Applying for National Public Health Accreditation: A

Comprehensive ApproachKaren Hagos, MPH

Priti Irani, MSPHNew York State Department of Health

National Public Health Improvement Initiative

PHAB Accreditation Overview

Building Accreditation Readiness Infrastructure

Development of Pre-Requisites and Prevention Agenda

Using a Quality Improvement Approach

Tracking Progress & E-PHAB

Today’s Session…

CDC National Public Health Improvement InitiativePerformance Management Initiative to Improve Health

Outcomes

Acknowledgement: This presentation was supported by funds made available from the Centers for Disease Control and Prevention, Office for State, Tribal, Local and Territorial Support, under CDC-RFA-CD10-101101PPHF12 Disclaimer: The content, findings and conclusions of this presentation are those of the authors and do not necessarily represent the official position of or endorsement by the Centers for Disease Control and Prevention.

http://www.cdc.gov/stltpublichealth/nphii/about.html

The Performance Management Group (PMG) focuses on building, institutionalizing, and implementing performance management and improvement capacity within the agency.

“The initiative is intended to strengthen public health infrastructure and systematically increase performance management capacity so that public health goals are effectively and efficiently met.” - CDC

Public Health AccreditationAccreditation Domains

Domain 1: Community Health Assessment

Domain 2: Investigate Domain 3: Inform and

Educate Domain 4: Engagement with

Community Domain 5: Public Health

Policies Domain 6: Enforce Public

Health Laws Domain 7: Access to Health

Care Services Domain 8: Competent Public

Health Workforce Domain 9: Performance

Management and Quality Improvement

Domain 10: Evidence-Based Public Health

Domain 11: Administrative and Management Capacity

Domain 12: Engage Public Health Governing Entity

Public Health Accreditation Board (PHAB)

Improve service, value and accountability to stakeholders

Identify improvement opportunities, develop leadership

Gain recognition as high quality, high performing agency

11 Health Departments Accredited in March 2013

Accreditation: Advancing PH Performancehttps://www.youtube.com/watch?v=WgwSivfASM0

Pre-Application◦ Online orientation◦ Submit Statement of Intent

Application◦ Submit Pre-Requisites: Community Health Assessment,

Community Health Improvement Plan, Strategic Plan◦ Submit form, fee◦ Attend Training

Document Selection and Submission

Site Visit Accreditation Decision Reports Re-accreditation

Seven Steps to Accreditation

Prevention Agenda 2013-2017Five Statewide Priorities

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Prevent Chronic Diseases Promote a Healthy and Safe Environment Promote Healthy Women, Infants and Children Promote Mental Health and Prevent Substance Abuse Prevent HIV, STDs, Vaccine Preventable Diseases

and Healthcare Associated Infections

Prevention Agenda 2013-2017

For each priority, action plans contain: Goals (at least one per priority) Measurable objectives including some on

disparities◦ 3-5 measures per priority: at least one impact/outcome

measure and at least two process measures Evidence based and promising practices sorted by

sector and by health impact pyramid.

http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/

January 11, 2013 7

Community Health Assessment (CHA): Part of a strategic plan that describes the health of the community by collecting, analyzing and using data to educate and mobilize communities, develop priorities, garner resources, and plan actions to improve public health. Mandated for local health departments as per New York State Public Health Law §6.

-Working Definition, New York State Department of Health

Assessment : the process of regularly and systematically collecting, assembling, analyzing, and making available information on the health needs of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems.

Source: http://www.health.ny.gov/statistics/chac/glossary.htm#C Lessons learned from our processes – good and bad (?) Time it took for completion, parties involved

Pre-Requisite - CHA

1. Priorities aligned with assessment findings and clearly articulated

2. Specific, measurable goals/objectives3. Evidence-based or best practice strategies4. Explanation of the process in assessment,

priority-setting, and action plan, and the roles of community partners

5. Measures to track process and outcomes and reporting of lessons learned

Pre-Requisites - CHIP

Local Health Department CHA-CHIP Blue = new

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Community Health Assessment1. Description of Community (i.e. Demographics, Health issues)2. Identification of major health challenges3. Succinct summary of assets and resources4. Documentation of collaborative process and methods

Community Health Improvement Plan5. Identification of at least two community priorities. At least one

must address a disparity.2,4,5 For each priority – goals, objectives, strategies and

practices, performance measures (process, outcome)3. Community stakeholder roles and responsibilities6. Process used to sustain engagement

Hospital CSP

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1. Mission Statement2. Definition of community served3. Public Participation (i.e. participants, dates,

process)4. Assessment and selection of at least two

community priorities. At least one must address a disparity.

5. 3-year plan of action6. Dissemination of plan to the public7. Process to sustain engagement

Key Points

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1. Purpose statement aligned with defined priorities2. Specific, measurable goals/objectives3. Tracking measures at implementation and

building on lessons learned 4. Use of best practice and/or evidence-based

strategies5. Brief explanation of the collaborative process:

assessment, prioritization, criteria for selecting priorities, strategies

6. Description of roles of community partners

Selected Resources

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State Prevention Agenda http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/index.htm

Community Health Assessment ImprovementCath. Health Assc. Assessing/Addressing Community Health Needs

http://www.chausa.org/Pages/Our_Work/Community_Benefit/Assessing_and_Addressing_Community_Health_Needs/

NACCHO Community Health Assessment and Improvement Planninghttp://www.naccho.org/topics/infrastructure/CHAIP/index.cfm

 

Data ResourcesNYS DOH Community Health Indicator Reports http://www.health.ny.gov/statistics/chac/indicators/

County Health Rankingswww.countyhealthrankings.org/

 

Evidence-Based /Promising Practices ResourcesGuide to Community Preventive Serviceshttp://www.thecommunityguide.org/index.html

Community Health Assessment and Improvement Process

Community Health Assessment and Improvement Process

Local health departments have been submitting periodic reports on collaborative community health assessment for years

Existing strong relationships with hospitals and community partners

Access to county-level health status, behavior risk data

Data interpretation

CHA Review - Strengths

Tracking and evaluation of interventions Balancing process and outcome measures Adapting evidence-based or best-practice

interventions to local context Identify tangible roles for partners

CHA Review - Challenges

Project Management Tools◦ Project Charter◦ Work Plan◦ Timeline◦ Team Membership

Team Structure per Domain◦ Cross-Cutting Teams◦ Over 100 internal staff involved in accreditation self-

assessment

Accreditation Self-Assessment

 Quality Improvement Tools

Brainstorming“A method for a group to generate a large number of ideas around an issue of interest.”

Nominal Group Technique“A process that helps teams prioritize by consensus.”

Improved participation, efficiency, and sense of ownership over the process.

Documentation Selection

SharePoint and Shared Drives for Documentation Storage

E-PHAB

Documentation Storage & E-PHAB

Planning within each phase is important

Use tools available to you to structure and organize (Project charter, QI Tools, SharePoint)

Involve others to create buy-in and support

Lessons Learned

Bialek, Ron et al. “The Public Health Quality Improvement Handbook.” (2009): 162, 175.

National Public Health Improvement Initiative. (2010): http://www.cdc.gov/stltpublichealth/nphii/about.html

References