SEVEN STEPS OF THE PHAB

1. Pre-application Health department prepares and assesses readiness, completes online orientation, and informs PHAB of its intent to apply.

2. Application Health department submits application form and fee, and completes applicant training

3. Document Selection and Submission Applicant selects documentation for each measure, uploads it to e-PHAB, and submits it to PHAB

4. Site Visit Site visit of the health department is conducted by PHAB trained site visitors and a site visit report is developed

5. Accreditation Decision PHAB Accreditation Committee will review the site visit report and determine accreditation status of the health department

6. Reports If accredited, the health department submits annual reports and fees for five years

7. Reaccreditation As accreditation status nears expiration, the health department applies for reaccreditation

1. Pre-application

2. Application

3. Document Selection and Submission

4. Site Visit 5. Accreditation Decision

6. Reports

7. Reaccreditation

SEVEN STEPS OF THE PHAB

ACCREDITATION PROCESS ADPH Target Date:

SEPTEMBER 30, 2015

July 2013

Handout #2 – PHAB Accreditation Team Meeting – July 18, 2013 Page 1

References

PROPOSED REVISION TO PHAB STANDARDS AND MEASURES

• The Public Health Accreditation Board (PHAB) has released a new version of the Standards and Measures (Version 1.5) for review and comment

o For more information, refer to email from Carol Heier to the Accreditation Team on Friday, July 12)

o Comments regarding the proposed revision can be submitted in one of two ways. . ASTHO will accept comments through August 1. ASTHO is coordinating a

response to PHAB on behalf of state health agencies. Submit comments and suggestions to Lia Katz at [email protected]

PHAB will accept comments directly through their on-line survey instrument until August 9. http://www.phaboard.org/accreditation-process/proposed-standards-measures-version-1-5/

PUBLIC HEALTH ACCREDITATION BOARD (PHAB) ORIENTATION

• All members of the health department’s accreditation team should complete o Please complete by September 27, 2013 and forward electronic Certificate of

Completion to Carol Heier o The Orientation is a free, web-based course that is accessible from the PHAB

website. http://www.phaboard.org/education-center/phab-online-orientation/

QUALITY IMPROVEMENT TRAIN-THE-TRAINER OPPORTUNITY

• Wednesday, August 28 - 9:30 - 10:30 AM, CST o Video conference to orient QI Teams regarding the training experience and help

them prepare for Part 1 of the on-site training • Monday, September 16 (10 AM - 5 PM) and Tuesday, September 17 (8 AM - 3 PM)

o Part 1 of the on-site QI Train-the-Trainer in the Montgomery area (exact location to be announced)

o Each QI Team will learn and use QI tools to begin planning their QI projects • Monday, October 21 (10 AM - 5 PM) and Tuesday, October 22 (8 AM - 3 PM)

o Part 2 of the on-site QI Train-the-Trainer in the Montgomery area (exact location to be announced)

o Each QI Team will report on their project to date and deliver a short presentation regarding a QI Tool that is assigned to them

• Wednesday, November 20 - 9:30 - 11:00 AM, CST o Video conference to report of the status and results of each QI project

Handout #3 – PHAB Accreditation Team Meeting – July 18, 2013

http://www.phaboard.org/accreditation-process/proposed-standards-measures-version-1-5/

http://www.phaboard.org/accreditation-process/proposed-standards-measures-version-1-5/

http://www.phaboard.org/education-center/phab-online-orientation/

Readiness

VERSION 1.0APPROVED MAY 2011

Public Health Accreditation Board

Checklists

Handout #4 - PHAB Accreditation Team Meeting - July 18, 2013

National Public Health Department Accreditation Readiness Checklists Version 1.0 Approved May 2011 Page 1

Overview The Readiness Checklists are lists of general expectations that PHAB defines for any health department that is considering applying for public health department accreditation. The checklists explore various aspects and activities of the health department and assist the department with charting a course of action to prepare for public health department accreditation. PHAB recommends that health departments complete all of the tasks listed in the checklists before submitting a Statement of Intent to PHAB. These checklists do not assist the department to determine if it is in conformity with or meets any of the PHAB standards and measures. The tasks in these readiness checklists are divided into four sections:

1. Initial Checklist Determines eligibility and support for seeking public health department accreditation.

2. Prerequisite Checklist Determines if the prerequisite community health assessment, community health improvement plan, and department strategic plan are in place.

