This document summarizes a local health department's experience with the national public health accreditation process. It discusses why the department applied for accreditation, the importance of accreditation, and their fast-paced and decentralized approach to the application and documentation submission. It then describes the site visit process and identifies areas for improvement that were recognized before and after the visit. Lessons learned are provided around taking more time, using a team approach, improving documentation, and aligning processes with accreditation standards. The importance of accreditation in identifying successes, promoting quality initiatives, and delivering results is also restated.

1. Overview of KCMO
Accreditation
PHAB Site Visit
January 31, 2012

2. 2
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).

3. 3
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

4. 4
 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.

5. 5
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

6. 6
Accreditation
Diagram

7. The Site Visit:
7
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.

8. 8 Day 1

9. 9 Day 1 & 2

10. 10
Identified Area’s of Improvement
Prior 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)

11. 11
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!

12. 12
Reviewer
Feedback
 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

13. 13
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)

14. Areas for Improvement
14
Pre-Site Visit Post Site Visit
 Domain 8:  Domain 1:
Health Department Workforce Community involvement in the
Development Plan Community Health Assessment process
 Domain 8:  Domain 2:
Cultural Competency Assessment Written Documentation: Document &
date protocols, processes and policies
 Domain 9:
Performance Management Plan  Domain 4:
Community capacity building
 Domain 9:
Quality Improvement  Domain 9:
Staff engagement in identifying
opportunities for improvement

15. 15
 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.

16. 16
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 forthe 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!

17. Next Time We Will:
17
 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.

18. Next Time We Will:
18
 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.

19. 19
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)

20. 20
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.

21. 21
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.

22. 22
 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.

23. 23
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”

24. 24
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.

25. 25
 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.

26. 26
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!

27. 27
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.

28. 28
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.

29. 29
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

30. 30
END of Presentation
Following slides are
background/reference
that can be used to field
questions info if needed

31. 31
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.

32. 32
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.

33. 33
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
 signed (authorized through e-PHAB) by the director of the health department.
Be

34. 34
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

35. 35
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.

36. 36