nclhda compliance update 3.28...2018/03/28 · 1. carefully review your site visit report and see...

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AmyBelflowerThomasHealthDirectors’LegalConference

April4,2018

ComplianceUpdate

North CarolinaLOCAL HEALTH DEPARTMENT ACCREDITATION

PresentationOverview

1. Programupdates1. ReaccreditationwithHonors2. ConditionalAccreditationProtocol3. Onlineevidencesubmissionpilot

2. ReviewofStandardrevisionprocess1. Annualchanges2. ChangesrequiringRulesCommission

3. Humanservicesconsolidation4. Questionsandcomments*

*

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ProgramUpdates


ReaccreditationwithHonors

• LHDsthatmissoneorfewerActivitieswithineachoffiveStandards

• Congratstoinauguralclass:– AnsonCountyHealthDepartment– CatawbaCountyPublicHealth– Granville‐VanceDistrictHealthDepartment– MaconCountyHealthDepartment

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OperationalGuidelinesAdoption

• 20+policies/proceduresreorganizedtothreesetsofOperationalGuidelines:– AccreditationProcess– Board– SiteVisitTeam


RequestforReviewoftheSiteVisitReport

• Processclarifiedfor:– WrittenResponse: ifadepartmentdisagreeswithafinding.– ErrorofFact: ifthedepartmentfindsanerrorthatisquantifiable,objectiveandnotsubjecttointerpretationinitsmeaning.

• LHDmaysubmitaReviewAppealtoBoardifdisagreewithBoard’sactionforWrittenResponseorAccreditationAdministrator’sfindingsofErrorofFact.

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ConditionalReaccreditationRecommendationProtocol

Purpose: togiveanLHDanadditionalopportunitytosubmitevidencecompiledduringtheiraccreditationcycleinordertomeetaccreditationrequirements.

Thewrittenevidencecannotbenewlycreatedorreviseddocumentation.Itmaybeanydocumentationthatwasinplaceasofthebeginningofthesitevisit.


1. CarefullyreviewyourSiteVisitReportandseewhichStandardsyoumissed.2. ConsultpagenineoftheNCLHDAAccreditationProcessOperational

Guidelines.3. IfyouhaveevidencetosubmitforanActivitywithinamissedStandard,

followProtocolandrequestevidencebereviewed.4. SiteVisitTeamwillreviewmaterialoff‐siteandreassess.

1. IfevidencenowallowsenoughActivitieswithinStandardtobemet,recommendationischangedtoReaccreditation.

2. Ifrecommendationisnotchanged(eithermaterialnotresubmittedorstilldoesnotmeet),agencywilllikelybecomeConditionallyReaccreditedatBoardmeetingandhastwoyearstoreapplyforReaccreditation.

WhatifourRecommendationisforConditionalReaccreditation?

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OnlineEvidencePortalPilot

• Adaptingasystemfornotonlyreal‐timeevidencesubmissionandreview,butaccountability

• 2018pilots:– AlbemarleRegionalHealthServices– HydeCountyHealthDepartment– GreeneCountyHealthDepartment– Martin‐Tyrrell‐WashingtonHealthDistrict– WayneCountyHealthDepartment


StandardRevisionProcess

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NCLaw

• SenateBill804‐ GS130A‐34.1– EstablishedNCLHDABoardwithinNCIPH(17membersappointedbyNCDHHSSecretary)

– DirectsCommissiontoadoptrulesestablishingStandardsforLHDs– MandatesallLHDstoobtain(byDecember1,2014)andmaintainaccreditation

• 10ANCAC48B– Definesscoringrequirementsbycorefunction– DescribesBenchmarksandActivities


NCLaw

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NCLaw

• Boardcanassignthefollowingstatus:• Accredited• ConditionallyAccredited:periodofuptotwoyearswithagencyreapplyingwhenready

• Unaccredited:uponexpirationofconditionalaccreditation

• Beingaccreditedistiedtofunding:


