case study 3 - public health accreditation board · 2013-06-14 · revised phab education services...
Post on 15-Jul-2020
3 Views
Preview:
TRANSCRIPT
PHAB EDUCATION SERVICES - Discussion Guide Page 1 of 49
CASE STUDY 3
E-PHAB DOCUMENTATION ASSESSMENT
DISCUSSION GUIDE
Site Visitor Training
PUBLIC HEALTH ACCREDITATION BOARD Education Services
Revised – April 2013
NOTE: The documents used during Site Visitor Training are for training purposes
only and do not represent actual documentation, nor is it indicative that similar
documentation should be accepted or rejected by site visitors.
This guide is to be used for discussion about the training documents and does not
cover all aspects of document quality, nor how they would or would not meet PHAB
requirements.
PHAB EDUCATION SERVICES - Discussion Guide Page 2 of 49
DOCUMENTATION EXERCISE GUIDE Site Visitor Training
Documentation Exercise using e-PHAB
Here are the measures that are in the SVT Training Health Departments. The
documentation is also located on the flash drive distributed at the training.
1.1.2 T/L
2.1.2 T/L
2.3.2 A
3.2.2 A
4.1.1 A
5.1.3 A
6.2.3 A
6.3.5 A
7.2.1 A
8.1.1 T/L
8.2.1 A
9.2.1 A
9.2.2 A
10.2.2 A
11.1.1 A
11.1.2 A
12.1.2 A
12.3.2 A
Acronyms
ACHC – Acme County Health Center
EH – Environmental Health
OFI – Opportunity for Improvement
NOTE: Many of the Measures are either largely or slightly demonstrated for training
purposes. They are not designed to show that health departments would submit many
measures that would be assessed as such – most measures will likely be fully
demonstrated.
PHAB EDUCATION SERVICES - Discussion Guide Page 3 of 49
Measure 1.1.2 T/L
Domain 1: Conduct and disseminate assessments focused on population health status and
public health issues facing the community
Standard 1.1: Participate in or Conduct a Collaborative Process Resulting in a
Comprehensive Community Health Assessment
1.1.2 T/L: Complete a Tribal/local community health assessment
Required Documentation 1: A Tribal or local community health assessment dated within the last five years that includes:
Documentation that data and information from various sources contributed to the community health assessment and how the data were obtained
A description of the demographics of the population A general description of health issues and specific descriptions of population groups
with particular health issues A description of contributing causes of community health issues A description of existing community or Tribal assets or resources to address health
issues Example 1
Title – ACHC Community Health Assessment – Part 1
File – Acme 2010 CHA Volume One
File Description – This is the primary report of the ACHC CHA from 2010. Example 2
Title – ACHC Community Health Assessment – Part 2
File – Acme 2010 CHA Volume Two
File Description – Part 2 of the ACHC CHA from 2010 contains Environmental Health data.
PHAB EDUCATION SERVICES - Discussion Guide Page 4 of 49
Required Documentation 2: Documentation that the Tribal or local community at large has had an opportunity to review and contribute to the assessment
Example 1
Title – Website Comment for CHA
File – Measure 1.1.2 Website Comment
File Description – This document details the CHA posting on the ACHC website inviting comment and questions.
Example 2
Title – Press Release for CHA
File – Measure 1.1.2 CHA Press Release
File Description – This press release was sent on 6-9-2010 announcing the CHA reports and asking for comment.
Measure Narrative The documentation in this measure related to the CHA process that the ACHC undertook in 2010. We use the CHA protocols established by Healthy Carolinians at the State Division of Public Health (See 1.1.1 L). For this CHA, we collaborated with the NC Institute for Public Health, which facilitated the process. The report was issued in two parts. The first dealt with health care needs, demographics and health data. The second dealt with environmental health issues and data. The examples of distribution and seeking of input are but two of many - others are available upon request. The Board of Health also sought input at BOH meetings. The press release and website posting were two primary means of publicizing the reports and seeking input. Referenced in Narrative (1.1.1L) Required Documentation 3: Description of the process used to identify health issues and assets
Title – CHA Guide Book
File – Measure 1.1.2 CHA Guide Book
File Description – This is the guide book for the CHA process established by the Healthy Carolinians Branch at the NC Division of Public Health.
PHAB EDUCATION SERVICES - Discussion Guide Page 5 of 49
Assessment
1. While all the required components are most likely in the reports, none of the bullet points have been flagged or highlighted. (The first four bullets are in the documents. The fifth bullet is touched on throughout but is not fully developed.) Unless the Site Visitor wants review some 330+ pages in the reports, the health department should be asked to provide narrative on where the required elements can be found in the document.
2. These two examples are fine. A documentation OFI to make the documentation stronger would be to have a screen shot from the web site showing the info that was posted and to include a fax cover or email showing distribution of the press release.
Pre-Site Visit Assessment: Pending, until the required elements in the CHA are located.
The material does fully demonstrate with an Opportunity for Improvement to better delineate the available community resources.
PHAB EDUCATION SERVICES - Discussion Guide Page 6 of 49
Measure 2.1.2 T/L
Domain 2: Investigate health problems and environmental public health hazards to protect the community
Standard 2.1 Conduct Timely Investigations of Health Problems and Environmental Public
Health Hazards
2.1.2 T/L: Demonstrate capacity to conduct an investigation of an infectious or communicable disease Required Documentation1: Audits, programmatic evaluations, case reviews or peer reviews of investigation reports against protocols (2 examples) Example 1
Title – Evaluation of HepA Response
File – Measure 2.1.2 ACHC – Evaluation of HepA Response 03-2012
File Description – Example 2
Title – Acme OSWW Program Review 2008
File – Measure 2.1.2 Acme OSWW Program Review 2008
File Description – Here is a complete program review of the On-Site Wastewater (OSWW) program in Environmental Health at ACHC. This was conducted by the State OSWW Division and was conducted in February, 2008. The report was dated May 16, 2008 and details the evaluation of the program against protocols.
Title – OSWW Plan of Action 8-10-10
File – Measure 2.1.2 Plan of Action 8-10-10
File Description – Here is the Plan of Action developed by the ACHC in August of 2010. This follows up and is in response to the Program Review of 2008. Note high-lighted text.
Required Documentation 2: Completed After Action Report (AAR)
PHAB EDUCATION SERVICES - Discussion Guide Page 7 of 49
Title – Acme Shigella Outbreak Report
File – Measure 2.1.2 Acme Shigella Outbreak report-final 1-21-10
File Description – Here is the final report of the November 2009 Shigella Outbreak in the county and the response of ACHC. The report was finalized on 1-21-2010 and forwarded to the State Division of Epidemiology.
