august 8 2019 nclhda workshop presentations...aug 08, 2019 · we will be staying in this room for...

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Thank you for being here!

* As of August 1, 2019

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Purpose

We hope you leave here feeling like your time was well spent and that you have ready-to-use tools

to improve your agency’s accreditation process.

Goal: participants will have the knowledge and skills to successfully use the NCLHDA Dashboard for the Accreditation process in their agency.

Objectives: participants will develop new skills in:

• Using and understanding application of the new NCLHDA Dashboard

• Applying different approaches to make use of the NCLHDA Dashboard by your agency most effective and useful

Housekeeping

Copies of presentations are on the NCLHDA website.

We will be staying in this room for the entirety of the workshop. Meals and breaks will be served in the adjoining area.Wi-fi is available at: TitanNet.

We will be sending a Qualtrics evaluation soon via email that will link to a certificate when completed.

Credit: Good Housekeeping

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WhatistheNCLHDADashboardMethod?

1. Commit yourself to tidying up your accreditationteam process a bit.

2. Imagine your ideal process for keeping everyoneaccountable for doing their accreditation tasks andmaking your four years easy.

3. Finish discarding first. Kiss those flash drivesgood-bye! But, be polite and thank them first.

4. Tidy your dashboard and get your team on boardthrough a planned roll-out, not haphazardly.

5. Follow Lori’s User Guides and Tutorials. Always.

6. Don’t ask yourself if it will spark joy. Anything is betterthan the MS Word HDSAI and flash drives. Trust us.

The NCLHDA Dashboard Method is a new tool that is a combination of the HDSAI, site visit review interaction, and performance management tracking. There are six basic rules to get you started:

It’s a GENERAL

magic theme, ok?

This is a Networking and Learning Opportunity

• Leave the stress you normally associate with Accreditation behind

• Engage: ask questions and make comments throughout these two days

• Have an open mind that the dashboard really will be a good thing for you and your agency

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Agenda Highlights• After hearing from me this

morning, Lori will wrap up with a general orientation to the NCLHDA Dashboard before lunch.

• This afternoon will focus on more detailed training with opportunities for you to practice.

• Don’t skip out early tomorrow-we have moved our awards to tomorrow morning, including some at the very end.

In the spirit of our theme….We are having an origami contest!

Over the next day, feel free to make some origami animals using materials and instructions at your table. Turn in your best attempt at the registration table by the end of tomorrow morning’s break. We will choose award winners in the following categories: Best style Best folds Most likely to need to be thanked & purged

2018-2019 Highlights

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In this Session….

Annual Survey Data

Annual Report

Predictions on 2019/2020

Upcoming Trainings

NCLHDA Annual Survey• Second annual survey of all Accreditation staff in all LHDs

• Regardless of accreditation cycle• To be comparable year to year

• Goals of survey:1. Measure impact of NC Accreditation program,

process, & resources2. Identify areas for NCLHDA program improvement

• Survey open June 12 – July 11, 2019

NCLHDA Annual Survey• Survey Overview

• General Satisfaction with Program & Process• Site Visit & Adjudication (if within past year)

• AACs & Health Directors only• Program Trainings• NCLHDA Dashboard*• Program Communications• LHD Administrative Information

• Health Directors only* New in 2019

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2019 Survey Respondents

• 196 total responses• Even distribution of

Accreditation roles• County was not asked of

respondents to maintain anonymity

36%

28%

37%

2019 Accreditation Survey Responses (n=196)

AAC (primary, co, backup) (70)

Health Director (54)

Other Accred Team Member (72)

Overall Value of Program

• Over half (60%) viewed the process as Very or Extremely valuable• 16% Slightly or Not at all

23%

37%

23%

15%

1%

0%

10%

20%

30%

40%

Extremely valuable Very valuable Moderately valuable Slightly valuable Not at all valuable

% of Responde

nts

How valuable is the NCLHDA process to your agency? (n=196)

Overall Value of Program by Respondent Type• Broken down by role, there is

lower perceived value among health directors:• 52% Very or Extremely• 28% Slightly or Not at all

23%

37%

23%

15%

1%

0%

10%

20%

30%

40%


% of Responden

ts


0%

10%

20%

30%

40%


% of Responden

ts


Other Accreditation Teammember

AAC (primary, co, backup)

Health Director

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Program Satisfaction - Processes

0% 20% 40% 60% 80% 100%

The Accreditation process is fair to all agencies.

The Accreditation process is consistent across all agencies.

The gains received from the NCLHDA Program are worth the cost.

I am satisfied with the peer model for site visit teams.

