 minute break!
Documents that you need that are not listed as Pre-‐Requisites
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* Governing entity and leadership awareness and commitment * List of “significant events of the past 5 years” * Health Promotion Plan * After-‐Action Reports * Health Trends Reports * Policy Review * Workforce Development Plan
Better to have sooner than later
* Performance Management System * Quality Improvement Plan * Ethical Issues Process * ADA Compliance Audit * Employee Wellness Activities * Employee Recognition Activities * Website with programs, data, laws, and 24/7 contact
Better to have sooner than later
* Community engagement/involvement * Staff participation at all levels * The process used * The product developed * The reports written * The distribution plan
What PHAB Wants to See
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Questions on What we have covered this morning?
Review and Reflect:
Measures where you need help and
Measures you believe you are strong
Lunch Break Reconvene at 12:45
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Insights on how to make a site visitor happy!
Elements of Good Documentation
Insight #1: READ –READ-‐READ
* Take the time to carefully read the Standards and Measures. * Review what PHAB is requesting * Is it asking for you to describe WHAT was done? HOW it was done? Or WHO was involved in getting it done? * How many examples and what is the time frame?
Insight #2: More is not always better
* For many measures, an excerpt is acceptable; reviewers can always ask to see more * Avoid tossing in extra examples – give us your best. To provide more is excessive and confusing; bogs down the review process * Free-‐standing documents preferred to buried in reports * Want to avoid “Scroll-‐down fatigue” by reviewers
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Insight #3: Use the Document Description Feature
* Site Visitors really do read these! * Use to “point” to where in the document the evidence is located * Give details on which element of the measure the documentation serves as evidence
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As an example…
“See page 4 for evidence required for: (a) mission, vision and guiding principles. See page 10 for evidence required for (b) strategic priorities. See pages 12-‐19 for evidence required for ( c) for time-‐framed targets. See page 27 for evidence required for (d) for external trends. See page 8 for evidence required for (e) for dept.'s strengths and weaknesses. See page 22 for evidence required for (f) linkages with the CHIP.”
Use Descriptive Titles
Insight #4: Be specific and concise
* Select documents that tell your story – not War and Peace * Documents should be focused and contain clear direction; scanned documents need to be readable * If submitting an agenda, also include either a sign-‐in sheet or signed/dated meeting minutes * Make sure the INTENT of the measure is met * Be mindful to respond to requests asking for barriers or factors causing problems.
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Show and Tell
* Tell the Site Visit Team where we can find the evidence within the document * Make sure the description aligns with the PDF page number * Show us by highlighting – using arrows –text boxes * Make sure we can open/read the document * If using links – make sure they are active during review process
If you don’t have it – say why
* Site visitors will appreciate your honesty * A memo from agency leadership explaining why you may not have the documentation, but what your plans are to produce it in the future is beneficial in the review
Insight # 5 – Review before hitting the submit button
* If possible, have a “fresh set of eyes” open and review documentation * Double check page numbers in description with document * Check to make sure document matches title * Look to make sure the document is dated, isn’t in “track-‐changes” format and it isn’t marked as a “draft” * Take the time to do a review
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A special mention about meeting minutes
Make sure they: * Are signed and dated * Contain the names, titles and organizations represented when demonstrating collaborative efforts and/or elective official participation * Are DETAILED – a simple sentence “plan was reviewed” will usually not suffice to meet the measure.
Insight #6: Make it a Team Effort
* During the site visit, the accreditation coordinator can not be in all of the Domain interviews – important for those who are a part of the site visit were also a part of the documentation submission process. * Decide as a team what documentation best represents your efforts and tells your story.
Why we ask questions and re-‐open measures
* Need verification or clarification of document submitted – may not be able to locate where in the document you want us to review. * May need an additional example to conform with the intent of the measure * Prepares site visitors – and YOU in advance of the on-‐site visit
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Insight #7: Site Visit is your time to shine!
* Be confident in your team and staff * Share stories that back up the documentation submitted * Select community partners who share your passion for public health * Remember – many of the site visitors have also been/are applicants – we know what you are going through! * Celebrate what you have accomplished!
Questions on Documentation Preparation?
Domain Documentation Learning and Helping Each Other
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Measures where you need help and
Measures you believe you are strong
Any Specific Domains You Want to Discuss in More Detail?