3. Process Readiness Checklist Determines if the health department has put in place the processes recommended for public health department accreditation.

4. Organizational Readiness Checklist

Determines if the health department has begun the tasks to prepare for public health department accreditation and is ready to submit their Statement of Intent to PHAB.

How to Complete the Checklists

In completing the checklists for the first time, review each task and indicate the initial status. In subsequent reviews, the “X” mark for the task may move into other columns until the task is complete. When completed,

the date is entered. These checklists can be used to document progress made in preparing to participate in the national public health department

accreditation process. The health department may choose to review these checklists on a regular basis. These readiness checklists are for a health department’s internal use only. The completed checklists are not to be submitted

to PHAB. Terminology Various terms used throughout the checklists are defined below:

Task the activity that is recommended for health department readiness to apply for public health department accreditation

Responsible Staff the person assigned to direct and/or complete a task

Not Yet Started the health department has not begun any work toward completing the task

Underway the health department is in the process of implementing the task or doing work towards its completion

Complete the health department has completed the work of the task

Date Complete the date that the review and/or work of this task was completed


1. Initial Checklist

Place an “X” in the “No” or “Yes” box and note the date completed.

Question No Yes Date Completed

Is the health department eligible for PHAB accreditation? (see definitions below) ☐ x July 2011

Does the director of the health department support the health department’s seeking PHAB accreditation? ☐ x 10/24/11

Does the appointing authority for the health department director support the health department’s seeking PHAB accreditation? ☐ x 6/13/12

If there is a Board of Health or other governing entity, does it support the health department’s seeking PHAB accreditation? ☐ x 6/13/12

Has the director of the health department considered the costs of applying for PHAB accreditation and the implications for the department’s budget? ☐ x 6/13/12

Has staff of the department reviewed the ten essential public health services and determined that the department is providing all ten? x ☐ Click here to

enter text.

TOTAL Click here

to

Click here

to

Click here to enter text.

All items in this initial evaluation of readiness should be “yes” before moving forward.

Definitions of Eligible Public Health Departments State and Territorial Health Department

A state or territorial health department is defined, for the purposes of accreditation, as the governing entity recognized in the state's or territory's constitution, statutes, or regulations, or established by Executive Order, which has primary statutory authority to promote and protect the public's health and prevent disease in humans. Health departments that are a part of an umbrella organization, super public health agency, and super agency that oversees public health functions as well as other government functions, are eligible to apply. However, it is only the public health function that will be reviewed and accredited.

Local Health Department

A local health department is defined, for the purposes of accreditation, as the governmental body serving a jurisdiction or group of jurisdictions geographically smaller than a state, which is recognized in the state's constitution, statute, or regulations or established by local ordinance or through formal local cooperative agreement or mutual aid, and which has primary statutory authority to promote and protect the public's health and prevent disease in humans.. The entity may be a locally governed health department, a local entity of a centralized state health department, or a regional, county or district health department.

Tribal Health Department

A Tribal health department is defined, for the purposes of accreditation, as a federally recognized Tribal government1, Tribal organization or inter-Tribal consortium as defined in the Indian Self-Determination and Education Assistance Act, as amended, with jurisdictional authority to provide public health services, as evidenced by constitution, resolution, ordinance, executive order or other legal means, intended to promote and protect the Tribe’s overall health, wellness and safety; prevent disease; and respond to issues and events. Federally recognized Tribal governments may carry out the above public health functions in a cooperative manner through formal agreement, formal partnership or formal collaboration. 1As evidenced by inclusion on the list of recognized Tribes mandated under 25 U.S.C. § 479a-1. Publication of List of Recognized Tribes.

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2. Prerequisite Checklist

Place an “X” in the box that describes where your health department is currently with finalizing the prerequisites.

Task Responsible Staff

Not Yet Started Underway Complete Date

Completed

The health department has a community health assessment that is ready to submit with an application for PHAB accreditation.

Domain 1 Lead, UAB,

AC ☐ x ☐ Click here to

enter text.

The health department has a community health improvement plan that is ready to submit with an application for PHAB accreditation.

Domain 5 Lead, UAB,


enter text.