Measure Narrative
ACHC has provided two examples of programmatic reviews. One was done by the state for
our On-Site Waste Water program. Another review was an internal review of our response
to a Hepatitis A outbreak. The AAR is from an investigation of a Shigella outbreak that the
ACHC responded to, mitigated and contacted those affected in the outbreak.
Assessment
1. There are two examples provided. The guidance specifies that the examples should be
related to the capacity to respond to outbreaks of infectious or communicable disease. Also
note that the guidance and the measure state that the documentation should be reviews of
investigation reports against protocols. Acme has provided two examples. The evaluation is
for a Hepatitis A outbreak. There is a need to have the protocol that was used as a part of
the evaluation and this should be asked for.
The OSWW example is a program review that is nonspecific to a particular outbreak
or disease situation. It could be possibly argued that the review does contain
information of work against protocol, and that improper disposal of sewage or a
system failure can cause an outbreak of disease, but this is a stretch and does not
meet the intent of the measure. This example would not be acceptable. There could
be a question with a reopen to ask for another example that has a focus of an
infectious or communicable disease.
2. The department does provide an AAR of a communicable disease outbreak and how the HD
conducted the response. This is acceptable evidence for this requirement. (Note that this
outbreak provides a means for developing documentation for the other requirement in this
measure. The AAR could be reviewed against the department’s communicable disease
response protocols to determine if the response was handled in the best way possible.
However do not ask for this specific type of evidence. However, you could mention this in
your comments regarding Opportunities for Improvement.
Pre-Site Visit Assessment: Largely Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 8 of 49
Measure 2.3.2 A
Domain 2: Investigate health problems and environmental public health hazards to protect the community
Standard 2.3: Ensure access to laboratory and epidemiological/environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards.
2.3.2 A: Maintain 24/7 access to laboratory resources capable of providing rapid detection, investigation and containment of health problems and environmental public health hazards
Required Documentation 1: 1. Laboratory certification
Document 1
Title – ACHC Laboratory CLIA Certificate
File – Measure 2.3.2 ACHC CLIA Certificate File Description – This is the CLIA certificate showing that the department is authorized to conduct the listed laboratory testing.
Document 2
Title – NC State Lab CLIA Certification
File – Measure 2.3.2 NC State Lab CLIA Certification File Description – This is the CLIA certificate for the NC State Lab of Public Health, which serves as a main reference lab for the health department.
Required Documentation 2: 2. Policies and procedures ensuring 24/7 Coverage
Title – ACHC Emergency Operations Procedures
File – Measure 2.3.2 ACHC duties – EOP
File Description – See highlighted text showing our responsibility to have full time coverage of all major services and for response to public health emergencies.
PHAB EDUCATION SERVICES - Discussion Guide Page 9 of 49
Required Documentation 3:
3. Protocols for handling and submitting specimens
Document 1
Title – Clinical Laboratory & Clinical Lab Specimens
File – Measure 2.3.2 Clinical Laboratory & Clinical Lab Specimens
File Description – none
Document 2
Title – Laboratory Specimen Handling Policy
File – Measure 2.3.2 Laboratory Specimen Handling Policy
File Description – none
Document 3
Title – Laboratory Specimens Protocol
File – Measure 2.3.2 Laboratory Specimens Protocol
File Description – none
Measure Narrative Through our own laboratory services and the reference labs we use, we maintain the necessary capacity for both daily services and emergency or outbreak response. We maintain a moderate level CLIA certified lab (offsite) and provide basic support at the health department. All laboratory policies follow both the department protocol and CLIA protocols for review and revision.
Assessment
1. There are two CLIA certificates provided – one for ACHC and one for the State Lab.
The State Lab Certificate has expired, so a new one will need to be requested. Also,
the team should ask if there are any other reference labs used by the HD. This could
be done as a question thru e-PHAB, or could be noted by the team as a question
during the interview. In either case, if there are other labs, the team would decide if
those certificate copies will be asked for.
PHAB EDUCATION SERVICES - Discussion Guide Page 10 of 49
2. There is only one weak piece of evidence here. It is a HD duties section from the Co.
EOP that states that the HD will maintain 24/7 coverage for the lab. However there
is no policy or protocol included. This does not meet the documentation
requirement. The team could ask for the policy on how the HD maintains the
coverage of the lab.
3. There are three polices/protocols attached and all are named for laboratory
specimens. While between the three this element is demonstrated, there is a
definite opportunity for improvement. All three protocols have components of
specimen handling and three different policy formats. How does staff know which
one to refer to? Or would all three have to be referenced, if needed, when handling
specimens? These three should be consolidated into one protocol. Also, there are no
protocols for handling environmental health specimens. This could be a question
now or during an interview. The team would determine if it would reopen to
request environmental health specimen handling protocols.
Pre-Site Visit Assessment: Slightly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 11 of 49
Measure 3.2.2 A
Domain 3: Inform and educate about public health issues and functions Standard 3.2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences. 3.2.2 A: Establish and maintain communication procedures to provide information outside the health department Required Documentation 1: Written procedures for communications, updated biennially, that include:
a. Disseminating accurate, timely, and appropriate information for different audiences b. Informing and/or coordinating with community partners for the communication of targeted and unified public health messages c. Maintaining a current contact list of media and key stakeholders d. Designating a staff position as the public information officer e. Describing responsibilities and expectations for positions interacting with the news media and the public, including, as appropriate, any governing entity members and any department staff member
Document 1
Title – Acme Media Policy
File – Measure 3.2.2 Acme Media Policy
File Description – Health Department media policy
Document 2
Title – ACHC Crisis Communication Policy
File – Measure 3.2.2 ACHC Crisis Communication Policy
File Description – This document demonstrates the appointment and role of the PIO
Document 3
Title – Acme County Emergency Pub Info Plan
File – Measure 3.2.2 Acme Co Emer Pub Info Plan
File Description – Contains communication procedures. See highlighted list of media contacts on page 24
PHAB EDUCATION SERVICES - Discussion Guide Page 12 of 49
Required Documentation 2: Dissemination of public health messages outside the health department
Example 1
Document 1
Title – Diabetes Press Release
File – Measure 3.2.2 Diabetes Press Release
File Description – 1st example of disseminated message Part 1
Document 2
Title – Diabetes Advocacy Day Press Release
File – Measure 3.2.2 Diabetes Advocacy Day Press Release
File Description – 1st example of disseminated message Part 2
Example 2
Document 1
Title – Heat Related Illness Press Release
File – Measure 3.2.2 Heat Related Illness Press Release
File Description – 2nd example of disseminated message
Measure Narrative
We submit our Crisis Communications Plan, our Media Policy and our Acme County
Emergency Public Information Plan, as referenced above, as examples of the department’s
ability to establish and maintain communications procedures to distribute timely
information in an appropriate fashion outside the agency.
