WELCOME Tribal Accreditation Readiness: Self-Assessment Tool
June 12, 2013 Support for this project was provided by a grant from
the Robert Wood Johnson Foundation Slide 2 TARGET Project: Tribal
Accreditation Readiness through Guidance, Education and Technical
Assistance Red Star Innovations Inter Tribal Council of Arizona,
Inc. California Rural Indian Health Board Tribal Epidemiology
Center Institute for Wisconsins Health, Inc. Support for this
project was provided by a grant from the Robert Wood Johnson
Foundation Slide 3 Objectives By the end of the presentation,
participants will: Have a basic understanding of accreditation and
its benefits Learn an approach to the self-assessment process using
a tool based on the Tribal standards Learn how the tool was used in
two Tribal communities Slide 4 Recommendations Familiar with public
health accreditation Eligibility requirements Accreditation Process
PHAB standards and measures If accreditation is new, we recommend
you view the PHAB Online Orientation in addition to this webinar at
www.phaboard.orgwww.phaboard.org This webinar will be recorded and
available online at www.redstar1.org.www.redstar1.org Slide 5
Overview Overview of public health accreditation, benefits and
readiness activities Introduce the self-assessment tool Share an
approach to planning, preparing and organizing for self-assessments
Discuss ways to use self-assessment results Slide 6 Public Health
Slide 7 What is Public Health Accreditation? Measurement of Tribal,
state and local health department performance based on a set of
national standards Issuance of recognition of achievement by a
nationally recognized entity Supports continuous quality
improvement in public health performance Slide 8 Public Health
Accreditation Board PHAB: Non-profit, non-governmental organization
dedicated to advancing continuous quality improvement of Tribal,
state, local and territorial public health departments. Accrediting
body for national public health accreditation. Vision: a high
performing governmental public health system that will make us a
healthier nation. Slide 9 Benefits and Opportunities Strengthen
self-determination Identify and act upon improvement opportunities
High performance and quality improvement Strengthen leadership and
employee performance Build stronger partnerships and increase
communication and collaboration Recognition, validation and
accountability Potential increased access to resources Its about
communities Slide 10 Accreditation Preparation Organizational
Readiness Public Health Performance Three Prerequisites For more
information about preparation activities see PHAB Readiness
Checklists at www.phaboard.org. www.phaboard.org Slide 11 Self
Assessment: Planning Preparation Process Slide 12 TRIBAL PUBLIC
HEALTH SYSTEMS Community Health Tribal Government Tribal Health
Dept. Federal agencies Private Industry Local/ State Health Dept.
Tribal Colleges Community ITCs/Tribal EpiCenters Slide 13 The
Essential Public Health Services 1.Monitor health status 2.Diagnose
and investigate health problems 3.Inform, educate and empower
people 4.Mobilize communities to address health problems 5.Develop
policies and plans 6.Enforce laws and regulations 7.Link people to
needed health services 8.Assure a competent workforce 9.Evaluate
health services 10.Conduct research for new innovations Slide 14 10
Essential Public Health Services (www.cdc.gov)www.cdc.gov Slide 15
Tribal Public Health Infrastructure Community Health Tribal Gov
Tribal Health Dept/Clini c Federal agencies Private Industry Local/
State Health Depart Tribal Colleges Communi ty Leaders ITCs/Epi
Centers Slide 16 PHAB Standards and Measures version 1.0 12 Domains
Each domain represents functions of the 10 Essential Public Health
Services and Core Functions (www.cdc.gov)www.cdc.gov Plus
Administration and Governance Each domain has a set of standards;
each standard a set of measures Required documentation for each
measure Slide 17 Domain Standards Measures Required documentation
Slide 18 Self-Assessment Workbook Created by the Institute for
Wisconsins Health through Wisconsins Public Health Quality
Initiative Slide 19 History of Workbook Adapted scoring system used
in NACCHOs Local Health Department Self-Assessment Tool Used PHAB
Beta standards initially Users recommended As initial scan &
discussion opportunity Creating new version for PHAB Version 1.0
PHAB 1.0 LHD and THD completed 2011 Slide 20 Features of Workbook
Excel file that incorporates PHAB Standards and Measures Version
1.0 Starting point for rating capacity by measure Encourages
collaborative process Provides illustration of strengths and areas
for improvement by domain Tool for priority setting and quality
improvement to prepare for accreditation Slide 21 Slide 22
Preliminary Review Identify possible documentation sources Identify
other staff and stakeholders to help identify, update and/or
develop documentation Discuss the activities that will be required
to meet the standard Discuss the amount of time required to follow
up and complete documentation Provide each measure with a score and
