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PHAB Accreditation Assessment Process Overview
- 2. Public Health Accreditation Assessment Process Bud Nicola , MD, MHSA, FACPM Chair, Assessment Process Workgroup Introduction and Overview
- 4. Workgroup Members Christine M. Abarca, MPH, CHES Florida Joan H. Ascheim, MSN New Hampshire Janet Canavese Missouri Alan V. Kalos, MED Kentucky Jerald W. King, MA Indiana Laura Rasar King, MPH, CHES Council on Education for Public Health (CEPH) Richard H. Matheny, Jr. MFS, MPH Connecticut Bud Nicola, MD, MHSA, FACPM (Chair) Washington State Bruce Pomer, MPA California Rita A. Schmidt, MPH Washington State David Stone, MS North Carolina Jeffrey J. Zayach, MS Colorado Dennis Lenaway PhD, MPH CDC Michael Hamm Consultant to PHAB
Editor's Notes
- – Note to Bud: I will advance this first slide to the second slide, at the start of the webcast. I will talk during the cover slide and then advance it to the “goals” slide. Then, you can take it from there. Robin
- Robin: Good afternoon everyone! Or, good morning. This is Robin Wilcox. I am very pleased to welcome PHAB Board members to this overview of the recommendations of the Assessment Process Workgroup. Dr. Bud Nicola, Chair of the Assessment Process Workgroup, will present to you an overview of the Workgroup’s recommendations for PHAB’s process of assessment for applicants for accreditation. The phone lines will open during this call so that you may ask questions and engage in discussions at any time. I would like to suggest that if you are not speaking, to please put your phone on mute. If you don’t have a mute button, you can dial *6. To un-mute your phone, dial *7. Please do not put your phone on hold, because your hold music might come through. Jessica Solomon and I will both be taking notes today to ensure that any issues that are raised are referred to the Board for discussion later this week. Before I turn the program over to Dr. Nicola, on behalf of PHAB, I would like to thank Dr. Nicola and all of the members of the Assessment Process Workgroup for their concentrated and careful consideration of each step of the assessment process. They completed their comprehensive work with dedication and good will. Dr. Nicola, . . . . .
- BUD: Thank you Robin. I would also like to thank the members of this workgroup. They worked very hard over four two-day meetings and completed their recommendations this past March. The Workgroup’s report that you received in your Board packets is for consideration during this week’s Board meeting. The report includes more details than we have time to address during this call. The purpose of this webinar is to provide you with an overview of the Workgroup’s recommendations. This is an opportunity for you to ask questions for clarification and to raise issues for further discussions. We do not expect to resolve issues today. That’s the responsibility of the full board later this week. And, as Robin said, she and Jessica are taking notes to be sure that issues raised today are forwarded to the Board for discussion at our meeting on Thursday. I want to point out that in addition to the workgroup’s report, you received a list of issues that require Board resolution. These are issues that the workgroup feels are appropriate for Board deliberations. I will not include all of those issues today, because you have already received them in writing.
- The workgroup has representation from Missouri and North Carolina, each of which have formal state-based accreditation programs. We have representation from Washington State which has an accreditation-like program. And, we have representation from CEPH which has been accrediting schools of public health since 1974. Each workgroup member actively contributed to the discussions and to the final report. We were also assisted by Mike Hamm who lead our discussions through the steps of the assessment process.
- The Workgroup adopted three overarching principles: The assessment process should encourage continuous quality improvement and not simply be a paper exercise that a department goes through and then forgets until it is time for renewal. The process should be as simple and clear as possible, and not create unnecessary barriers or hurdles or be punishing. And, finally, the process should be as paperless as possible. These principles guided the workgroup and were incorporated into every decision.
- The process recommended buy the workgroup includes 7 steps. It begins with the PHAB providing information when a department first considers the possibility of seeking accreditation, and then transforms into a cycle of ongoing quality improvement.