We also have provided examples related to two programs – diabetes care from adult
health/chronic disease and heat related illness from community health promotion – to
demonstrate the implementation and following of our plans.
Assessment
1. The three documents include two department policies and a county plan. The
documentation listed is only part of what is needed. The attached policies do not
PHAB EDUCATION SERVICES - Discussion Guide Page 13 of 49
have the required elements. We do know that they have a PIO, so requirement d is
well covered. Some of requirement e is covered also. While there is a list of media
contacts, there is no list of key stakeholders included for requirement c.
Requirements a and b have some documentation in the county plan, but they are not
pointed out or highlighted, so the site visitor would have to read thru and pick out
what they think applies.
2. Here two examples are presented and one is a chronic disease - diabetes. The other
is within health promotion (injury prevention?). This section is met. An OFI would
be to include the email or fax cover showing that the releases went out.
Pre-Site Visit Assessment: Largely Demonstrated
The main deficiency is within required documentation 1.
PHAB EDUCATION SERVICES - Discussion Guide Page 14 of 49
Measure 4.1.1 A (NOTE: This documentation is the same as in 7.2.1)
Domain 4: Engage with the community to identify and address health problems
Standard 4.1 Engage with the Public Health System and the Community in Identifying and Addressing Health Problems Through Collaborative Processes
4.1.1 A: Establish and/or actively participate in partnerships and/or coalitions to address
specific public health issues or populations
Required Documentation: 1. Documentation of current collaborations that address specific public health issues or
populations Example 1
Document 1
Title –Access to Care Annual Report
File – Measure 4.1.1 Coalition Report File Description – This is an annual report on the Access to Care project of the ABO Health Care Coalition.
Document 2
Title – Agreement for Nurse Practitioner Services
File – Measure 4.1.1 Agreement for NP Services
File Description – This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner to serve at the ACHC clinic sites.
Example 2
Document 1
Title – Access to Care Action Plan 2010
File – Measure 4.1.1 Access to Care Action Plan
File Description – This is the action plan regarding access to care from the 2010 Community Health Assessment. Partners are highlighted (for required documentation 2).
PHAB EDUCATION SERVICES - Discussion Guide Page 15 of 49
Document 2
Title – Access to Care Talking Points
File – Measure 4.1.1 Access to Care Talking Points File Description – This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders.
2. List of partner organizations or representation in each collaboration
Title – List of Coalition Partners
File – Measure 4.1.1 List of Coalition Partners
File Description – Here is a list of partners for both coalitions, also highlighted in other documents in this measure.
3. Description of process used to mobilize the Tribal/state/local community
Title – Action Plan with process highlights
File – Measure 4.1.1 Access to Care Action Plan - process highlights
File Description – The efforts to engage coalition members and the community is highlighted through our marketing plans for the project.
Measure Narrative
The examples included demonstrate the active participation of the ACHC in the coalitions
submitted. The needs addressed by these efforts are supported through our CHA and
CHIP. We work to engage both our partners and the community in these efforts to address
public health needs.
Assessment
1. Though there are two examples the (ABO coalition and HealthNet), it appears that
the HealthNET project involves the ABO coalition and is one piece of their work.
Can you argue that there is a coalition between BestHealth and ACHC? No, the NP
contract is just that – a contract – and is a support to the HealthNet project.
Nonetheless, they both are working on the same public health issue – access to care,
so another example of a coalition is needed. This can be a question with a reopen if
desired.
2. Provided is a listing and both examples in required documentation 1 have the
partners highlighted in the documents.
PHAB EDUCATION SERVICES - Discussion Guide Page 16 of 49
3. This is the same document that was submitted for required documentation 1. That
is fine and the health department has highlighted different information in the
document. The work of the ABO coalition has some process listed in the Action Plan
– though weak and lacking in detail. The HealthNet report has no real info on
process at all. This required documentation is not present.
Pre-Site Visit Assessment: Slightly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 17 of 49
Measure 5.1.3 A
Domain 5: Develop public health policies and plans
Standard 5.1 Serve As a Primary and Expert Resource for Establishing and Maintaining
Public Health Policies, Practices, and Capacity
5.1.3 A: Inform governing entities, elected officials, and/or the public of potential public
health impacts, both intended and unintended, from current and/or proposed policies
Required Documentation 1:
Documentation of the health department informing policy makers and/or the public about
potential public health impacts of policies that are being considered or are in place
Document 1
Title – County Commissioner Agenda Abstract
File – Measure 5.1.3 BOCC Agenda Abstract July 12, 2010
File Description – This document is the abstract of what the Health Director presented to the Board of County Commissioners at their meeting on July 12, 2010.
Document 2
Title – County Commissioner Meeting Minutes
File – Measure 5.1.3 BOCC Minutes - 7-12-10
File Description – This document is a page from the meeting minutes of the Board of County Commissioners held on July 12, 2010. Highlighted is the Health Director’s report on policy changes in the Environmental Health Water Sampling Program.
Document 3
Title – Board of Health Agenda
File – Measure 5.1.3 BOH Agenda Dated August 17, 2010
File Description – This document is the agenda for the Board of Health meeting held on August 17, 2010. On the agenda is discussion of Environmental Health policies.
Document 4
Title – Board of Health Meeting Minutes
PHAB EDUCATION SERVICES - Discussion Guide Page 18 of 49
File – Measure 5.1.3 BOH Meeting Minutes Dated August 17, 2010
File Description – This document is the meeting minutes of the Board of Health for August 17, 2010. Highlighted are the two policy change discussions.
Document 5
Title – Environmental Health Water Sampling Policy
File – Measure 5.1.3 EH Water Sampling Policy
File Description – This is the Environmental Health water sampling policy discussed at the Board of Health and Board of County Commissioner meetings.
Measure Narrative
In the documentation requirement, “policies” is plural so two examples are needed. The
documents for this measure contain two examples of policy change - state immunization
policy and the ACHC Environmental Health water sampling policy. Presentations to policy
makers and processes for public notification are included.
Assessment
1. The documentation provided gets at what the measure is assessing but is disjointed.
It appears that the department did inform both the governing entity and elected
officials about the impact of a policy change. We are just unsure what the public
health impact is. There are two issues here – changes in immunizations and changes
to an EH policy. The Board of Health agenda and minutes are uploaded, but the
immunization fact sheet was not. That document is needed to help complete the
requirement.
For the EH policy, it is noted that the potential impact was discussed with the Board
of Health, but no detail is recorded. The policy is included but again, we do not
know what the changes are and how it could impact the community from a public
health perspective. Also, the impact was discussed with the Commissioners, but the
materials, comments presented or presentation itself needs to be added.