* Surveillance Systems and Surveillance Sites * Data Sources * Data Transmission – both received and sent out * Confidentiality * 24/7 capacity and testing of system * Training * Primary and secondary data collection and distribution * Trend data and discussions with others * How Data are used in policy development, programs, processes, or interventions
Domain 1 – Data, Assessment and Surveillance
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* Protocols for disease investigations and environmental health issues – who does what (locally and with partners) * Evaluations conducted of actual events against protocols * Investigation logs and After Action Reports (AAR) * Laws on website * Containment and mitigation protocols
Domain 2 –Investigating health problems and environmental health hazards
* What rises to the level of activating the EOC/EOP * List of significant events * 24/7 coverage for lab and surge capacity * Trainings conducted * Mutual Aid Agreements * Risk Communication Plans
Domain 2
* Provision of health info to the public “plain language” * Evidence that you consulted with target group on messaging * Examples of working with other health departments with press releases * Health Promotion Approach and Strategies-‐ evidence-‐based or promising practices * Engagement of community and partners in the development of health promotion messages
Domain 3-‐Inform and Educate
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* Efforts to address health equity * Branding and value of public health * Media Contact List * PIO Designation * Risk Communication Plan * Website with 24/7 contact, laws (can be same as in Domain 2) * List of languages spoken, assistive devices available * Culturally appropriate materials
Domain 3
* Documentation of active participation in either single issue coalitions, comprehensive coalition or a mix of both. * Examples of community, policy or program changes created as a result of the coalition(s). * Involvement of community groups in policy/strategy proposals that impact them * Engagement of the governing entity in policy/strategy proposals
Domain 4-‐ Coalitions and Collaboration
* Tracking of potential local/state/federal laws and policies * Contributions to policy/law deliberations that impact public health/policy – advisory group participation, public testimony * Provision of information to policy makers on the public health implications of proposed policy/law. * Emergency Operations Plans – Developed-‐Reviewed-‐Revised-‐Shared-‐tested * Other standards – Community Health Improvement Plan and Strategic Plan
Domain 5-‐ Public Health Policy and Plans
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* Examples of current laws reviewed to determine if revisions are recommended. Reviews need to include consistency with evidence-‐based practices, a guide/template used, input from stakeholders and collaboration with other levels of government; shared with governing entity/elected officials * Access to legal counsel
Domain 6-‐ Review and Enforcement of Existing Laws
* Staff training on laws; training for regulated entities * Evidence demonstrating enforcement and application * Access to permit/application process * Authority to conduct enforcement activities * Procedures/Protocols for enforcement area programs * Inspection frequency information and demonstrate compliance with frequency schedule.
Domain 6
* Annual summaries of complaints and enforcement activities – must include patterns, trends or compliance with enforcement activities in YOUR department. 6. 3.4 is a bit confusing; be sure to read it carefully! * Protocol is needed to state how enforcement activities are communicated to other entities and to the public and demonstrate the notification process
Domain 6
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* Document how the health department participates in the collaborative process to assess health care availability and reduce barriers, and gaps in service * Sharing of data and discussions on emerging issues in public health, financing and healthcare systems. * Process used to identify “un-‐served/under-‐served” populations gaps in services and barriers to care; report of findings * Implementation plan developed to improve access
Domain 7-‐ Assessing and accessing health care services
* Public Health as a career choice – make sure that internship examples demonstrate the opportunity to explore all aspects of public health * Workforce Development Plan that includes assessment of core competencies * Staff training where capacity and capability gaps are identified and how the department will address gaps in staff competencies * Demonstration of implementation of the Workforce Development plan
Domain 8-‐ Workforce Development
* Leadership training opportunities * Professional development opportunities for all staff * Recruitment activities/process * Retention activities-‐ supportive work environment, employee recognition and wellness activities * Position descriptions available to staff * Process to verify qualifications; evidence this has been done.
Domain 8
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* Staff at all levels participate in the creation of the agency performance management system * The performance management system that is implemented – demonstrate implementation with examples from programs/administrative area * Evidence of a PM Team/Committee and self-‐assessment
Domain 9-‐ Performance Management and QI
* Customer satisfaction surveys-‐ two different groups * Staff training in PM and QI * A written QI plan * Examples of non-‐clinical QI initiatives – one has to be administrative and one has to be from a program area * Staff participation in QI efforts
Domain 9
* Implementation of evidence-‐based programs, process or intervention and the source must be cited * IRB Policy – or statement indicating the organization does not participate. * Availability of experts – internal and/or external. * Communication of findings and public health implications – must share with state health department.
Domain 10-‐ Evidence and Research
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* Organization policies and procedures; table of contents and two examples required * Organizational Chart * Evidence of review/revision of policies * Staff accessibility to policies * Ethical issues process and one example * Confidentiality policies; signed form * Policy on health equity is a goal in program/policy development * Assessment of cultural competence and provision of training
Domain 11-‐ Administrative and Management Capacity
* Human Resource policies; staff access * Employment agreements; letters of employment * Evidence that Human Resources are a function of the agency; provision of HR services. * Evidence of information technology – system security, maintenance and assets * Inspection reports of facility(ies) and ADA Compliance Audit
Domain 11
* Agency audit reports * Program reports that are submitted to funding agencies * Disclosure of “high-‐risk grantee” status if applicable. * Funding agreements with state and one other organization are required. * Approved health department budget * Finance reports * Efforts to seek additional financial resources and the public health infrastructure.
Domain 11
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* Laws that provide the authority to conduct public health services * Description of how agency provides mandated services * Description of governing entity’s authority and structure
Domain 12-‐ Governing Entity Engagement
* Communicating with governing entity on the responsibilities of health department; governing entity orientation process * Communications on important health issues * Review of governing entity’s actions; patterns, opinions and/or positions taken * Communicating health department’s performance and where improvements are being made; sharing of improvements
Domain 12
Final Reflections and Questions
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Thank You! Have a healthy day!
Mary Kushion Consulting, LLC P.O. Box 363, Alma, MI 48801 [email protected] 989-‐463-‐1875