The health department has a department strategic plan that is ready to submit with an application for PHAB accreditation.

Domain 5 Lead, UAB,


enter text.

TOTAL PREREQUISITES COMPLETED AND CURRENT Click here to enter text.

All items in this prerequisites evaluation of readiness must be complete and current (within the past 5 years) prior to submitting an application for PHAB accreditation. An application will not be considered complete and will not be accepted by PHAB without these three prerequisites. For descriptions of these documents and the elements that they should include, see the PHAB Standards and Measures

Version 1.0.

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3. Process Readiness Checklist

Place an “X” in the box that describes the status of your health department in implementing processes to prepare for national public health department accreditation.



Completed

Has the department designated an Accreditation Coordinator?

Valerie Cochran

(Oct 2011) Carol Heier (May 2013)

☐ ☐ x 10-21-11

Has the Accreditation Coordinator completed the PHAB online orientation? Carol Heier ☐ ☐ x

Valerie Cochran 10-9-12; Carol

Heier 6-21-13

Has the director of the health department completed the PHAB online orientation?

Dr. Williamson;

request forwarded July 2013

x ☐ ☐ Click here to enter text.

Has a department multidisciplinary accreditation team been established?

Click here to enter text. ☐ ☐ x 10-24-11

Have all members of the accreditation team completed the PHAB online orientation?

To discuss at A-Team

Meeting July 2013


Is the appointing authority for the health department director engaged in the accreditation process?

Dr. Williamson ☐ ☐ x 6-13-12

If there is a Board of Health or other governing entity, is it engaged in the accreditation process?

Board of Health ☐ ☐ x 6-13-12

Does the department have the capability to produce electronic documentation? IT ☐ ☐ x 10-24-11

Does the department have the capability to establish an internal electronic filing system, with a separate file for each measure, to be a repository for documentation?

Document Library ☐ ☐ x 4-12-13

Does the department implement a process to systematically review department policies and procedures and revise and date them, as needed?


Meeting July 2013

☐ ☐ ☐

Is there evidence that collaboration with Tribal, state, or community partners and stakeholders is inherent in how the health department conducts planning, develops policy, and completes its work?


Meeting July 2013

☐ ☐ ☐

Please note that the items listed on this checklist are key activities but that this list is not an all-inclusive list of activities for the preparation for accreditation. Each health department that is considering applying for national public health department accreditation needs to develop

its own unique work plan to ensure that it is ready for national public health department accreditation.

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4. Organizational Readiness Checklist

Place an “X” in the box that describes the status of your health department in completing tasks to prepare for accreditation.



Completed

Has the department accreditation team begun to meet to discuss tasks and how to organize the work?

Propose new plan at A-

Team Meeting July

2013

☐ x ☐ Organized 10-24-11

Has the department established an internal electronic filing system, with a separate file for each measure, to be a repository for required documentation?

Document Library ☐ ☐ x 4-12-13

Has a process been developed to select potential program documentation that is the most relevant for each measure and the best example for the department?

Propose plan at A-

Team Meeting July

2013

☐ x ☐ Click here to enter text.

Has the department accreditation team reviewed the Guide to National Public Health Department Accreditation?

Click here to enter text. ☐ ☐ x May 2011

Has the department accreditation team reviewed the PHAB Standards and Measures?

Click here to enter text. ☐ ☐ x May 2011

Has the department considered the timeframes required for each piece of documentation?

Propose plan at A-

Team Meeting July

2013

☐ ☐ ☐

Has the department reviewed department documents and dated and signed them, as needed?

Propose plan at A-

Team Meeting July

2013


Has the department completed an initial “self-study” or review of the standards, measures, and required documentation to determine areas of strength and opportunities for improvement?

Discuss at A-Team

Meeting July 2013

☐ x ☐ Click here to enter text.

Has the department developed and begun implementation of plans to address identified opportunities for improvement?

Discuss at A-Team

Meeting July 2013


Has the department sought and secured technical assistance to address opportunities for improvement? PHF QI TTT ☐ ☐ x July 2013

Has the department identified a target date for submitting a Statement of Intent to PHAB?

Timeline to be

completed by Sept 2013


Please note that the items listed on this checklist are key activities but that this list is not an all-inclusive list of activities for the preparation for accreditation. Each health department that is considering applying for national public health department accreditation needs to develop

its own unique work plan to ensure that it is ready for national public health department accreditation.

