GOOD AFTERNOON!We will be starting shortly.

• Please orient yourself to Live Meeting including use of Q and A

• Please mute your microphones and/or telephone

• Please email Tegan Ruland at tegan.ruland@wisconsin.gov if you are having any difficulties

Performance Improvement in Public

Health Learning Session #4:

Wisconsin Public Health Voluntary Accreditation

Welcome and Introductions

• Brief description of Learning Sessions

• Brief introduction of those participating

• Overview of Live Meeting process including muting, accessing handouts, and asking questions

Learning Sessions Planned:• Today:

Wisconsin PH Improvement Initiative 101

• 5/9/2011: PH Performance Management 101

• 5/16/2011: PH Quality Improvement 101

• 5/23/2011: PH Accreditation 101

By the end of this session you should be able to:

• Describe current efforts in Wisconsin related to voluntary accreditation.

• Access additional information and resources for learning.

Where is Public Health at now with voluntary accreditation?

• Nationally

• Wisconsin

Essential Services of Public Health• Monitor health status

• Diagnose and investigate

• Inform, educate, and empower

• Mobilize community partnerships

• Develop policies and plans

• Enforce laws and regulations

• Link people to needed services / assure care

• Assure a competent workforce

• Evaluate health services

• Research

Voluntary Accreditation for Public Health

• State, Tribal, Local Health Departments

• Voluntary……

What’s the point?

Improve & protect health of public

• Measure performance according to national system of common standards

• Drive continuous improvement

• Advance quality & performance of ALL health departments

• Demonstrate accountability

What is required?

• 2 sets of standards & measures– Local/Tribal – State

• 30 standards• 102 measures for LHDs• 3 specific documents

– Community Health Assessment– Community Health Improvement Plan– Strategic Plan

Essential Services/Domains

1. Monitor health status

2. Diagnose & investigate

3. Inform & educate

4. Mobilize partnerships

5. Develop policies & plans

6. Enforce laws & regulations

7. Link people to services

8. Assure competent workforce

9. Evaluate

10.Research

In Statute

• 2005 Wisconsin Act 198– Section 4.250.03 (1)(L)

• Assess how WI is meeting requirements

• Aligns with Healthiest

Wisconsin 2020

Evidence

• Must be reviewed, finalized, and dated• Can be electronic, web-based, or hard

copy• QI Assessment of each measure

Documentation is NOT needed by every program for every standard

Example• Domain 1: Conduct and disseminate assessments

focused on population health status and public health issues facing the community.– Standard 1.3 B: Provide and use the results of

health data analysis to develop recommendations regarding public health policy, processes, programs or interventions.

• Measure 1.3.1 B Use data to recommend and inform public health policy, processes, programs and/or interventions.

– Required documentation: 2 examples that demonstrate use of data to inform public health policy, processes, programs and/or interventions.

Steps to Accreditation

1. Appoint Accreditation Coordinator

2. Complete PHAB orientation

3. Submit Statement of Intent

4. Attend Accreditation Process Training

5. Submit application & 3 documents

6. Complete Self-Assessment Tool

7. Host site visit

8. Receive PHAB decision

How to PrepareForm Core

Team

Review standards

Review evidence

Collect evidence

Identify gaps

Develop work plan to

address gaps

Accreditation

Accreditation Resources

• www.phaboard.org

• www.naccho.org/topics/infrastructure/accreditation/preparing.cfm

• www.astho.org/Programs/Accreditation-and-Performance/

Accreditation: A local Perspective

Terry Brandenburg, MPH, CPH

May 23, 2011

Objectives:

Review what it will take to pursue accreditation

One agency’s perspective on why and how they are preparing for accreditation

“I believe it would be in the best interest of our department to seek national accreditation within the next 1-2 years”.

You Want To Do What!!!

What it takes to meet accreditation standards

Have plans/policies/procedures in place Show that you are using these

plans/policies/procedures In some cases, show that you have

trained staff on plans/policies/ procedures

NOT REQUIRED!!

No required staffing levels No required education levels over

current Wisconsin Statutes

When will LHD’s apply for accreditation?