OverallGoalofChanges

Improve LHD’s

Ability to Succeed

Provide training

Remove un-

necessary structural barriers

Provide clear and consistent guidance

Support sharing of

best practice

Make requirements

easier to meet

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• AnychangestomaterialsmadeonanannualbasiseffectiveJanuary1– Agenciesheldtowhatiseffectiveasoftheir90‐daynotification

• Allmaterialsonwebsite• Annualcolorschemeforchanges— 2018• ChangesalsodetailedinSummaryofChangesdocument


SummaryofChanges

• Providedwheneverchangesaremadetoassessmentdocuments(HDSAI,Interpretation)

• Listsanddetailschangesmadesincelastupdate

• Correspondstochangesmarkedinorangeinupdateddocuments

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HumanServices

Consolidation


Changesin2015

• 10ANCAC48BamendedApril1,2015duetoHB438

• ChangesweremadetoHDSAI/Interpretationeffective6.1.15:– Benchmark34shuffled,includingdeletingoneActivity– WhereAdvisoryCommitteeallowed,specificallyidentified(38.2,38.3,39.1,39.4,40.1,40.2,41.1,41.2,41.3)

– WhereConsolidatedHumanServicesDirectorapplicable,specificallyidentified(37.1,37.3,37.4,37.5,37.6)

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AretheNCLHDAStandards

achievableforaCHSA?

AretheNCLHDAStandardsclearfordifferentconsolidationscenarios?

IsitharderforaCHSAtobe

reaccredited?

WhatdoIdoifmyagencyis

consolidatinginthefuture? HowdoItalktomy

countyleadersaboutNCLHDA?

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Recentdata ToolswithinInterpretation

Guidance Thingstoconsiderfor

consolidatedagencies TrainingsandGuidance

documents


ReaccreditationDataAssessment

• 131Reaccreditations2011‐2018*– 17initialConditionalReaccreditationrecommendations(13%)

• HealthAgencyConsolidationallowedin2012– 24Reaccreditationsforconsolidatedagencies

• 13GovernedbyBoardsofCountyCommissioners• 11GovernedbyConsolidatedHumanServicesBoard

– 107ReaccreditationsforBoardofHealth‐governedagencies

107

1311

Governance Structure of Local Health Agency Reaccreditations, 2011-2018

Traditional Consolidated - BOCC Consolidated - CHS*Includesspringsitevisitreports,butnotfallfor2018

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ReaccreditationDataOverview

• 131ReaccreditationSiteVisits,2011‐2018

1 1

7 6 63

8 10

1313

15

13

20

15

0

5

10

15

20

25

30

2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018

Nu

mb

er o

f A

gen

cies

Fiscal Year of Reaccreditation

Reaccreditation Site Visits (n=131) by Governance Structure, 2011-2018

Traditional (n=107)

Consolidated (n=24)


SummaryofActivitiesNotMet

• Ofthe131ReaccreditedLHDs:

– ActivitiesNotMetrangedfrom0to19Activities

– Mean=4.3Activities

– Median=3Activities

311 6 4

10

66

24

61

0

10

20

30

40

50

60

70

80

0 1-5 6-10 11-15 16-20

Nu

mb

er o

f A

gen

cies

Number of Not Met Activities

Traditional (n=107)

Consolidated (n=24)

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ActivitiesNotMet,2011‐2018

13%11%

23%

41%

13%11%

16%

29%

33%

12%

0

5

10

15

20

25

30

35

40

45

50

Assessment Policy Development Assurance Facilities &Administrative Services

Board ofHealth/Governance

% A

ctiv

itie

s M

isse

d

Activities Not Met, by Standard & Governance TypeFY2011-2018 LHD Reaccreditations (n=131)

Traditional (n=107)

Consolidated (n=24)


SummaryofActivitiesNotMetByConsolidationStatus

• Onaverage,consolidatedagenciesmissedanaverageofonlyonemoreActivitythantraditionalLHDs– 5.4vs4.1Activities

• Thisfindingisnotstatisticallysignificantduetolimitedsamplesize,butstillnotable

0

5

10

15

20

Traditional(n=107)

Consolidated (n=24) Overall(n=131)