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The 10 Essential Public Health Services Scan

Does ADPH provide all of these?

Name ______________________________ Date ________________

Core Function 1 - Assessment Assessment, monitoring, and surveillance of local health problems and needs, and of resources for dealing with them

1. Monitor health status to identify and solve community health problems. Identification of threats to health and assessment of health service needs

Timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services

Attention to the vital statistics and health status of specific groups that are at higher risk than the total population

Collaboration to manage integrated information systems with private providers and health benefit plans

2. Diagnose and investigate health problems and health hazards in the community. Informing the public about an epidemiological outbreak investigation in the

community

Epidemiologic identification of emerging health threats

Public health laboratory capability using modern technology to conduct rapid screening and high volume testing

Active infectious disease epidemiology programs

Technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury

Handout #5 – PHAB Accreditation Team Meeting – July 18, 2013 Page 1 of 4

Resource: The Community Tool Box, a service of the Work Group for Community Health and Development at the University of Kansas.

http://www.communityhealth.ku.edu/


Core Function 2—Policy Development Policy development and leadership that fosters local involvement and a sense of ownership that emphasizes local needs and that advocates equitable distribution of public resources and complementary private activities commensurate with community needs

3. Inform, educate, and empower people about health issues. Health education and health promotion to prevent heart disease

Social marketing and targeted media public communication (e.g., Toll-free information lines)

Providing accessible health information resources at community levels (e.g., free, mobile health screening initiatives)

Active collaboration with personal health care providers to reinforce health promotion messages and programs; and

Joint health education programs with schools, churches, and worksites (e.g., stress reduction seminars; parenting support groups for enhancing mental health; and health fairs)

4. Mobilize community partnerships and action to identify and solve health problems. Convening and facilitating community groups and associations, including those

not typically considered to be health-related, to undertake defined preventive, screening, rehabilitation, and support programs

Skilled coalition-building ability in order to draw upon the full range of potential human and material resources in the cause of community health

5. Develop policies and plans that support individual and community health efforts. Leadership development at all levels of public health

Systematic community-level and state-level planning for health improvement in all jurisdictions

Development and tracking of measurable health objectives as a part of continuous quality improvement strategies

Joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services

Development of codes, regulations, and legislation to guide the practice of public health





Core Function 3—Assurance Assurance that high-quality services, including personal health services, needed for protection of public health in the community are available and accessible to all persons; that the community receives proper consideration in the allocation of federal, state and local resources for public health; and that the community is informed about how to obtain public health, including personal health services, or how to comply with public health requirements

6. Enforce laws and regulations that protect health and ensure safety. Maintenance of a sanitary restaurant environment for public well-being

Full enforcement of sanitary codes, especially in the food industry;

Full protection of drinking water supplies;

Enforcement of clean air standards;

Timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings;

Monitoring quality of medical services (e.g., laboratory, nursing homes, and home health care); and

Timely review of new drug, biologic, and medical device application.

7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Promoting enrollment in a federally subsidized health insurance program

Assuring effective entry for socially disadvantaged people into a coordinated system of clinical care

Culturally and linguistically appropriate materials and staff to assure linkage to services for special population groups

Ongoing “care management”

Transportation services

Targeted health information to high risk population groups

Technical assistance for effective worksite health promotion/disease prevention programs





8. Assure competent public and personal health care workforce. Education and training for personnel to meet the needs for public and personal

health service

Efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up

Adoption of continuous quality improvement and life-long learning within all licensure and certification programs

Active partnerships with professional training programs to assure community-relevant learning experiences for all students

Continuing education in management and leadership development programs for those charged with administrative / executive roles

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Ongoing evaluation of health programs based on analysis of health status and

service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs

Core Function 4—System Management 10. Research for new insights and innovative solutions to health problems.

Continuous linkage with appropriate institutes of higher learning and research

An internal capacity to mount timely epidemiologic (e.g., outbreak investigations) and economic analyses (e.g., cost-benefit studies)

An internal capacity to conduct needed health services research (e.g., survey design; conducting interviews and facilitating focus groups; conducting clinical trials; and accessing and using public records)





National Public Health Department Accreditation for the Alabama Department of Public Health

Initial Project Period (July 1 – September 27, 2013) School of Public Health

University of Alabama at Birmingham Objectives

1) To establish the organization of the Alabama Department of Public Health (ADPH) Public Health Accreditation process with a goal of uploading complete final documentation to PHAB by September 30, 2015.