Agency staff are adequately engaged throughout the Accreditationprocess.

The Suggestions for Quality Improvement are actionable and attainable.

Agency leadership is supportive of the Accreditation process.

Agreement with NCLHDA Process Statements(n=191)

Strongly agree Somewhat agree Neither agree nor disagree Somewhat disagree Strongly disagree

Program Satisfaction - Takeaways

• For the NCALHD process, most agreed there is support for the process by agency leadership and that the SQI are actionable and attainable. • Continued perceptions of inadequate fairness and

consistency across all agencies• Questions about cost/benefit of program

• This agreement was generally consistent across roles, although Health Directors typically disagreed more than AACs and Other Accreditation Team Members.

Site Visit Experience32% had a site visit in the past year. Of the Health Directors and AACs:

0% 20% 40% 60% 80% 100%

We value attending the NCLHDA Board meeting for the adjudication.

The Site Visit Team was objective in their assessment of our agency.

The questions asked by the Site Visit Team were easy to understand.

The Site Visit Team Coordinator was helpful during the site visit.

The assessment by the Site Visit Team was fair.

The site visit schedule gave us enough time to get records pulled.

The Site Visit Team Coordinator was helpful before the site visit.

The site visit schedule gave us enough time to get questions answered.

The Site Visit Team conducted themselves in a professional manner.

The final reports were understandable.

Agreement with Site Visit Statements (n=32)

Strongly agree Somewhat agree Neither agree nor disagree Somewhat disagree Strongly disagree

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Following the Site Visit…• All respondents had started to address the

Suggestions for Quality Improvement

• 80% reported celebrating their agency’s reaccreditation• Staff luncheon (30%)• Incentive items to staff (18%)• Other (33%)

• 75% shared a press release with the media

Areas Identified for Improvement

• Concerns about resources spent to prepare for site visit process• Demonstrating fairness & consistency across all agencies

Overall process & program

• Ensuring consistency & objectivity of site visitors• Doing away with antiquated method of selecting personnel

records for review

Site visit

Training Programs & Satisfaction

• 68% attended at least 1 NCLHDA training

• 64% agreed trainings met staff needs• 5% disagreed

32% 32% 30% 4%

0% 20% 40% 60% 80% 100%

1

The trainings offered through the Accreditation Program adequately meet our staff's needs (n=185)

Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree

• 61% had used skills/knowledge from trainings to assist accreditation team• 50% had presented Roles and Responsibilities of Boards of Health Related to

NCLHDA to their board within previous year

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Dashboard Usage & Satisfaction

20% had started to use the Accreditation Dashboard for evidence submission

71% feel confident the dashboard will assist in tracking activities throughout the 4-year cycle

71% feel confident the dashboard will increase accountability among team members

NCLHDA Program Website & Communications

Over 80% agreed that program changes are clearly communicated and done in a timely manner

72% agreed the annual report is helpful75% agreed the monthly highlights are helpful

86% are satisfied with the NCLHDA website as a resource during the accreditation process

78% agreed the use of the NCLHDA website improved their experience with the accreditation process

Health Director Questions• 10% of Health Director respondents (54/85 participated) indicated they

contracted with an outside agency for accreditation

• Within their agency, the average FTE dedicated for AACs for accreditation activities was 0.92 FTE (range from 0.0 to 3.0)• Highest investment was by Tier 2

agencies (1.13 FTE)• Tier 1 & Tier 3 were equivalent

(0.69 & 0.70 FTE, respectively)

• The average hours invested per month for accreditation activities was 24.3 hours• Highest time investment was in Tier 3 agencies (30.2 hours)• Tier 1 & Tier 2 were equivalent (23.1 & 23.5, respectively)

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Concerns & Future Directions• Several respondents (primarily Health Directors)

indicated general support for the program, but raised concerns about the effort involved in preparing for the site visit for reaccreditation

• Similar concerns about current model of Accreditation vs Reaccreditation – ongoing reaccreditation is seen as a burden once initial accreditation was received

• Perceptions of fairness and consistency were raised both last year and in this current survey

NCLHDA Annual Survey Summary• Overall, satisfaction with all factors of NCLHDA Program

though downward shift over past year is concerning

• Next Steps:• Internal review of open-ended questions, specific comments & feedback• Planning for continued program improvement• Will share with NCALHD Accreditation Workgroup on August 14• Additional results presented through a future report on our website

THANK YOU TO THE RESPONDENTS!!!

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NCLHDA in 2019/2020 Continue:

training series support of regional workgroups and AAC Advisory

Council annual report and survey full roll-out of NCLHDA Dashboard participating in NCALHD Accreditation Workgroup

Refine: NCLHDA Dashboard and processes program and requirements as needed

Upcoming HDSAI

Interpretation Changes?!