Act

ivit

ies

No

t M

et

Box Plot of Activities Not Met, by Consolidation Status2011-2018 LHD Reaccreditations (n=131)

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SummaryofActivitiesNotMetByAgencyGovernance

• ConsolidatedagenciesgovernedbyaCHSboardaveraged2.5moreActivitiesmissedcomparedtotraditional– 6.7vs4.1Activities

• ConsolidatedagenciesgovernedbyaBOCCwerecomparabletotraditionalagencies– 4.2vs4.1Activities

• Smallsamplesizes,butstillmeaningfulresults 0

5

10

15

20

Traditional(n=107)

Consolidated -BOCC(n=13)

Consolidated - CHS(n=11)

Overall(n=131)

Act

ivit

ies

No

t M

et

Box Plot of Activities Not Met, by Governance Structure2011-2018 LHD Reaccreditations (n=131)


ToolswithinInterpretationGuidanceSections

AddedGuidanceforConsolidatedHumanServicesAgenciesforeveryActivity

• Helpswithspecificscenarios• RemindsaboutwhetherAdvisoryBoardcanaddress

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WhatGoestoLocalBoardofHealth

IfBOCChasassumedpowers/dutiesoftheBoardofHealth,wheneverBOHisreferredto,itequatestoBOCC(e.g.,Activity2.4— diseaseincidence/trendreport).


WhatCanGotoAdvisoryCommittee

GuidancewillbeclearaboutwhethertheAdvisoryCommitteecanfulfillrole(e.g.,Activity38.2— CHAreview).

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BOCCisActingonBehalfofTheirRoleasBOH

IfBOCChasassumedpowers/dutiesoftheBOH,evidencemustshowthatcertainActivitiesaredonefirmlyintheirroleasaBOH(e.g.,Activity14.4— draftingordinancesandrules).


WhoNeedstobeTrained

IfBOCChasassumedpowers/dutiesoftheBOH,theymustbetrainedonroles/responsibilitiesofBOH.YoucanchoosetotrainyourAdvisoryCommittee,butthatisnotrequired.

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WhoHiresaHealthDirectorandWhoSupervises

Assurethattheappropriateperson(BOHorconsolidateddirector)inthechainofoversightisidentified(e.g.,Activity37.1— qualifiedLHD).Thisappliestohiringaswellasthingslikesigningoffonperformanceevaluationsandjobdescriptions.


TrainingsandGuidanceDocuments

Slidesandfour‐pageguideonwebsite(updated1.1.18)

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ResourcesandTraining

Opportunities


Accreditation101:NewAACBi‐annualTraining

SavetheDate:September18from9to4

HiltonCharlotteUniversityPlaceFee:$60

RegistrationavailableinJune

NexttrainingwillbeSpring2019inEasternN.C.

Audience:NewAACs,Co‐AACsorBackupAACs

PleasenotethisisNOTforexperiencedAACs.

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Accreditation101:Team‐basedTraining

• Offeredbyrequestatyourlocalsite(Jan.‐MayandOct.‐Nov.only)

• Forgroupsof15‐20• STRONGLYencouragepartneringwithneighboringLHDs

• Request“NCLHDAtechnicalassistance”fromyourlocalAHEC


AnnualSkills‐buildingWorkshop

SavetheDate:BuildingYourAccreditationToolboxAugust14‐15,2018SheratonImperialinDurham

RegistrationwillopeninJulywithanexpectedfeeof$150andstaterateguaranteeattheSheraton.

Sessions focused on sharing best-practice models and

addressing common challenges.

While aimed at AACs of all levels of experience, local

accreditation team members are also invited.

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AllcountiesinNorthCarolinahavebeenaccredited,andbyMay2018,all85willhavebeenreaccreditedatleastonce.


! Questions&Discussion?

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Thankyou.

AmyBelflowerThomas,MHA,MSPH,[email protected]

(919)843‐3973

TheNorthCarolinaLocalHealthDepartmentAccreditationProgramispartoftheNorthCarolinaInstituteforPublicHealthattheGillings SchoolofGlobalPublicHealthattheUniversityofNorthCarolinaatChapelHill.