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Preparing for National Accreditation review. Susan Ramsey, Director Office of Performance and Accountability November 7, 2011. Training Agenda. Topics for today: Overview of the 2011 PHAB version 1.0 Standards How to Interpret the 2011 PHAB version 1.0 Standards and Measures - PowerPoint PPT Presentation
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PREPARING FOR NATIONAL ACCREDITATION REVIEWSusan Ramsey, Director
Office of Performance and Accountability
November 7, 2011
TRAINING AGENDA
Topics for today:Overview of the 2011 PHAB version 1.0
StandardsHow to Interpret the 2011 PHAB version
1.0 Standards and MeasuresStandards Review ProcessOrganizing for Self-AssessmentMock Review of Selected Standards
Pre-requisites: Online Standards Orientation – SmartPH Review 2011 Standards Review Introduction to the Guidelines
2
OVERVIEW OF PHAB VERSION 1.0 STANDARDS FOR 2011
3
INTERPRETATION OF PHAB STANDARDS AND MEASURES
Changes from 2010 Beta Test Standards Numbering System (Taxonomy) Scope of Domains Domains/Standards/Measures Quality Improvement Built into Standards
4
DEVELOPMENT FRAMEWORK / CONVENTIONS Structural Taxonomy
Example – Measure 5.3.2 S for state health departments
Example – Measure 5.3.2 L for local health departments
Standards and measures begin with an active verb
Focus on core Public Health activities and services, including environmental health 5
Domain 1
Standard 1.1
Measure 1.1.1
Tribal, State, Local or ALL
DOMAINS CROSS ALL PROGRAMS
Family Planning Program
STD and HIV/AIDS Programs
Food Safety Program
On-site Septic Program
Immunization Program
Com
mu
nic
atio
n
Domains
Use o
f Qu
ality
Im
pro
vem
en
t
Mon
itor H
ealth
S
tatu
s
Programs C
om
mu
nity
In
volv
em
en
t
Health
Polic
y &
P
lan
s
6
The 12 Domains apply at the agency level - they cut across programs and activities
12 Domains (10 Essential PH Services plus administration & governance)
32 Standards
105 Measures
Documentation
PHAB STANDARDS FRAMEWORK
7
SCOPE OF DOMAIN 1
Domains address specific topics [help avoid redundancy]Domain 1: Health Status and PH Issues data monitoring and reporting
Population health data from a variety of sources
Current services providedAssessment information on website; press
releases, waiting rooms, annual reportSamples of emails; SharePoint Sites4 Standards
8
SCOPE OF DOMAIN 2 Domain 2: Diagnosis/investigation of
health problems and environmental hazardsWritten protocols that include procedures for
conducting investigations of health problems and hazards (Agency CD Plan and Foodborne Outbreak procedures)
Completed after action reports of outbreaks which illustrates that the department and its partners have the capacity to conduct investigations for both infectious and non-infectious diseases
4 Standards
9
SCOPE OF DOMAIN 3 Domain 3: Provide Health Education/Promotion
and Communicate PH functionsPublic presentations/press
releases/brochures/flyers/pubic service announcements to promote role of PH and related messages
Evidence that target population helped frame message
Evidence of unified messaging with community partners
Media plan (risk communication plan)2 Standards 10
SCOPE OF DOMAIN 4 Domain 4: Engage the Community to
Identify & Address Health ProblemsCurrent collaborations – Family planning advisory councils – Great Start collaboratives, Flu coalitions, Child-death review teams
Does not have to be agency facilitated, but agency must actively participate
Engage the community on policy development to promote public health
2 Standards11
SCOPE OF DOMAIN 5 Domain 5: Develop & Implement PH Policies
and PlansConduct a process to develop a
community/state health improvement planMaintaining an all-hazards emergency
operations plan4 Standards
12
SCOPE OF DOMAIN 6 Domain 6: Education and Enforcement of
PH LawsReview of public health lawsDocument how staff have been trained in laws
to support public health lawsConduct and monitor enforcement activitiesFollow up on complaintsFood service hearings/compliance plans3 Standards
13
SCOPE OF DOMAIN 7 Domain 7: Assess Healthcare Capacity &
Access & Implement Strategies to Address GapsConvene and/or participate in a collaborative
process to assess availability of health care services – Provide description of partnership
Convene and/or participate in a collaborative process to establish strategies to improve access to health care services
2 Standards
14
SCOPE OF DOMAIN 8 Domain 8: Competent PH Workforce &
Assess Staff Competency & Address GapsDocument relationships that promotes
public health as a careerHealth department workforce development
planNationally adopted core competenciesCurricula and training schedules
2 Standards
15
SCOPE OF DOMAIN 9 Domain 9: Program Evaluation & Quality
Improvement Plans and activitiesEvidence of maintaining an agency