add notes where needed Slide 23 Rate each measure on a scale 0-4 0=
No Capacity 1= Minimal Capacity 2= Moderate Capacity 3= Significant
Capacity 4= Optimal Capacity Rating Criteria: Capacity Slide 24
Rating Criteria: Time Consider your rating by or the amount of time
(example time frame) 0 = More than 18 months 1 = At least one year
or more 2 = More than 6 months and less than 9 3 = More than 3
months and less than 6 4 = Measure met or less than 3 months Slide
25 Slide 26 After The Self- Assessment 26 What did we learn about
our department and community? What did we learn about our readiness
for accreditation? Should accreditation be a strategic goal for our
department? Next year? In 5 years? Are there elements we can
include as priorities in our strategic plan? Are there measures we
can address in our quality improvement plan? What are our next
steps? Slide 27 Self Assessment Limitations Self assessment isnt a
one time shot. It is often a process that is repeated. Slide 28
Self Assessment Process Will be dependent on: Size of the Tribal
Health Department Organizational structure Knowledge and expertise
Roles and responsibilities As they relate to domains Collecting
and/or developing documentation Time required to self-assess Slide
29 Organizing for Self-Assessment Identify an Accreditation
Coordinator(s) Become familiar with PHAB domains and overall
content of each Identify domain groupings based on organizational
structure Identify who will participate in the self- assessment:
Health Director, Management/Supervisors, Program Staff Provide a
department-wide orientation to accreditation and self-assessment
process Slide 30 Example: Domain Groupings Identify domain
groupings based on organizational structure, programs and people:
Domains 1, 2 (data surveillance and public health hazards) Domains
3, 4, 7 (promotion and prevention) Domains 5, 6 (law and policy)
Domains 9, 10 (QI, evaluation, research) Domains 8, 11, 12
(governance, administration) THD needs to decide the best groupings
and strategy Slide 31 Domain Teams Identify who should be on each
Domain Team for conducting the self-assessment Consider program
managers and staff with strong knowledge and expertise Some
individuals may be on more than 1 team; prioritize which team for
self-assessment Identify a team lead for each Domain Team Identify
mechanisms for accountability (such as quarterly or monthly
meetings) 31 Slide 32 Domain Teams Challenges and Strategies THDs
may be small and only have 1-3 teams Limited staff with technical
expertise to adequately review, assess and score Smaller number of
teams means more time will be required to self-assess all domains
Strategies: Focus staff time on the domains where they have
greatest expertise Use domain groupings to review similar or
related functions Self-assessments can be scheduled for completion
in sections or individually Slide 33 Self-Assessment Outcomes
Identify THD strengths and opportunities for improvement Prioritize
opportunities for inclusion in your strategic plan (prerequisite)
Use findings to inform the development of a Quality Improvement
Plan ( measure 9.2.1 and 9.2.2 ) Update self-assessment tool as
improvement activities are completed Slide 34 Slide 35 Forest
County Potawatomi PHA Self-Assessment Tool TPHA Readiness Webinar
Lorrie Shepard, RN June 12, 2013 Slide 36 Introductions: Lorrie
Shepard, RN CH Department Supervisor Oversee all CH Programming and
In-Home Care Program AAAHC, TPHA (Co-Coordinator), Infection
Control Committee Slide 37 FCP Community Health Department Part of
the FCP Health & Wellness Center Medical (OBY-GYN, Pediatrics,
Podiatry, Radiology, Lab), Dental, Optical, Physical Therapy,
Mental Health & AODA Community Health Department Programs &
Services Car Seat ProgramMCH/HOCDiabetes Prevention
SDPIImmunizationsInfant Nutrition Program WICHPDPHIV/AIDS
WWWPGlucose Test & BP ScreeningHead Checks Smoking
CessationNutrition CounselingHome Health/Visits Slide 38 Forest
County Potawatomi Checkerboard Tribal Land Stone Lake, Blackwell,
Carter Population in Forest County 725 Tribal Members Service All
Tribal Members 1,444 Tribal Members Slide 39 Where are We At with
PHA? TPHA Committee Est. HWC Admin Approval HAC Approval Logic
Model/Timelines PHA Coordinators Assigned Self-Assessment Tool
Electronic Filing System CHA Completed CHIP Workgroups Est.
Strategic Planning Slide 40 Readiness Self Assessment Approach TPHA
Committee completed the assessment as a group SuccessesChallenges
Lessons Learned Opportunity to Review PHAB Requirements Identify
Strengths & Weaknesses Prioritize Projects Delegate tasks to
staff based on knowledge & expertise Attendance by ALL
Committee Members Interpreting Domains, Standards, Measures
Overwhelmed Staff Need to review regularly- not a one time thing
Dont do it too Early Easy to delegate, difficult to follow through
Review more often at Committee Meetings to ensure progress is being
made. Slide 41 FCP Self- Assessment Workbook Slide 42
Recommendations Review Domains, Standards and Measures prior to
completing the Self-Assessment Tool. Complete assessment with THPA
Committee or key staff involved in the accreditation process.