2) To develop and present a plan or model for developing the Public Health Accreditation Prerequisites.

3) To convene Domain Workgroups 1 and 5 to develop and adopt detailed plans for the development of the Community Health Assessment, Community Health Improvement Plan, and ADPH Strategic Plan with a goal of completion by September 30, 2014.

4) To begin work on the Standards and Measures of Domains 1 & 5. Scope of Work

1) Facilitation of the Organization of Accreditation

a) The UAB Project Team will work with the Accreditation Coordinator to establish Accreditation teams, team leadership, and a reporting structure including:

• A document Review Panel, • Twelve Domain Workgroups, and • Accreditation Champions. b) The UAB Project Team will meet with the twelve Domain Workgroup leaders to

establish their charges and timelines.

c) The UAB Project Team will meet individually with the Domain Workgroups or the Workgroup leaders as needed.

2) Planning and Organization of Accreditation Prerequisites

a) Community Health Assessment (CHA) – The UAB Project Team will develop and

initiate a step-by-step plan, including organization and timelines, for accomplishing a statewide CHA which will include methodologies for:

• Incorporating a variety of sources of data, • Demonstrating population demographics, • Identification of health issues, • Identification of special populations with health issues, • Identification of contributing causes of health issues, • Description of statewide assets to address health issues, and • Documentation of input from stakeholders.


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b) Community Health Improvement Plan (CHIP) – The UAB Project Team will develop

and initiate a step-by-plan, including organization and timelines, for developing a Community Health Improvement Plan based on the CHA. The CHIP plan will include steps for:

• Setting health priorities, objectives, strategies, measures and time-frame targets, • Identifying needed policy changes, • Identifying individuals and organizations responsible for implementation, • Identifying measureable outcome indicators, and • Alignment of the plan with other health department and national priorities.

c) Health Department Strategic Plan – The UAB Project Team will develop and initiate

a step-by-step plan, including organization and timelines, for developing a Strategic Plan for ADPH. The step-by-step plan will address the development of:

• External trends and issues affecting the health status of the state, • Departmental strengths and weaknesses, • Mission, vision, and values, • Strategic priorities, • Goals and objectives, and • Linkage to the CHIP and QI plan.

3) Implementation of the CHA, CHIP and Strategic Plan

a) The UAB Project Team will work with the Accreditation Coordinator to convene Domain

Workgroup 1 to initiate work on Standard 1.1 – the development of a collaborative process resulting in a comprehensive CHA. The UAB Project Team working with Domain Workgroup 1 will: • Identify participating stakeholders, • Develop a plan for regular stakeholder meetings, • Identify a process for the identification of health issues and assets, • Establish a community review process, and • Establish a timeline for completion of the CHA

b) The UAB Project Team will work with the Accreditation Coordinator to convene Domain

Workgroup 5 to initiate work on Standard 5.2 – the development of a collaborative process resulting in a CHIP. The UAB Project Team working with Domain Workgroup 5 will: • Identify participating public health partners, • Identify a process for the development of a CHIP, • Establish a process for setting statewide health priorities, measureable objectives,

improvement strategies and performance measures, and • Establish a timeline for completion of the CHIP.

c) The UAB Project Team will work with the Accreditation Coordinator to convene Domain

Workgroup 5 to initiate work on Standard 5.3 – Development and implementation of a

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health department Strategic Plan. The UAB Project Team working with Domain Workgroup 5 will: • Establish membership of the strategic planning group, • Identify the strategic planning process steps, • Establish a timeline for completing the strategic plan.