performance management systemEvidence of a written quality improvement
plan2 Standards
16
SCOPE OF DOMAIN 10
Domain 10: Identify and Use Evidence-based practices and Use of ResearchDemonstrate and document examples of using
evidence-based or promising practicesDocumentation of availability of expertise
(internal or external) for analysis of research2 Standards
17
SCOPE OF DOMAIN 11 Domain 11: Operational Infrastructure - IT
and Human Resource and Finance Written operational policies – accessible to the
staffOrganizational chartRegular reviews and updatingAudited financial statementsProgram reports/MOU’s2 Standards
18
SCOPE OF DOMAIN 12 Domain 12: Engaging the Public Health
Governing EntityDocumentation of the statutes, rules, regs. and
ordinances for mandated services which gives public health the authority to conduct the programs
Examples of communication with governing entity regarding public health issues and/or actions of the health department
3 Standards
19
QI IS BUILT INTO THE STANDARDS:PLAN-DO-STUDY-ACT-STANDARD 9.1
20
Plan
Act
Do
Study
9.1.1 : Engage staff at all organizational levels in establishing or updating a performance management system
9.1.3: Use a process to determine and report on achievement of goals, objectives, and measures
9.1.2: Implement a performance management system – self-assessment, committee or team
Conduct specific program activities that contribute to achieving goals and performance measures.
QI IS BUILT INTO THE STANDARDS:PLAN-DO-STUDY-ACT-STANDARD 9.2
21
Plan
Act
Do
Study
9.2.1: Establish a quality improvement program based on organizational policies and direction
9.2.2: Demonstrate staff participation in quality improvement activities based on the QI plan
9.2.2: Documentation of quality improvement activities based on the QI plan
9.2.2: Implement QI efforts
DOCUMENTATION AND SCORING GUIDANCE
22
GUIDE TO ACCREDITATION:
23
The 2011 Guide provides seven steps to national public health accreditation process: 1.Pre-application
Applicant prepares and assesses readiness checklists, views online orientation to accreditation, and formally informs PHAB of its intent to apply
2.ApplicationApplicant submits application form with pre-requisites, and first fee payment. Applicant attends in-person training (included in fees)
3.Documentation Selection and SubmissionApplicant selects documentation and submits it to PHAB
for review4.Site Visit
Site visit is conducted by a team of peers and report developed
5.Accreditation DecisionPHAB board will award accreditation status for 5 years
6.ReportsAccredited health department submits annual reports
7.Reaccreditation (5 years later)Accredited health department applies for reaccreditation
MAJOR CHANGES IN THE GUIDE
24
• Sequence for in-person training changed• Process is paperless• Four readiness checklists• Statement of Intent Time Frame Waived• Application shortened• Site visit report changed• Scoring scale changed• Reports post accreditation changed• Appeals procedure included
PRE-REQUISITES
25
• Submitted with the application• Reviewed by PHAB staff for completeness but
not quality and content• Reviewed for quality and content by site
reviewers• Criteria included in Domains 1 and 5
GUIDANCE PROVIDED IN STANDARDS AND MEASURES
26
The 2011 Guide provides seven steps to national public health accreditation process: •Statement of the Standard and individual measure•Specific applicability for each measure, •Interpretation and explanations of the requirements for each measure•Additional examples of documentation for the measure•Timeframes stated as part of the explanation of the requirements, and •Crosswalk to the 2007 Washington Standards with reference to the Exemplary Practice documentation in each measure
USING THE STANDARDS AND MEASURES FOR INTERPRETATION
1. Read the statement of the Standard and of the specific measure
2. Read the “Purpose” of the measure
3. Review the “Significance”
4. Read the specifics in “Required Documentation”
5. If specific documentation is required, read each requirement carefully. You will need to validate that each of these requirements are present in the documentation to score the measure as “Demonstrates”
6. The “Guidance” section provides guidance specific to the required documentation. It states if the documentation is department-wide or if a selection of program’s documentation is required
27
What you must submit for proof
Guidance specific to the required documentation
States if the documentation is department-wide or if a selection of programs’ documentation is required
Purpose: describes the public health capacity or activity in which the health department is being assessed
Domain
Measure
Numbers
Standard
Describes the necessity for the capacity of activity
28
Read the requirements
then look at the next slide –
does the document meet the measure?