Not planning any for 2020-will respond in 2020 as applicable related to recommendations of NCALHD Accreditation Workgroup and Board approval

Expect small change to NCLHDA Process Operational Guidelines

Accreditation 101: New AAC Biannual Training

Registration Now Open:September 24, 2019

Fee: $60GTCC Conference Center, Colfax Audience:

New AACs, Co-AACs or Backup AACs

Please note this is NOT for experienced AACs.

Please let us know if your agency needs New AAC training in the Spring

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Accreditation 101: Team-based

Training

• Offered by request at your local site (Jan.-May and Oct.-Nov. only)

• For groups of 15-20

• STRONGLY encourage partnering with neighboring LHDs

• Request “NCLHDA technical assistance” from your local AHEC

NCLHDA Dashboard OverviewPlanning to present via webinar bi-annually

Upcoming:September 27, 2019, 10 a.m. – 11 a.m.

**No-cost, but registration is required and is open via the website**

Etc.• Board of Health Roles and

Responsibilities for NCLHDA slides and 4-page guide now on website (updated 1.1.19)

• Annually in January: webinar update (materials and dashboard)• Save the Date: January 21, 2020

from 9:30 – 11:30 a.m.• Presentations at professional

association meetings

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Archived Trainings

Remember:You can always access archived trainings on our website via the Training tab.

Keep Updated!

• Regularly review website for updated information

• Make sure we have up-to-date contact information for agency AAC and backup AAC

EmailUs!

[email protected]

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Questions!?

Sparking Joy: Communicating the Value of Accreditation

In this Session….

Overview of Program-related Value DataStrategies for Communicating Value to Your Team

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80% Improves Specific Processes and Policies

within Agencies

Quality Improvement

73% Helps Our Agency Become More Effective

cv

cv

cv

Stimulates QI and Performance Improvement

Opportunities within Our Agency

69%

Helps Our Agency Become More Efficient

60%

Gives Our Agency Credibility with Our

Partners

Improves Relationships with Our Community

Gives Our Agency Credibility with Our

Community

Relationships

70%

65% 50%

ccc

Helps Our Agency Focus on Key Priorities

Gives Our Agency Objective Information to Request Funding and/or

Other Resources

Challenges Our Agency to Think About How It

Does Business

Strategy

72%

66%

62%

ccc

ccc

ccc

ccc

ccc

ccc

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Other Identified Sources of Value

Credibility with County Manager, Board of Health, and County Commissioners

Staff collaboration across departments

Advanced ability to advocate for public health funding

Better documentation across agency

Strengthens agency policies and understanding of them

Confidence building within organization and pride of staff

Internal External

How to Communicate the Value of Accreditation to

Your Agency• Have the right viewpoint

yourself• Educate your staff• Institutionalize quality

improvement at your agency• Create a supportive culture

• Do not take Site Visit results personally

• Take time to reflect on not just meeting the Activity next time, but actually improving practice

• Be a champion and develop champions

Have the Right Viewpoint as a Leader

We do not learn from experience … We learn from reflecting on experience.

–John Dewey

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Engage ALL of Your Staff• Share the Annual Report and maybe play during a staff meeting

• Show how your agency is specifically achieving value

• Conduct short trainings on accreditation for different teams

• Host an Accreditation 101: Team Training

• Share best practices identified within the program

Institutionalize Accreditation as Quality Improvement• Demonstrate that Accreditation is more than

checking a box• Accreditation is but one component of agency

quality improvement efforts• It shouldn’t be about checking a “Met” but

integrating program audits, corrective action plans, customer/community satisfaction, strategic planning, community assessment and PDSA/Genba/Kaizan projects

• Stay positive and encourage positivity

• Make all staff involved in some way

• Emphasize the benefits vs. the costs

• Celebrate successes

Create a Supportive Culture

Purpose is the reason you journey.

Passion is the fire that lights the way.

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Simplifying and Organizing the Accreditation Process:

Overview of the NCLHDA Dashboard

In this Session….

Overview of the Dashboard for the NCLHDA Program

Overview of User Types

General Orientation to Navigating the Dashboard

Setting the Stage….

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PleasePlease

PleaseDo NOT log in to the

dashboard untilasked to

Knowledge Check• One user per group log in at a time

• Training Website • User Name • Password

Knowledge Check Team• Carl Carroll• Fred Erickson• Lori Rhew• Andrea Schon• Wendy Smith• Ashley Stoop• Amy Belflower Thomas

Wave your wand if you have a question

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Innovation

Keep in Mind….