2.9% - Less than 1 year

20.0% - 1 – 2 years

18.6% - 3 – 5 years

1.4% - 5 or more years

1.4% - Never!

55.7% - Not sure!

Challenges to Accreditation

91.4% - Time

87.1% - Dedicated Staff

67.1% - Funding

31.4% - Support from Staff

17.1% - Support from Administration

11.4% - Support from Board

The BIG THREE

Community Health Assessment (CHA) Community Health Improvement Plan

(CHIP) Strategic Plan (Agency Specific)

What percent of LHD’s have not yet started work on an agency strategic plan?

Answer: 47.8%

Example: Strategic Plan

Communications Visibility in the Community Safety and Security Physical Space Technology Community Health Improvement Plan

Examples of Required Plans/Policies/Procedures

Protocols for Disease Investigation Emergency Public Health Preparedness Plan Protocols for Urgent 24/7 Communications Risk Communication Plan Protocols and Procedures for Conducting

Enforcement Actions Work Force Development Plan Quality Improvement Plan

Lessons Learned

Timing

Accreditation Coordinator

Document, Document, Document!

Share Resources/Steal Shamelessly

What Gets Assigned, Gets Done

WIStatute/Rule

HW2020: Capacity and

Quality

CDCInfrastructure

Grant

Prevention Block Grant

WIQI

Public Health Accreditation and Quality Improvement

CDC Infrastructure Grant 2011• Grant focused on preparing state, local, tribal

health departments for adopting performance management and quality improvement into their daily practice. Goal is improved performance and readiness for accreditation.

• State health department working with a team to do Accreditation Self-Assessment.

• Tribal and Local Health Departments working on pre-requisites and self-assessment. Thirty six (36) received local mini-grant funding.

Prevention Block Grant 2011

Competitive Grant – Focus on improving resources available to local health departments and tribes

related to Accreditation - $30,000.

• Polk County Health Department was recipient

• Grant focusing on doing rapid assessment of local health departments related to accreditation, developing website as repository of local accreditation document examples, and providing basic support of accreditation.

Prevention Block Grant 2011

Local and Tribal Health Department Template Objectives

• Accreditation: By December 31, 2011, Health Department will implement continuous quality improvement, strategic planning, and/or self assessment to prepare for accreditation. (18)

www.phawisconsin.com

• Intent is to assist local health departments and tribes begin preparing for public health accreditation. 

• Currently, the documents posted only address Part A: Administrative Capacity and Domains 1, 4 and 9. 

• It is important to note that these documents should not be considered as “PHAB approved evidence,” rather types of evidence that some Health Departments are planning to submit for their accreditation process.

• For access, email Tegan at tegan.ruland@wisconsin.gov

Prevention Block Grant 2011

Healthiest Wisconsin 2020: Everyone Living Better, Longer

HW2020 Capacity and Quality

• By 2020, all Wisconsin health departments will be accredited using an established standard.

http://www.dhs.wisconsin.gov/r_counties/VoluntaryAccreditation

What can I find on this site?• Information on what is happening in Wisconsin

related to public health accreditation with links to key partners/sites for Wisconsin local public health departments, Tribal health departments, and the Division of Public Health.

• Links to key national resources

DHS Accreditation Site

Institute for Wisconsin’s Health, Inc.IWHI

• Provides accreditation preparation and quality improvement leadership and assistance.

• The Institute's website features a Public Health Quality blog featuring conversation, key links and resources that encourage innovation and connection among local, Tribal and state health department partners.

• For more information, please visit the IWHI website:

http://www.instituteforwihealth.org/project-portal/

National Resources:• CDC: http://www.cdc.gov/ostlts/NPHII/index.html

• NACCHO: http://www.naccho.org/topics/infrastructure/

• ASTHO: http://www.astho.org/Programs/Accreditation-and-Performance/

• PHAB: http://www.phaboard.org/

• PHF: http://www.phf.org/focusareas/pmqi/pages/default.aspx

• NALBOH: http://www.nalboh.org/Board_Governance.htm#

• NIHB: http://www.nihb.org/public_health/accreditation.php

Conclusion:

“Do what you can, with what you have, where you are.”

Teddy Roosevelt

Tell us what you thought of today’s session:

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