29
USING THE PHAB ACRONYMS AND GLOSSARY
1. Review the PHAB Acronyms and Glossary to clarify definition of terms and how they are used in the Standards
2. Glossary contains a list of acronyms used in the Standards
3. Offers assistance in understanding the Standards and Measures
30
TYPES OF DOCUMENTATION TO DEMONSTRATE PERFORMANCE: Written descriptions of process, such as policies
and procedures, protocols, EPRP, manuals, flowcharts, logic models or other documentation.
Reports, such as health data summaries, survey data summaries, data analysis, audit results, meeting agendas, committee minutes and packets, after-action evaluations, CE tracking reports, work plans, financial reports, QI reports or other documentation.
Materials, such as email, memorandum, letters, dated distribution lists, phone books, health alerts, Fax, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website screen prints, news releases, newsletters, posters, contracts or other documentation.
31
DOCUMENTATION REQUIREMENTS No “wet ink” - documents must be in use,
not designed only for the review Documents must show their effective
date No draft documents will be allowed If no specific timeframe is cited, all
documentation should be from the last
five years
DOCUMENTATION IN DAILY WORK Build documentation into regular
processes: Use summary formats for regular
reporting Minutes of working committees Case write-ups, logs, and progress
reports Emphasize conclusions, actions and
results
33
DOCUMENTATION TIMEFRAMES Some measures state a specific timeframe
for the documentation, defined below: Annual - within the last 14 months dating
back from 10-10Current - within the last 24 months prior
to 12-09Biennial - within each 24 month period, at
the least, previous to 12-09 Regular – within a pre-established
schedule as determined by the health department
Continuing – activities that have existed for some time, are currently in existence and will remain in the future
34
SCORING Not demonstrated
Documentation does not provide evidence that the measure is met or documentation is missing.
Slightly DemonstratedDocumentation is not provided for one or more of
multiple documentation items that are required for a measure, or the department does not meet the measure in one or more areas of the department, or the department provides partial evidence.
Largely Demonstrated Fully Demonstrated
Documentation is complete and provides evidence that the measure is met. 35
WHAT QUESTIONS DO YOU HAVE?
36
STANDARDS REVIEW PROCESS AND ORGANIZING FOR YOUR REVIEW
37
PREPARING FOR STANDARDS REVIEW
38
STANDARDS REVIEW PROCESS Determine scope of review: required
measures Review assignments for Other Program for the
program review measures Required to submit all documentation
November 1, 2011 Documentation mock review conducted
November 7 & 8, 2011 After mock review, reviewers to follow-up with
programs for more documentation if review score is not Demonstrates 39
TELL YOUR STORY…. Reviewers may not be familiar with your
department Provide a short summary or note that
describes your processes for the topic being addressed – “Read Me” file
Be laser-focused on the specific requirement of that measure
Provide only the documentation that is needed to demonstrate performance. More is not better!
40
ORGANIZING YOUR DOCUMENTS Collect and organize all documents for
reviewers to review Online document library with folders for each
standard and measure Mind Manager submittal tabled for this year
State page number (or highlight with text box) where specific information addressing the measure is located if document more than 3 pages long
Can use same document for multiple measures--- just indicate all measures that are relevant and page of document 41
MORE DOCUMENTS IS NOT BETTER!!
Be compulsively attentive, “laser focused” on the specific language used to describe what will meet their requirements
Watch “and” vs. “or” language in the required documentation language
A single document may serve more than one measure, and conversely, it may take more than one document to prove a measure.
Only show what is needed and no more
LABELING & MARKING DOCUMENTS There must be a title and date on each
document Highlight the title and date in yellow Unless it is a brief document and the proof is
very obvious, highlight the text that proves the measure.
If you are using a hyperlink to our web site for proof, paste it into a Word document and describe it briefly.
EXAMPLE OF DOCUMENTATION - MEASURE 2.4.3 (KITSAP)
WHAT QUESTIONS DO YOU HAVE?
45
MOCK REVIEW 46
MOCK REVIEW INSTRUCTIONS Teams of 2 people Review Scoring Sheets Individually read each Standard and then the
measure that you will be scoring. Identify if there is “Required Documentation” for
the measure Determine timeframe for the documentation for
the measure Identify if the measure is a “health department
level” or “sample of programs” Read documentation and come to consensus on
the score for the measure
47
MOCK REVIEW ASSIGNMENTSREVIEWERS DOMAINS NUMBER OF
MEASURES
Megan DavisDeborah ToddTerry Taylor
1, 2, 6 39
Diana EhriMichele Maddox
3, 4, 5, 9 32
Susan RamseyAmy Ferris
7, 8, 10, 11, 12 34
48
WHAT QUESTIONS DO YOU HAVE?
49
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