Project Timeline

UAB Project Team W. Jack Duncan, Ph.D is Professor of Management Emeritus & University Scholar Emeritus in the Department of Health Care Organization & Policy in the School of Public Health at the University of Alabama at Birmingham. Duncan is a Senior Scholar in the Lister Hill Center for Health Policy and Fellow of the Academy of Management. Duncan is the author or co-author of numerous books including Strategic Management of Health Care Organizations (with Peter Ginter and Linda Swayne) which is in its 7th edition and Management: Ideas and Actions. His book Great Ideas in Management has been translated into seven languages in addition to English. His scholarly articles have been published in the leading management and health care journal. He holds a Ph.D. from Louisiana State University. Peter M. Ginter, Ph.D. is a nationally recognized professor of strategic management in the UAB School of Public Health. He is also the Director of the South Central Preparedness and Emergency Response Learning Center. Ginter is the author or co-author of 16 books including Strategic Management of Health Care Organizations, 7th ed. (2013) with Duncan and Swayne and Public Health Leadership and Management: Context and Cases (2002) with Capper and Swayne. Peter has published more than 150 articles, papers, and cases. He holds a Ph.D. from University of North Texas.

Lisa McCormick, DrPH is an Assistant Professor in the Department of Health Care Organization & Policy in the School of Public Health at the University of Alabama at Birmingham. She has been involved in public health practice work since coming to the University in 1995. Prior to becoming a faculty member in 2010, she has worked directly with federally funded public health training centers since coming to the University in 1995. She worked as Co-PI with the Tulane University South Central Public Health Training Center from 2008-2011 and is now PI of the HRSA funded Alabama Public Health Training Center. Dr. McCormick has participated as investigator or principal investigator on numerous other federal and state awards including several directly with ADPH.

Jesse Pevear III, MSPH is the Program Director for the Survey Research Unit, a service unit at UAB. Prior to that he was the Behavioral Risk Factor Surveillance System Coordinator for the Alabama Department of Public Health for seven years. He has taught Math and Statistics at Tulane University and

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Troy University. He has conducted analysis for the Office of Naval Research and various smaller projects on a contract basis. He has a Master of Science in Public Health in Biostatistics from Tulane University.

Andrew C. Rucks, Ph.D. is a nationally recognized public health academician with an emphasis on regional coalition building, pediatric health care surge capacity, and preparedness drills and exercises. Dr. Rucks has authored more than 40 peer-reviewed papers and has more than 30 years’ experience in project management. He serves as Executive Director of the Survey Research Unit of the UAB School of Public Health. He holds a PhD in management science from the University of North Texas.

Rongbing Xie, MPH is a doctoral student with a concentration in Outcomes Research in the Department of Health Care Organization and Policy at the University of Alabama at Birmingham, School of Public health. Mrs. Xie has a master’s degree in Preparedness Management and Policy and some expertise in strategic management. She has been an instructor for a graduate level Strategic Management course. She also has assisted in the online course development of Management Concepts in Public Health Programs, which focuses on organization structure, management, finance and budgeting and other key elements in public health settings. She has years of experience in data analysis and been involved in studies in evaluating the cost-effectiveness and outcomes of health care practices, interventions and policies.

Personnel Principal Investigator – Peter M. Ginter, Ph.D. Dr. Ginter will provide overall leadership and management responsibility for the project, facilitate meetings, and collaborate in document development devoting 30% effort to the activities of the project. Investigator—Andrew C. Rucks, Ph.D. Dr. Rucks will facilitate meetings and collaborate in document development devoting 30% effort to the activities of the project. Investigator – W. Jack Duncan, Ph.D. Dr. Duncan will facilitate meetings and collaborate in document development devoting 50% effort to the activities of the project. Investigator – Lisa C. McCormick will collaborate in document development devoting 5% effort to the activities of the project. Program Director – Jesse Pevear, III, MSPH – Mr. Pevear serves as the BRFSS coordinator in the Survey Research Unit (SRU) of the School of Public Health. He will focus on data identification, data documentation, and development of statistics for the CHA devoting 25% effort to the project. Program Coordinator – Rongbing Xie, MPH – Ms. Xie will work under the direction of Dr. Ginter to conduct online and library research in support of the project and its documentation. Ms. Xie will devote 25% effort to the project. Administrative Associate – Sylvan Parker – Ms. Parker will provide administrative assistance to the P.I. and Investigator. These duties include purchasing, paperwork processing, coordinating project activities, and other administrative duties. She will devote 25% effort to the project.

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Consultant - Cathy Johnson – Ms. Johnson will serve as consultant to the project and be responsible for process and document integrity. Ms. Johnson has more than 25 years public health experience and has served as Accreditation Coordinator for Jefferson County Department of Health.