• A basic orientation • The requirements for the accreditation process

We provide:

• What works best for your agency

You decide:

Overview of the NCLHDA Dashboard

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Dashboard

A Public Health Performance Management System- Cloud-based- Real-time

Health Departments can…..

Add activity notes –HDSAI narrative

Upload & link documents

Monitor status of activities

Run reports Send automated emails

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Site Visitors can…

Download and review evidence Run reportsAsk questions Post status of review

Adjustments for the NCLHDA Program

User Permissions

Quick Update Only

ArchivedDashboard

Dashboard Users

Each health department gets 10 users

Users can be assigned different levels of access

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Additional Users

10 Users already included

Up to 50 users - $60/user per year51-124 users - $12/user per year125 and up - $6/user per year

User Types - Permissions

Quick Update Only

• Update activities they have been assigned

User

• Update any activity

Organizational Administrative

(Org Admin)• Update any activity• Change user

permissions• Assign tasks• Set-up notifications

User Types - Permissions

Manager

• Can update any activity in the dashboard

• Can view hidden services/hide services

Partner

• Can update any activity in the dashboard

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What is different for NCLHDA?

Cannot delete any planning element: activity language, activity description, performance metric

Normally….Can edit or delete planning elements

Super Users

Email us: [email protected]

• Amy Belflower Thomas, NCLHD Accreditation Administrator• Lori Rhew, Training and Accreditation Coordinator• Deanna Hedgepeth, Program Assistant

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Accessing the Dashboard

Google Chrome – latest version

Firefox – latest version

Please DO NOT use Microsoft Internet Explorer or Edge Browsers – many known issues

Use Browsers in this Order of Preference:

Login.VMSGDashboard.comWebsite

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Navigating the Dashboard

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• Main Menu

Dashboard

Quick Access Menu

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Reports

Quick Access Menu

Main Menu

Quick Access Menu

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Help

Quick Access Menu

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Note….NCLHDA Specific Resources: [email protected]

Log OutQuick Access Menu

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Orgs – health department will be listed here

Groups – North Carolina Local Health Department Accreditation - 2019

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Vision, Mission & Values – none listed for this project

Service/Initiative Selection & Management = Complete the NCLHDA Process

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Goals = Standards

Goals = Standards

Objectives = Benchmarks

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HDSAI Narrative

Dashboard Lights

Entering evidence = no requirement on use from the NCLHDA program

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Review Process= Defined Lighting System

Dashboard Lights

Questions?

Lunch

• Pre-Function Space• Classroom 132• Start again at 1 p.m.

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Setting Up and Adding Evidence to Your Dashboard

In this Session…

Updating Users

Activity Leaders and Members

HDSAI Narrative

Documentation

Reports/Dashboard

Setting up Your Dashboard

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Quick Update Only User = User + Quick Update Only

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Note: This page is set up based on the Organizational Chart you sent

with the requested dashboard information

Lori Rhew

Email: [email protected]

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Dashboard Basics

All lights set to red

Use the lighting system that work bestfor you

User permissions can be changed asneeded

Optional to use start and end dates**Needed if using automated email notifications **

Knowledge Check• One user per group log in at a time


Remember, we need audience participation…..

Knowledge Check Team• Carl Carroll• Fred Erickson• Lori Rhew• Andrea Schon• Wendy Smith• Ashley Stoop• Amy Belflower Thomas

Wave your wand if you have a question

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Knowledge Check #1

• Group Right : Complete the knowledge check with your team

• Group Left: Complete the user activity

5-8 minutes then switch

• Large Group Discussion

Assigning Activity Leads and Team Members

• No limit on number of Team Members

Team Members

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Activity Leaders

• One Leader per Activity • Receive the email notifications• Quick update

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Viewing Activity Assignments

Dashboard View a list of the Leads for each Activity. You will see a list of the Leads and the Activities they have been assigned.

Activity Selection & Management Page View who has been assigned as Lead or as a Team member for a selected Activity.

Team/Lead Report View everyone who has been assigned to an Activity whether they are the Lead or a Team member.

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Dashboard

Dashboard

Dashboard

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Dashboard View

Dashboard View

Dashboard View

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Activity Selection & Management Page


Team/Lead Report

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Team/Lead Report

Team/Lead Report

Team/Lead Report

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Team/Lead Report

Setting up Automated Notifications


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Knowledge CheckRemember….• One user per group log in at a time


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Knowledge Check #2

• Group Left: Complete the knowledge check

• Group Right: Complete the Activity Member/Lead activity


• Large group Discussion

Adding Evidence


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Enter the HDSAI Narrative. Begin with A., B., C., etc.

