PREPARING FOR A PHAB SITE VISIT 1 Susan Ramsey Pearls of Wisdom Consulting Lia Katz ASTHO (202)

Site Visit Process 2

Site Visit Purpose (1) Assess documentation for conformity (2) Develop Site Visit Report  Expert peer review  Verify documentation  Onsite review o Visual observations o Interview staff o Meet with governing entity o Meet with partner organizations and community partners ‣ Request additional documentation 3

4  Your work begins years before you consider a PHAB site visit  Fortunately many health departments have worked with standards and QI  Agency culture change occurs that can prepare you for PHAB review

5  Work with your PHAB coordinator to finalize the site visit agenda  Share with staff and partners the agenda as soon as possible  Identify who will interview with the site visit team for each Domain area  Determine how the governing entity and partners will engage with the site visit team

 Applicability Matrix – Who Is Assigned What Measures (have back-up identified) Excel  Share folder – Mind Manager maps  Outlook appointment notices  FAQ for partners and staff  4 meeting rooms (a room for each reviewer and a home room)  Name tents for partner meeting, site reviewers, staff interviewees 6

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8  Involve them in the agenda times  Ensure they know the documentation they will be speaking about  Provide training on the do’s and don’ts during the site visit  Keep them informed in all steps of the process  Celebrate all the hard work

The role as a reviewer is to determine the level of conformity of the supplied documents (along with what is learned on-site) to affirm or deny the truth of the department’s assertion of demonstrating the measure 9

Site Visit  Two days (usual)  PHAB will schedule with HD and SVs  PHAB will set and provide site visit agenda to health department prior to visit ◦ Organized by Domain  Health Department selects staff for participation ◦ Include specific sessions to meet with:  Members of governance entity  Community partners  Health Department director 10

Preparing for Your Site Visit  Work with PHAB Program Specialist on schedule of visit  Work with your Accreditation Specialist on the SV agenda  Review site visit agency with: ◦ Health Department director ◦ Accreditation team ◦ Governing entity ◦ Partner organizations and community partners 11

Your Site Visit Preparations  Review AC Handbook  SV dates on the HD Director’s calendar  HD staff, community partners, partner organizations, governance representatives: ◦ Notified, informed, scheduled and available  Keep a list of arrangements and detailed schedule 12

Making the Most of Site Visit Domain and Partner Interviews  Explain to staff what to expect  Remind staff they are speaking for the agency  Select the best staff (just like the best documentation)  Instruct staff on do’s and don’ts  Indentify cross cutting issues and coordinate in advance for consistent messaging  Let staff know the schedule and get contact information in case of last minute changes  Let partners know they don’t have to make formal presentations, just participate in the conversation 13

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 PHAB will provide you with an agenda for your site visit prior to the scheduled arrival of your site visitors  We will review a SAMPLE site visit agenda – keep in mind that the agenda is set by PHAB and will likely differ from the agenda provided here 16

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 Map/streets of local surroundings  Agency organizational chart  Building layout – meeting rooms  Chart of staff being interviewed  Restaurants/menus nearby health department  Local activities 21