Questions could be asked to define the impacts from the EH policy. The measure
could be reopened to request the missing documentation.
Pre-Site Visit Assessment: Slightly Demonstrated
Missing documentation and no cohesive documentation about the EH policy impact
PHAB EDUCATION SERVICES - Discussion Guide Page 19 of 49
Measure 6.2.3 A
Domain 6: Enforce public health laws
Standard 6.2 Educate Individuals and Organizations On the Meaning, Purpose, and Benefit of Public Health Laws and How to Comply 6.2.3 A: Provide information or education to regulated entities regarding their responsibilities and methods to achieve full compliance with public health related laws Required Documentation 1: Written record of the provision of information or education to regulated entities concerning their responsibilities for compliance with public health laws
Example 1
Title – ACME Well Rules
File – Measure 6.2.3 - ACME Well Rules 2008
File Description – Acme County Well Rules adopted in 2008
Example 2
Title – Effective Date of Well Rules
File – Measure 6.2.3 - Effective Date of Well Rules
File Description – Board of Health authorization on when the well rules will take effect.
Example 3
Title – Open Forum Agenda
File – Measure 6.2.3 - Open Forum Agenda
File Description – Open forum for well-drillers regarding the well rules held March 15, 2008.
Example 4
Title – Open Forum Minutes
File – Measure 6.2.3 - Open Forum Minutes
File Description – Minutes from the open forum held March 15, 2008.
PHAB EDUCATION SERVICES - Discussion Guide Page 20 of 49
Example 5
Title – Proposed time line for well rules
File – Measure 6.2.3 - Proposed time line for well rules 10-07
File Description – Timeline for the adoption of the well rules
Measure Narrative
These documents relate to the adoption of county well rules in 2008 and the sharing of the
information with those who would be most impacted – well drillers who work in the
county. A copy of the rules are included as well as the information regarding a forum held
to inform the well drillers. The rules and the timeline were distributed at the forum.
Assessment
1. First, there is only one example here and two are needed. This is something that the
AS will check for when doing the completeness check. They would notify the
department that only one example has been provided (though there are multiple
documents for that one example.
Should something like this make it through the completeness review, the team
would ask for another example since two are required by the health department.
2. There was some good evidence here but it applies to one example. Since the rules
are signed and dated, there is no need for the effective date document, which isn’t
signed anyway. Just disregard this document – it adds nothing. The minutes give the
number of attendees. The guidance states an attendance list, so an OFI would be to
include the list of participants or sign in list as a part of the minutes.
The time line document doesn’t really add anything here either and is just extra
documentation. While it does show plans for the open forum, the minutes and
agenda are stronger evidence.
Pre-Site Visit Assessment: Pending
Leave as pending since two examples are required
PHAB EDUCATION SERVICES - Discussion Guide Page 21 of 49
Measure 6.3.5 A
Domain 6: Enforce public health laws
Standard 6.3 Conduct and Monitor Public Health Enforcement Activities and Coordinate Notification of Violations among Appropriate Agencies 6.3.5 A: Coordinate notification of violations to the public, when required, and coordinate the sharing of information among appropriate agencies about enforcement activities, follow-up activities, and trends or patterns Required Documentation 1:
Communication protocol for interagency notifications
Title – ACHC Notification Policy
File – Measure 6.3.5 ACHC Notification Policy interagency
File Description – This is the health center’s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for interagency notifications.
Required Documentation 2:
Protocol for notification of the public when required
Title – ACHC Notification Policy
File – Measure 6.3.5 ACHC Notification Policy public
File Description – This is the health center’s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for public notifications.
Required Documentation 3: Documentation of notification of enforcement actions, and sharing information concerning enforcement activities
Title – Environmental Health Notice of Violation
File – Measure 6.3.5 EH Notice of Violation
File Description – Here is an example of a Notice of Violation that is a part of the Environmental Health rules. This sample was delivered in person by Environmental Health to the owner of the septic system that had failed.
PHAB EDUCATION SERVICES - Discussion Guide Page 22 of 49
Title – HIV Isolation Order
File – Measure 6.3.5 HIV Isolation Order
File Description – This is a copy of an HIV Isolation Order that was given to an individual in July of 2009. This follows enforcement action as detailed by State Statute (listed in the letter). The individual information has been blacked out.
Measure Narrative
The communication protocols for both interagency and public notifications are included in
the same policy. This policy is submitted for required documents 1 & 2, with sections
highlighted to demonstrate how it contains that requirement. There are a number of
communication protocols that are define by rule and statute. ACHC adopts those by
reference as we are the agent of the state that enforces those regulations.
ACHC has attached two examples of notification that we do as a part of our Environmental
Health and Communicable Disease programs. Both follow the guidelines established by
law and State Government.
Assessment
1 & 2. The health department submitted the same document for both requirements. It is
fine to have both required elements in the same document and they have
highlighted the differences. Note that there are several references to statute.
Guidance requires the submission of these laws. Thus the need to have the
reference that includes lists of communication requirements in law or rule. This is a
case of “I said so”, but the Site Visitors will not know the rules that the health
department must operate by.
While there are 4 other possible documents about protocols for interagency
communications on the flash drive, none of the documents really deal with
notification of violations.
• Measure 6.3.5 ACHC Communication and Media Protocols • Measure 6.3.5 ACHC Crisis Communication Policy • Measure 6.3.5 Acme co Emer Pub Info Plan • Measure 6.3.5 Acme Media Policy
These other protocols fit better in Measure 3.2.2
3. The department did provide two examples of enforcement letters that was sent
from the department. Both are fine examples of enforcement of laws, but notice that
PHAB EDUCATION SERVICES - Discussion Guide Page 23 of 49
this correspondence goes to individuals and not the public or other agencies. So
while the documents fulfill the requirement, they do not fulfill the measure.
Remember to put the documentation requirement in the context of the measure. If
these had been examples that 1) went to other residents in the mobile home park
regarding the sewage leak, and; 2) the issuance of the isolation order had been
communicated to the state public health department; then the requirement would
have been demonstrated. This is an OFI for this measure and the note in the
conformity box.
Pre-Site Visit Assessment: Slightly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 24 of 49
Measure 7.2.1 A (NOTE: This documentation is the same as in 4.1.1)
Domain 7: Promote strategies to improve access to health care services
Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services
7.2.1 A: Convene and/or participate in a collaborative process to establish strategies to improve access to health care services Required Documentation 1: Documentation that a coalition/network/council is working on collaborative processes to reduce barriers to health care access or gaps in access
Document 1
Title – Access to Care Action Plan 2010
File – Measure 7.2.1 Access to Care Action Plan
File Description – This is the action plan regarding access to care from the 2010 Community Health Assessment. This document supports both required elements of documentation.