Review and update workbook regularly. When selecting Domain
Leaders, make sure you assign staff who are engaged in the
accreditation process and willing to do the work otherwise no
progress is made. Regular reminders to Domain Leaders and
workgroups to review domains and update assessment tool. Hold
Domain Leaders accountable by having them report back to the TPHA
Committee. Slide 43 Thank You!! Forest County Potawatomi Communtiy
Health Department Lorrie Shepard, RN: 715-478-4341
[email protected] Slide 44 Tribal Public Health
Accreditation Readiness Webinar Apryl Krause, ND May 7, 2013 Slide
45 Introduction Apryl Krause, ND MPH- PY Diabetes Prevention and
Treatment Program Manager Oversee the Diabetes Program comprised of
Outreach, Fitness, and Recreation See patients as a Naturopathic
Doctor in the PY Alternative Medicine Clinic once a week Slide 46
Pascua Yaqui Tribe Reservation in Tucson, AZ. 18,311 enrolled
members Approximately 3934 live on the reservation, and another
~4000 live in Yaqui communities in Tucson and Phoenix metro areas.
About 10% live in California Aboriginal lands in Sonora, Mexico,
and are tightly bound to the communities there.
http://commons.wikimedia.org/wiki/File:Yaqui_Ri ver.jpg Slide 47 PY
Health Department Contract Health Dervices Public Health and
Clinical The Pascua Yaqui Tribe is a 638 tribe Its contracted
health services provider is El Rio Community Health Centers. El Rio
has a primary care clinic and a pharmacy on the PY reservation as
well as 11 other locations throughout Tucson. PY took over the
administrative responsibility for their healthcare plan in 2010.
The Yoeme Health plan serves tribal members living in Pima county
who are not eligible for other healthcare coverage. By 2014 PY
plans to take over their primary care and the pharmacy. The PYHD
has an extensive Behavioral Health Program, a busy Dental clinic,
an innovative Alternative Medicine Clinic, and leases space to
DeVita to provide hemodialysis. Tribal Health programs and services
include: Diabetes Prevention, WIC, HIV/AIDS, CHRs, CHNs, Sewa Uusim
(similar to social services), injury prevention, traditional
healing, and wound care. PYHD has arranged for specialty care on
the reservation including: Rheumatology, Cardiology, & Podiatry
Slide 48 Progress with Accreditation Effort Getting approval and
forming a team Moving forward PYHD director approved the idea to
pursue accreditation and chose a team. Accreditation team attended
trainings for Tribal Public Health Accreditation Readiness and
Self-Assessment Training and a 3-Prerequisites training in the
spring of 2012. Due to conflicting priorities, a new team was
formed in the fall and co- coordinators were appointed. The new
team started meeting in November 2012. Dr Krause will officially
present accreditation details to the council health department
oversight committee in June. Unofficial approval has been procured.
Co-coordinators and Health director watch accreditation overviews
Complete self-assessment (first run) Assign accreditation team
members to PHAB domains Arrange for electronic filing system Create
timeline Read already existing CHAs as a group. Co-coordinators
meet with tribal programs who have recently completed CHAs or who
need to conduct one. Slide 49 Self-assessment We chose to go
through the self-assessment quickly, ~10 hours, with the
understanding that it will be gone through again by domain teams.
Benefits Challenges The team became familiar with PHABs Standards
and Measures The team now has a very good idea of where PYHDs
strengths and weaknesses lie. The process made the accreditation
effort feel concrete- like something that is going to happen.
Feeling overwhelmed in light of some of the improvements that need
to be made (i.e. writing policies and statutes and then enforcing
them) Getting the accreditation team together in one room on a
regular basis Need to have more structure, with team being willing
to follow that structure. Slide 50 Recommendations Become familiar
with the Domains, Standards, and Measures, and review them often.
Look for tools for helping organize accreditation efforts from such
organizations as NACCHO & PHAB, to name a few. Select
accreditation team members, and domain leaders who are
self-motivated are interested in the project Dont bog down in the
details. Move on when necessary, and then go back later. Cultivate
positive relationships with Departments outside of the Health
Department. Dont be afraid to bug people, especially people who
have agreed to participate in the accreditation effort.
http://www.drfranklipman.com/disease-transformation/ Slide 51 Thank
you! Pascua Yaqui Tribe Health Department Apryl Krause, ND MPH:
520-879-6137 [email protected] Slide 52
Questions/Comments Slide 53 Thank You! Theresa Cario, MEd
[email protected] Webinar will available at:
www.redstar1.org