- The pre-application process was designed to ensure that prospective applicants (1) are aware of the process and requirements and (2) fully assess their readiness and engage in preparation activities. The intent of the Workgroup is that no department would apply unless they were fully prepared. And, therefore, no department, once they apply, would fail receiving accreditation status. In that way the process’s focus is on quality improvement and not on penalties or embarrassment. PHAB will refer potential applicants to their associations - APHA, ASTHO, NACCHO and NALBOH - for quality improvement technical assistance. The Assessment Process workgroup debated whether or not PHAB should publish training/technical assistance resources of other organizations. This is an issue that the Board may want to consider. The purpose of orientation - - B on the slide - - is to provide an overview of the process, timeline, and standards. It will be targeted towards any department that is considering accreditation as well as for those who are simply curios about it. Any department considering accreditation will be encouraged to have several staff members complete orientation. Orientation will be available online and will be free. And, PHAB will be able to track who, in what department, has completed the online orientation. This will be important because the orientation must be completed before the next formal step - - - the letter of intent. Of course all potential applicants will be encouraged to assess their readiness. It is recommended that PHAB develop assessment tools. For example, PHAB should make available a readiness checklist and information concerning requirements.
- The workgroup is recommending that a non-binding letter of intent be required. This will enable PHAB to plan its workload and develop training and application queues. The letters must include the name of the person designated by the applicant as the accreditation coordinator . The coordinator will be the primary contact person for PHAB. This person must have completed the online orientation and must also attend the PHAB training - - that we will talk about next. The workgroup is recommending that participation in PHAB training be required for all applicants. Training should be face-to-face to allow for case studies, discussions, and robust questions and answers. It should provide an overview of the accreditation process, review the standards and measures, describe the required self-evaluation, and discuss preparation for site visits. Again, the training will not teach applicants how to meet the standards or measures. This type of technical assistance will be provided by PHAB’s partner organizations.
- The application itself is a form of a contract. That is, when a department submits an application, they formally begin the process and agree to abide by the current and future rules of the accreditation program. The form needs to provide PHAB with the necessary information to determine eligibility. A unique application form should be developed for joint applications, with specific documentation of the relationship required. The workgroup debated on what signatures should be required. Of course the department’s head should sign the application. But we were undecided about whether the governance board should sign it or be required to submit a letter of support. That’s something for the Board to think about. PHAB staff will review all applications for completeness to determine whether the applicant is eligible. They will determine if the required documentation is included, and if the fees have been paid. Eligibility includes the required submission of a strategic plan, a community/state health assessment, and a community/state health improvement plan. These documents serve as an indicator of the applicant’s readiness. Multi-agency applicants will be required to submit documentation describing their relationship. The Workgroup recommends that the Board consider what criteria would be used for acceptance of a multi-agency application.
- Self-assessment is a key step in the accreditation process. It is where the applicant gathers and provides documentation to show that they meet the standards and measures. The self-assessment must be submitted to PHAB within 12 months of their application being accepted. When a self-assessment is received by PHAB, staff will determine if a sufficient type and volume of documentation has been submitted to proceed with the review and that the applicant is ready for review by a site visit team. This is not a decision making step – it’s a screening step. The final adequacy of this documentation will be determined through the site visit. The self-assessment will follow the language of the standards and measures. There is enough flexibility in the process to allow applicants to demonstrate how their particular processes or approaches to meeting a measure may differ from those provided in other health departments, but still meet the intent of the standard or measures.
- The purpose of the site visit is to verify the accuracy of the self-assessment materials and to seek answers to questions raised during the review of the materials. Formal site visitor training will need to be developed by PHAB. Training should be a two-day face-to-face course that includes hands-on work exercises as well as classroom training. Training might also include observation of a site visit and practice scoring. Site visitors will be encouraged to participate in one or more visits per year to stay current in the process. Site visitor training will need to include refresher courses. When it is time for a site visit, PHAB staff will appoint a site visit team and a team chair. The chair will be responsible for managing the site visit and for preparing the report. Site visit teams will usually be 3 to 4 members. One member of the team should have management expertise at the program or higher level. And, one member of the team should have a public health background. This could be expertise in: Community Health; Health Education; Epidemiology; Public health nursing; Registered Environmental Health Specialist; Medicine; Veterinary medicine; or Social Work. A board of health representative might also be a team member, if one is available. All site visit team candidates will be required to disclose any conflicts of interest to PHAB during the team selection process. And, the applicant will have an opportunity to challenge any appointed site visit team member.