Document 2
Title – Access to Care Talking Points
File – Measure 7.2.1 Access to Care Talking Points File Description – This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders.
Required Documentation 2: Development of strategies through the collaborative process to improve access to health care services
Document 1
Title – Access to Care Annual Report
File – Measure 7.2.1 Coalition Report File Description – This is an annual report on the Access to Care project of the ABO Health Care Coalition.
PHAB EDUCATION SERVICES - Discussion Guide Page 25 of 49
Document 2
Title – Agreement for Nurse Practitioner Services
File – Measure 7.2.1 Agreement for NP Services
File Description – This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner (NP) to serve at the ACHC clinic sites. Contraction for a NP is one of our strategies to address access to care issues.
Measure Narrative
These documents demonstrate the efforts of the ACHC and community partners, including
local medical providers and partners to increase and improve access to care. Through a
regional coalition and the CHA, we are working to increase access by providing services
and staffing, by contracting for NP services onsite at the ACHC, to meet identified needs.
Assessment
Is it OK to use the same material for different measures? Yes, but remember that the
contents must conform to the requirements of the measure. If using documents more
than once, there should be different elements in the documentation that meets the
requirements for the separate measures. However, the documentation is a better
match in this measure than in 4.1.1
1. There is evidence of a collaborative process here in the action plan. The talking
points would be better under Required Documentation 2, since it gets at strategies.
2. While there is documentation of strategies being used (and the HD submits that
contracting for a NP is one), there is only sketchy evidence of how the strategies
were developed by the coalition partners. This would be an OFI. The Annual Report
has soon elements that could be highlighted for Required Documentation 1.
While the documentation could be better arranged in the submission process, that’s
OK for assessing as what is needed is here.
Pre-Site Visit Assessment: Fully Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 26 of 49
8.1.1T/L
Domain 8: Maintain a competent public health workforce
Standard 8.1: Encourage the Development of a Sufficient Number of Qualified Public
Health Workers
8.1.1 T/L: Establish relationships and/or collaborations that promote the development of future public health workers Required Documentation 1: Documentation of relationships or collaborations that promote public health as a career
Document 1
Title – Internship Learning Agreement
File – Measure 8.1.1 Learning Agreement
File Description – This document is a copy of an agreement to place an intern from Bowman University at the ACHC.
Document 2
Title – Acme Comm College Contract
File – Measure 8.1.1 Acme Comm College Contract signed
File Description – This is our agreement with the local community college regarding placing students in the Health Center for internships or practicums.
Measure Narrative
Included are two samples of agreements or contracts used by the ACHC to give students an
opportunity to experience public health and gain exposure to a possible career choice.
There are executed contracts on file at the department that can be reviewed on request.
Assessment
1. There are two documents and only one example is needed. The Acme Community
College contract has been signed and appears to be in place. Based upon the
narrative, there are records at the Health Department demonstrating the use of the
contract. The learning agreement is an executed document showing how a student is
PHAB EDUCATION SERVICES - Discussion Guide Page 27 of 49
working in the health department for an internship. Again the narrative insinuates
that there may be other contracts at the Health Department as well.
While both are excellent in developing future public health workers, an OFI (based
on guidance) would be for the Health Department to also document instances of
making presentations to a university, college, high school or club about public health
as a career.
Pre-Site Visit Assessment: Fully Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 28 of 49
8.2.1
Domain 8: Maintain a competent public health workforce
Standard 8.2: Assess Staff Competencies and Address Gaps by Enabling Organizational and Individual Training and Development 8.2.1 A: Maintain, implement and assess the health department workforce development plan that addresses the training needs of the staff and the development of core competencies Required Documentation 1: Health department workforce development plan that includes:
a. Nationally adopted core competencies b. Curricula and training schedules
Document 1
Title – Workforce Development Policy
File – Measure 8.2.1 Workforce Development Policy File Description – This document is the ACHC Workforce Development Plan that was adopted in 2008 and revised in 2010
Document 2
Title – Training Calendar 2011
File – Measure 8.2.1 Training Calendar 2011 File Description – This is the schedule of trainings for ACHC staff held in 2011
Required Documentation 2: Documentation of implementation of the health department workforce development plan
Title – Workforce Development Implementation Report
File – Measure 8.2.1 Workforce Development Implementation Report File Description – This is the 2010 report showing implementation of the Workforce Development Plan.
PHAB EDUCATION SERVICES - Discussion Guide Page 29 of 49
Measure Narrative
The documentation included for this measure are the workforce development policy and
plan for the ACHC. The plan was initially adopted in 2008 and has been guiding our
workforce development since. It was revised in 2010 and has the support of the Board of
Health. The implementation report and the training schedule are completed each year and
are used in review and needed revisions of the plan.
Assessment
While the basics seem to be here, the documentation is weak.
1. There is a plan present. While the plan has a short paragraph on using the national
core competencies, there is no real link to any of the implementation or training
plans. Also, the plan just mentions using the competencies without any supporting
detail about how they will be used for staff. There is a training calendar but it is
very limited. There is no info on who is targeted, what the topic might cover and
who is responsible. Also, some of the trainings are listed as updates and may just be
info sharing versus an educational session.
2. There is an implementation report with a number of trainings listed. This will work
but what is needed is the agenda, participant list and materials for two of the
sessions to show who attended and the elements covered in the training and how
those trainings relate back to the Workforce Development Plan.
Pre-Site Visit Assessment: Slightly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 30 of 49
Measure 9.2.1
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions
Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions
9.2.1 A: Establish a quality improvement program based on organizational policies and
direction.
The following documentation (2 files) and descriptions have been uploaded into this
measure.
Required Documentation 1:
A written quality improvement plan
Example 1
Document 1
Title – ACHC Quality Improvement Plan (Example 1)
File – Measure 9.2.1 Quality Improvement Policy and Plan
File Description – none
Document 2
Title – ACHC Quality Improvement Plan (Example 2)
File – Measure 9.2.1 Quality Improvement Policy and Plan with highlights
File Description – The QI Plan has highlights to note how the plan correlates
to the guidance for the measure.
Document 3
Title – Companion to ACHC QI Plan (Example 2a)
File – Measure 9.2.1 Companion to QI Plan
File Description – This companion document is the key that supplements the
highlights in the QI Plan. This document is color-coordinated to match with
the QI Plan in highlighting the key elements.
PHAB EDUCATION SERVICES - Discussion Guide Page 31 of 49
Example 2
Title – ACHC Quality Initiatives 2011-12
File – Measure 9.2.1 ACHC QI Initiatives for FY 2011-2012
File Description – This is a work plan for the three initiatives from 2011-2012.