Adding Documentation

Activity Selection & Management PageThe blue folder is the Document Management page

where the documents are uploaded.

This blue folder shows that two documents have been

uploaded to this Activity.

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Uploading Documents

Uploading Documents

Uploading Documents

Put the name of the document in the Document Description box.

If there is a specific location in the document that is being referenced, put it in the Documents Notes box.

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Linking Documents

Linking Documents

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Linking Documents

Linking Documents

Download Documents

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Download Linked Document

Document Management Page

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What do you notice about the document descriptions?

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Icons to the right show what type of file type has been uploaded.

Most documents for the Accreditation

Program should be Pdf.

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Searching

Searching

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Knowledge Check #3

• Group Right: Complete the knowledge check

• Group Left: Complete the adding evidence activity


• Large group discussion

Monitoring Process

Operational Plan Report Dashboard

Operational Plan

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Dashboard

Dashboard

Includes Supplemental Materials

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Dashboard

Refreshments available in the

pre-function space

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Site Visit Review Process Using the Dashboard

Review Process

In this Session….

Overview of the Site Review Process

Dashboard and Reports

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Review process

*specific dates outlined in the 90-day notification letter*

Dashboard locked to the health department

Site Visit Team reviews, add questions

Health department regains access

Site visit conducted

Site Visit Report

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Site Visit Process: LightsThe Site Visitors will use the following system:

Activity met

Question for the Activity or onsite review needed

Activity not met

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Site Visit Review Process: LightsPrior to review:

When the dashboard is locked to the health department, all lights are turned to red.

When the Site Visitors conduct their initial review, they will change lights to yellow or green using this system:

Activity met

When the Site Visitors conduct their initial review, they will change lights to yellow or green using this system:

More information needed – Site Visitor question or on-site review needed.

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Site Visit Review Process: LightsPrior to the Site Visit:

Activity met - write the word “met” in the reviewer box

Question for the Activity or onsite review needed

Site Visit Review Process: LightsDuring the Site Visit:

Activity met

Question for the Activity

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Site Visit Review Process: LightsAfter the Site Visit when the health department receives their Site Visit Team Report:

Activity met

Activity not met

In SummaryWhen the dashboard is locked, all lights will be red.

After the site visitors conduct their initial review, all lights should be green or yellow.

If a light is green, the word “met” should be typed in the reviewer box.

If a light is yellow, there should be a question, or a comment listed in the reviewer box.

At the conclusion of the site visit, all lights should be green or yellow.

Supplemental Materials

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Personnel Records

Personnel Records

Submit a roster of the agency’s entire staff, with names, hire dates, and position titles (alphabetized by last name)

Review

Click the Review button add your response

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Site Visit Review Process: Lights

Review BoxActivity Selection & Management

Objective Selection & Management

Goals Selection & Management

234

1

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Roll up from the Review box to the Activity Selection & Management page.

Review Box – Activity 1.1 Green

Roll up from Activity Selection & Management page to Objectives (Benchmarks) Selection & Management page.



Roll up from Objectives (Benchmarks) Selection & Management page to Goal Selection & Management page.

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Review BoxActivity Selection & Management

Objective Selection & Management

Goals Selection & Management

12

3

4

Monitoring Progress

Dashboard

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Dashboard

Dashboard

Dashboard

Numerical Order

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Review Report

Review Report

All Report

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Not Met Report

Suggestions for Quality Improvement (SQI) Report

Filtering Reports

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Filtering Reports

Filtering Reports

Print

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Knowledge Check #4

• Group Left : Complete the knowledge check

• Group Right: Complete the review activity


• Large group discussion

Dashboard ScheduleHDSAI Due Date – Good faith effort to have evidence in the dashboard

Set date and time - Dashboard locked to the health department

Site Visit Coordinators conduct initial review

Site Visitors gain access and complete reviewDashboard open to the health department two days before the site visit. Site Visitors still have access – Please do not log in to the dashboard during this time. Site Visit Conducted

Following the site visit the health department will have view only access to the Dashboard.

Reminder: Upcoming Trainings

Accreditation 101: New AAC Training: September 24, 2019, 9 a.m. – 4 p.m., Colfax, N.C.

NCLHDA Dashboard Overview: September 27, 2019, 10 a.m. – 11 a.m., webinar, **Registration is required**

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Dashboard Webpage

Teams Channel

Thank you!

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• Breakfast 7:30 – 8:30 a.m. • Session begins at 8:30 a.m.• Fun AWARDS!