ALABAMA DEPARTMENT OF PUBLIC HEALTH Proposed Structure of Accreditation Teams and Reporting

STATE BOARD OF HEALTH

Governance

STATE HEALTH OFFICER

Health Officer

DEPUTY DIRECTOR FOR PROGRAM OPERATIONS

(Domain 1 and 5 Lead)

ACCREDITATION COORDINATOR/ PERFORMANCE IMPROVEMENT

MANAGER Manages and coordinates

accreditation process (Domain 9 Lead)

DOCUMENT REVIEW PANEL Staff who review documentation proposed by the Domain Leads to

ensure that it meets PHAB Standards

ACCREDITATION CHAMPIONS

Staff who advise/assist Accreditation

Coordinator with marketing and

employee education

ACCREDITATION TEAM (12 Domain Leads - Led by Accreditation Coordinator)

DOMAIN WORK GROUPS (12 Workgroups – 1 for each Domain – Led by Domain Leads)

REPORTING: The Accreditation Coordinator tracks work of the Accreditation Team/Domain Workgroups, Document Review Panel, and Accreditation Champions to meet agency target dates and shares information with Deputy Director for Program Operations who informs the State Health Officer and State Board of Health regarding progress.


Accreditation Team Recommendations Regarding Domain Leads/Work Group Members

Name _______________________________________ Date _________________________

DOMAIN LEAD or CO-LEAD (Central Office)

WORKGROUP MEMBER (Central Office or Area)


1. ASSESS: Conduct assessments focused on population health status and health issues facing the community

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

2. INVESTIGATE: Investigate health problems and environmental public health hazards to protect the community

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

3. INFORM AND EDUCATE: Inform and educate about public health issues and functions

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

4. COMMUNITY ENGAGEMENT: Engage with the community to identify and solve health problems

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

5. POLICIES AND PLANS: Develop public health policies and plans

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

6. PUBLIC HEALTH LAWS: Enforce public health laws and regulations

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

7. ACCESS TO CARE: Promote strategies to improve access to healthcare services

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

Handout # 8 – PHAB Accreditation Team Meeting – July 18, 2013

DOMAIN LEAD or CO-LEAD (Central Office)



8. WORKFORCE: Maintain a competent public health workforce

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

9. QUALITY IMPROVEMENT: Evaluate and continuously improve processes, programs, and interventions

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

10. EVIDENCE-BASED PRACTICES: Contribute to and apply the evidence base of public health

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

11. ADMINISTRATION AND MANAGEMENT: Maintain administrative and management capacity

Name:

Position

Program Area:

Name:

Position

Program Area:

Name:

Position

Program Area:

12. GOVERNANCE: Build a strong and effective relationship with governing entity

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OTHER WORKGROUPS

13. DOCUMENT REVIEW PANEL

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14. ACCREDITATION CHAMPIONS

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July 17, 2013 DRAFT – Accreditation Team Roles and Responsibilities

Domain Leads • Serve as the subject matter expert for their assigned domain • Enlist their Domain Team and facilitate their team work plan • Complete PHAB orientation; become familiar with the accreditation process and documentation requirements • Become well-versed in respective domain required documents • Understand documentation guidance and submission process • Serve as the document providers for their assigned domain • Generate team meeting

o Agendas o Sign-in sheets o Minutes (if applicable to documents that are being created by work group)

Domain Work Group Members • Become familiar with the accreditation process and documentation requirements • Be well-versed in respective domain required documents • Serve as the document finders for their assigned domain • Determine status of required documents, then either collect or develop

Document Review Panel • Become familiar with the accreditation process and documentation requirements • Final reviewers of documents before submission • Composed of DOH staff with expertise in document reviewing • Assist Accreditation Coordinator to monitor Accreditation Team progress on work plan to ensure adherence to targeted completion dates

Accreditation Champions • Become familiar with the accreditation process • Assist Accreditation Coordinator to spread awareness regarding accreditation across ADPH staff, community partners, governance and residents • Vision is to have every ADPH employee understands the value of achieving accreditation and enthusiastically contributes to our Department’s

successful application. • Market accreditation through publications, one-on-one information exchanges, trainings, staff meetings, email alerts, etc.


Documents

SEVEN STEPS OF THE PHAB