Measure Narrative
The ACHC QI Plan has been adopted to provide the guidance in developing and
implementing a strong QI plan at the health department. The Plan was initially adopted in
2008 and has been used in strategic planning and in programs review. It is reviewed
annually by both the leadership of the ACHC and the Board of Health. A copy is on file in
the County Manager’s Office.
Also included is the worktable of the QI initiatives undertaken at ACHC during the most
recent Fiscal Year (July, 2011 to June 2012).
Assessment
NOTE: The examples are two representations of what could be submitted. The department
would not submit both examples, but either 1 or 2.
For example 1, the plan is OK, but would be frustrating and time consuming to review. The
plan needs to have key elements highlighted or detailed so the site visitors can easily locate
as they review the file. So it is fine to send a question to the health department asking them
to point out the elements in the plan as listed in the guidance.
For example 2 & 2a, the plan has highlighted the key elements as listed in the guidance.
This plan is acceptable, though site visitors may fine some opportunities for improvement
for some areas that need more detail, for example identifying and selecting projects.
Also, there are the goals for the last year, but since a new year has started there should be a
new work plan that can be included. It is fine to ask for this document (it must have been
written prior to hitting the submit button) or offer it as an OFI. Note: the date uploaded
date is not the submitted date. OFI – add in elements of the process that is being studied
for QI.
Pre-Site Visit Assessment: Fully Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 32 of 49
Measure 9.2.2
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions
Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions 9.2.2 A: Implement quality improvement activities The following documentation (3 files) and descriptions have been uploaded into this
measure.
Required Documentation 1: Documentation of quality improvement activities based on the QI plan Document 1
Title – QI Team Notes for Media Relations Initiative
File – Measure 9.2.2 Media Relations 2010
File Description – This document is one of the working records of the QI Team. It demonstrates working through the QI process.
Document 2
Title – Family Planning Storyboard
File – Measure 9.2.2 Acme QI Storyboard
File Description – Storyboard of the ACHC project to decrease Family Planning waiting time – results of the project are demonstrated. See highlighted areas in text to show project participants as well as actions taken and follow-up meeting QI plan guidelines.
Required Documentation 2: Demonstrate staff participation in quality improvement activities based on the QI plan Document 3
Title – QI Team Minutes for July 2011
File – Measure 9.2.2 QIT Minutes July 2011
File Description – Minutes of the Quality Improvement Team showing actions of the group and the members of the team, thus demonstrating staff participation in QI – see highlighted text.
PHAB EDUCATION SERVICES - Discussion Guide Page 33 of 49
Measure Narrative
These three documents show how the QI Team at the ACHC are workings to implement the
QI plan and bring meaningful change to the department through the involvement of both
leadership and frontline staff.
Assessment
1. There are two examples provided. The storyboard is a good example, but needs
some narrative to meet the required elements stated in the guidance. Based on the
storyboard alone, site visitors cannot discern what is asked for in the guidance -
what the problem was, what the process was, etc.
The media project certainly has some QI aspects, but seems to focus on workforce
development around specific staff, versus an administrative process. If there is
documentation on how this is a QI project – such as what is the problem regarding
media exposure, how can it be improved, what are the steps, etc. – it may be more
acceptable. Also as a team report, it’s written in a manner that only the HD can
understand and doesn’t clearly answer the questions that the examples must
demonstrate.
Also, the HD is submitting this as an administrative QI project. It really needs to be
tossed and select another project with a focus on the administrative processes of the
health department. One question with a reopen could be to ask for such a project.
2. The HD has provided a set of minutes with the QI Team members present. Both
projects also list participants. However for the projects, it is not clear who actually
participated in the project. The storyboard list the QI Team, but no project
personnel.
Pre-Site Visit Assessment: Slightly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 34 of 49
Measure 10.2.2 A
Domain 10: Contribute to and apply the evidence base of public health
Standard 10.2 Promote Understanding and Use of Research Results, Evaluations, and Evidence-based Practices with Appropriate Audiences 10.2.2 A: Maintain access to expertise to analyze current research and its public health implications Required Documentation 1: Documentation of availability of expertise (internal or external) for analysis of research
Title – CV of Vincent Dude
File – Measure 10.2.2 Dude CV – data expert
File Description – Mr. Dude serves as our expert for data and research analysis. He is employed by the state Division of Public Health. He resides in the local public health regional office and serves a number of counties including Acme.
Measure Narrative
No entry
Assessment
1. There is a CV that looks like a person who can provide the expertise is available to
Acme. However according to guidance, since he is outside the HD some type of MOU
is needed and should be developed by the HD/State and uploaded here. The MOU or
documentation containing a description of this person’s expertise and training
would make the evidence stronger. Also, we don’t know if there is a set amount of
time dedicated to Acme County or if it is on an as needed basis. The MOU could be
asked for in a reopen.
Pre-Site Visit Assessment: Slightly Demonstrated
Since the CV is nothing more than that without the MOU
PHAB EDUCATION SERVICES - Discussion Guide Page 35 of 49
Measure 11.1.1 A
Domain 11: Maintain administrative and management capacity
Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the
Performance of Public Health Functions
11.1.1 A: Maintain policies and procedures regarding health department operations,
review policies and procedures regularly, and make them accessible to staff
Required Documentation 1:
Policy and Procedure Manual or individual policies
Document 1
Title – Admin Policy Manual Table of Contents
File – Measure 11.1.1 Admin Policy Manual Table of Contents
File Description – This document list the policies in the ACHC administrative policy manual. The full manual is available online and is available upon request or onsite.
Document 2
Title – ACHC Dress Code Policy
File – Measure 11.1.1 Dress Code Policy
File Description – This policy is an example from the department’s administrative policy manual.
Document 3
Title – ACHC Orientation Policy
File – Measure 11.1.1 Orientation Policy
File Description – This policy is an example from the department’s administrative policy manual.
PHAB EDUCATION SERVICES - Discussion Guide Page 36 of 49
Required Documentation 2:
Health department organizational chart
Title – ACHC Organizational Chart
File – Measure 11.1.1 ACHC O-chart 07-11
File Description – This is the most recent organizational chart for the ACHC.
Required Documentation 3:
Reports of review at least every five years or proof of regular updating process
Document 1
Title – Policy on Policies (Revising Policies)
File – Measure 11.1.1 Policy on Policies - review & revise
File Description – This is the ACHC policy on policies with sections highlighted that define how the department reviews and revises policies.
Document 2
Title – Admin Policy Manual Signature Page
File – Measure 11.1.1 ACHC Policy Manual Signature Page
File Description – This is the signature page for the Administrative Policy Manual showing annual review.
Required Documentation 4:
Description of methods for staff access to policies
Title – Policy on Policies (Employee Access)
File – Measure 11.1.1 Policy on Policies - employee access
File Description – This is the ACHC policy on policies with sections highlighted that define employee access to departmental policies.