- Before a site visit, each member of the site visit team will review all of the materials submitted by the applicant. The team will conduct a conference call to review the materials, determine potential areas of non-conformity, identify missing documentation, and formulate questions. The site visit itself will include: a review of the agenda and purpose of the site visit; a walk-through/tour of the health department; a schedule for interviews, work sampling and collection of additional information; review of any new materials submitted on site; and an exit conference to review identified strengths, areas of potential non-conformance or opportunities for improvement. The typical site visit will take two to three days, depending upon the scope of the application. For quality improvement, sometimes site visit teams will be encouraged to utilize co-scoring to improve inter-rater-reliability for some measures. By that I mean that two or three people will look at the same documentation and score it separately, and then compare their results. We also encourage team members to confer on any measures that the applicant is in non-conformity. The workgroup is recommending that an evaluation system be utilized at the conclusion of each site visit. It would allow the applicant to rate the entire site visit team, the Chair to rate other team members, and team members to rate the performance of the Chair. PHAB will use these findings to improve the process and to make decisions regarding the future inclusion of specific individuals on site teams. The site visit report will describe the strengths and weaknesses of the applicant, as well as suggested areas for improvement. The report will include the team’s collective score for each measure. The report will not include a recommendation for accreditation status. Accreditation decisions will be made by the Board of PHAB. The written report will be made available to the applicant for their review. They will have an opportunity to respond to the report, but will not be permitted to provide additional documentation, unless it is to correct a factual error.
- The Board will need to determine criteria for awarding accreditation status. The Board will make all final decisions on accreditation status. When the volume of applications grows to a point where the Board cannot issue decisions in a timely manner, a Review Committee may be established to review materials and recommend accreditation decisions to the Board. Applicants will not be permitted to attend board or review committee meetings, though PHAB may disclose when the board will review their application. No verbal feedback will be given to the applicant before the official written decision letter is sent. The workgroup recommends that accreditation may be awarded for up to 5 years. The range of decisions includes: - Full accreditation (5 years); - Conditional accreditation , up to 5 years. Conditions would have to be resolved within a specified period of time for full accreditation; or - Non-accreditation The Workgroup requests that the Board consider what criteria and scoring should be used for conditional accreditation and what length of time an applicant can remain conditional.
- The workgroup recommends that PHAB develop a detailed appeals process and a list of appealable issues. For example, applicants might appeal the eligibility decision, accreditation status, and listed deficiencies. The workgroup recommends that the process be designed to not require the involvement of attorneys, as much as possible. The workgroup recommends that there will be two levels of review of appeals: The first level of review would be before a panel of PHAB Board members. The second level of review would be by an external group appointed by the PHAB Board. At this second level of review the applicant is appealing the decision of the first level of review. The Workgroup also recommends that PHAB develop a complaint process. Complaints would include issues related to standards and measures or the accreditation process.
- After receipt of accreditation, departments would be required to report substantive changes when they occur. Contact information should be updated at least annually. A mid-term report – or at the 2 ½ year mark - will be required of all accredited departments. Reports will describe how the department has implemented performance improvement plans, addressed all opportunities for improvement outlined by PHAB, and addressed ongoing quality and performance improvement. Failure to submit a required report will result in revocation of accreditation. In order to receive re-accreditation, health departments will be required to submit a new application and participate in a site visit. However, they may submit information concerning only what has changed. That is, applicants may use their originally submitted material with appropriate changes and additions. Applicants will retain their accreditation status after they have submitted an application for re-accreditation but before re-accreditation status has been approved by the Board. Departments will not retain accreditation status if they have received notice of the expiration of their status and have not submitted an application and paid required fees within time frames to be determined by the PHAB Board.
- I want to mention that a flow chart is attached to the report that you have received in the Board packets. NACCHO developed this chart for us. I think it helps a great deal in understanding the process that the workgroup has proposed. Please take a look at it.
- And, this is just the second half of the chart.
- I hope that this overview has been helpful. If you have not had a chance to review the workgroup’s report, I hope that you will before the Board meeting. There are many more details in the written report. Also, please consider the list of issues that the workgroup has referred to you. It’s in the Board packet too. Are there any final comments or questions before we close today? Thank you all for your attention. I look forward to seeing you in Arizona in a few days. Safe Travels everyone.
- ROBIN: That concludes today’s webcast. Thank you very much.