PHAB EDUCATION SERVICES - Discussion Guide Page 37 of 49
Measure Narrative
Provided is the table of contents for the administrative policy manual for the department. A couple of examples of policies from the manual have been included. All policies are initially approved and signed off, then the manual as a whole is reviewed and annually signed and dated by the health director.
The department has a policy on policies that defines the process for developing, approving, revising and accessing policy. This has been included under required documentation 3 & 4 with the appropriate sections highlighted demonstrating both the revision process and employee access. Assessment Documentation is fine for this measure. The Administrative Policy Manual is available online and should be reviewed. This is a measure that uses visual observation to verify the submissions. Look for locations of policies during the facility review (if hard copies are used for employee access). Also interviews could be used to ask about accessing policies or the review process. Pre-Site Visit Assessment: Fully Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 38 of 49
Measure 11.1.2
Domain 11: Maintain administrative and management capacity
Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the
Performance of Public Health Functions
11.1.2 A: Maintain written policies regarding confidentiality, including applicable HIPAA requirements Required Documentation 1: Confidentiality Policies
Document 1
Title – HIPAA Manual – Table of Contents File – Measure 11.1.2 ACHC HIPAA Policy Manual Table of Contents Description – This is the Table of Contents from the department’s HIPAA Policy
Manual. The full manual, including all forms used by the ACHC for privacy is
electronic and is available for review upon request or on-site.
Document 2
Title – Maintaining Privacy Policy File – Measure 11.1.2 Maintaining Privacy of Individuals Description – This policy details how the department will maintain privacy of
individuals who are receiving services through the ACHC.
Required Documentation 2:
Training content and staff participants Document 1
Title – Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In Description – This is the sign-in roster for the HIPAA training of 04-30-09.
PHAB EDUCATION SERVICES - Discussion Guide Page 39 of 49
Document 2
Title – Makeup Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In – Makeup Description – This is the sign-in roster for the makeup HIPAA training of 05-12-09.
Document 3
Title – HIPAA Training Agenda File – Measure 11.1.2 HIPAA_Training_Agenda 04-09 Description – Here is the agenda used for the HIPAA training, and makeup session.
This was the last department wide training. HIPAA training is now conducted
individually during orientation for each new staff member.
Required Documentation 3: Signed employee confidentiality forms, as required by policies
Document 1
Title – ACHC Confidentiality Statement File – Measure 11.1.2 Confidentiality Statement Description – This is a copy of the Confidentiality Statement that is signed by every
employee. As noted on the agenda copy, copies are kept in personnel files and
signed copies are available for review on site.
Measure Narrative
As demonstrated by these documents, the ACHC takes confidentiality of clients and of
information very seriously. Our manuals and training regarding HIPAA and confidentiality
are very thorough and every employee is responsible for following protocol. This is shared
among all staff and leadership. Failure to comply can invoke the disciplinary process.
Better
The HIPAA manual and privacy policy are examples of how ACHC approaches
confidentiality of both medical information and program activities. Policies for HIPAA and
privacy are well-defined and available to all staff. Training begins with orientation and all
new employees are trained on confidentiality of clients in all programs. The training
records are an example of one such training. The confidentiality statement, updated or
reviewed with the employee during the annual evaluation, is kept in every personnel file.
PHAB EDUCATION SERVICES - Discussion Guide Page 40 of 49
Assessment
1. The HD has provided 2 documents to show their privacy policies. One is the table of
contents for the HIPAA manual. Ask to see that on-site. The other policy deals with
other privacy issues. These are fine.
2. A training roster, along with the make-up, and the training agenda has been
submitted. However, this is only for HIPAA and there is no evidence of training content (if any was available). There is also no training records for the other privacy policy and that needs to be requested.
Here you can be specific and asked if there is any evidence of training for the
Maintaining Privacy of Individuals policy.
3. The form has been included. A statement that all have signed the form and the
copies can be seen upon request has been put in the description. This may be a
visual observation when on site – during the tour, you could ask to see where the
statements are kept. Or you could ask to see a couple of signed copies. If there is a
need for an interview on Domain 11, you could ask during that time.
Pre-Site Visit Assessment: Largely Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 41 of 49
Measure 12.1.2
Domain 12: Maintain capacity to engage the public health governing entity
Standard 12.1 Maintain Current Operational Definitions and Statements of the Public Health Roles, Responsibilities, and Authorities 12.1.2 A: Maintain current operational definitions and/or statements of the public health governing entity’s roles and responsibilities The following documentation (3 files) and descriptions have been uploaded into this
measure.
Required Documentation 1:
Authority of the governing entity
Document 1
Title – General Statutes for the Board of Health
File – Measure 12.1.2 BOH public health statutes - 130A
File Description – This document list the NC statutes that define the makeup and
duties of the local board of health, as well as the appointment of the director (which
is a BOH role).
Required Documentation 2:
Description of governing entity
Document 2
Title – Board of Health Operating Procedures
File – Measure 12.1.2 BOH Operating Procedures 9-21-2010
File Description – This document defines the operating guidelines of the Board, such
as officers, meeting times and agendas.
Document 3
Title – Board of Health Overall Operations
File – Measure 12.1.2 BOH Overall Operations Policy 7-17-2009
PHAB EDUCATION SERVICES - Discussion Guide Page 42 of 49
File Description – Based upon statute, this document details the overall operations,
duties & responsibilities of the BOH including appointments, training, rule-making
authority and policy development.
Measure Narrative
The three attachments for this measure demonstrate that the roles, responsibilities and
authorities of the board are well defined in both statute and in policy. Board Members are
oriented and regularly trained on this content. This evidence shows that the Acme BOH
takes serious its responsibility to represent the county, the department and our residents
in setting and supporting public health policy.
Assessment
Three documents are provided. The statutes provided are about the authority and make-
up of the Board of Health. There are two documents that provide operational guidelines for
the Board of Health. There is an OFI to combine the documents into one operations
protocol.
Overall, info is what is needed and is complete.
Pre-Site Visit Assessment: Fully Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 43 of 49
12.3.2
Standard 12.3 Encourage the Governing Entity’s Engagement in the Public Health Department’s Overall Obligations and Responsibilities 12.3.2 A: Track actions taken by the governing entity 1 file uploaded Required Documentation 1: Review issues discussed, actions taken, and policies set by the governing entity at least annually
Title – Board of Health Meeting Minutes
File – Measure 12.3.2 BOH Meeting Minutes 09-21-2010
File Description – This is a copy of the Board of Health minutes from September 21, 2010. There are two highlighted sections addressing the requirements of the measure.
Measure Narrative
None
Assessment
1. The minutes provided do show a summary of actions taken and notes that the
review of the Board Manual includes info the Board needs to know. Also the
minutes show that there was discussion and review on EH policies. However, there
is not clear documentation on a review of issues discussed or on all policies set by
the governing entity. There is also missing documentation as recommended by the
guidance. The evidence here needs much more development.
Pre-Site Visit Assessment: Slight-ly Demonstrated
PHAB EDUCATION SERVICES - Discussion Guide Page 44 of 49
Exercise Handouts
PHAB EDUCATION SERVICES - Discussion Guide Page 45 of 49
The National Challenge phab.demo.eaccreditation.org/login
SVT Chair – Sandra Willow
o Assign Domains to Team Members
Team Member Domains
Sandra Willow 2, 3, 8, 12
Larry Magnolia 1, 5, 6, 11
Don Frasier 4, 7, 9, 10
Open Measure 8.1.1 L (T/L)
o In “Build Site Visit Report” in the “Areas of Excellence” text box, add the
comment, “The health department has a very strong partnership with the
universities and colleges in the state. It is impressive that 60% of all
internship opportunities result in hiring full time public health employees.”
(remember to click save).
o Select “Reviewed” as the Pre-Site Visit Review Status for the measure.
o Choose “Fully Demonstrated” as the Pre-Site Visit Assessment for the
measure.
o Click “Accepted by Chair”.
Open Measure 8.2.1 A
o Select “Reopen” as the Pre-Site Visit Review Status for the measure (it is
required to write a request for another document). Your request could
be, “Please provide evidence of an annual update; the competency
documents are dated in 2010.”
o Choose “Slightly Demonstrated” as the Pre-Site Visit Assessment for the
measure.
o Click “Accepted by Chair”.
PHAB EDUCATION SERVICES - Discussion Guide Page 46 of 49
The National Challenge phab.demo.eaccreditation.org/login
SVT Member – Larry Magnolia
Open Measure 1.1.2 L (T/L)
o In “Build Site Visit Report” in the “Opportunities for Improvement” text
box, add the comment “The health department acknowledges a future
effort to seek input on the CHA before actual publication.” (remember to
click save).
o Type a note in the Site Visitor Notes section and select the Chair as the
“user to alert” (remember to click post). The note to the Chair could be,
“The health department stated the committee meets quarterly, but the
last meeting was from 2011, should we ask for an example from 2012
even though the documentation is within the PHAB timeframe so we are
sure the collaboration is still current?”
o Select “Reviewed” as the Pre-Site Visit Review Status for the measure.
o Choose “Largely Demonstrated” as the Pre-Site Visit Assessment for the
measure.
Open Measure 6.2.3 A
o In “Build Site Visit Report” in the “Conformity” text box, add the
comment, “The health department provided documentation in multiple
formats, web-based, FAQs, PowerPoint, each demonstrating a written
record of efforts to inform and educate regulated entities on their
compliance with public health law”. (remember to click save).
o Select “Reopened” as the Pre-Site Visit Review Status for the measure (it
is required to also submit a request/question). Your request could be,
“How often are your web-based fact sheets updated?”
o Choose “Largely Demonstrated” as the Pre-Site Visit Assessment for the
measure.
PHAB EDUCATION SERVICES - Discussion Guide Page 47 of 49
The National Challenge phab.demo.eaccreditation.org/login
SVT Member – Don Frasier
Open Measure 4.1.1 A
o In “Build Site Visit Report” in the “Areas of Excellence” text box, add the
comment, “The health department has a very strong partnership with the
universities and colleges in the state. It is impressive that 60% of all
internship opportunities result in hiring full time public health employees.”
(remember to click save).
o Select “Reviewed with Questions” as the Pre-Site Visit Review Status for
the measure (it is required to also submit a request/question). Your
question could be, “It is unclear how recruitment activities are organized.
Does the youth council or the health department take the lead for the
Tobacco Coalition?”
o Choose “Fully Demonstrated” as the Pre-Site Visit Assessment for the
measure.
Open Measure 7.2.1 A
o In “Build Site Visit Report” in the “Conformity” text box, add the
comment “The partnership between the health department and the Tribal
Leaders health coalition has met on an annual basis. The strategies
summarized in the 2009 report were clearly implemented in 2011.”
(remember to click save).
o Type a note in the Site Visitor Notes section and select Larry Magnolia as
the “user to alert” (remember to click post). The note to Larry could be, “I
remember you saying you used to be the WIC Coordinator. Could you take
a look at the Maternal infant health meeting strategies and let me know
what you think?”
o Select “Reviewed” as the Pre-Site Visit Review Status for the measure.
o Choose “Fully Demonstrated” as the Pre-Site Visit Assessment for the
measure.
PHAB EDUCATION SERVICES - Discussion Guide Page 48 of 49
DOCUMENTATION ASSESSMENT & RATING
demo.phab.eaccreditation.org/login
As you review the documentation – both individually and at your table (team), remember the four questions: 1. What documents/evidence do I have?
o Look at the documentation that has been uploaded into e-PHAB.
2. What does the Health Department want this to say? o Does the documentation appear appropriate to the measure? o Are the documents supported by the guidance? o What information has been submitted in the file descriptions and
measure narrative?
3. How does it demonstrate conformity? o How does the documentation compare to the requirements and the
guidance for the measure? o Are you able to locate the required elements?
- If not, what’s the documentation missing? - What questions should I ask the health department?
4. How would it be assessed & rated?
o What rating would you give the measure? o What are strengths within the documentation? o What are opportunities for improvement within the documentation?
Go over as a group:
Measure 3.2.2 A 1. Read the measure and the documentation requirements. 2. Look at the file descriptions (scroll the mouse over the document title). 3. Look at the measure narrative (beneath the required documentation). 4. Answer the four questions. 5. Draft a conformity statement.
PHAB EDUCATION SERVICES - Discussion Guide Page 49 of 49
Participants complete and report out: 1. Read the measure and the documentation requirements. 2. Look at the file descriptions. 3. Look at the measure narrative. 4. Answer the four questions.
- Open & review the documentation submitted - Make notes & send questions (if desired) - Assess the measure noting areas of strength & improvement - Individually review the assigned documents and then discuss your
findings with your ‘team’ 5. Write up a conformity statement. 6. Write up areas of excellence and opportunities for improvement, as needed.
SVT Chair – Sandra Willow
Measure 2.1.2 L (T/L) Measure 12.1.2 A
SVT Member – Larry Magnolia
Measure 5.1.3 A Measure 11.1.2 A
SVT Member – Don Frasier
Measure 9.2.1 A o First, open Example 1 and try to find the required elements o Then open Example 2 & 2a and note the required elements
Measure 9.2.2 A
top related