Working Toward Accreditation Joan Ellison, Public Health Director Mary Margaret Stallone, Director Center for Preventive Services Livingston County Department of Health Conference of Environmental Health Directors / NYSACHO Meeting December 18, 2012

Be A Part Of Achieving Excellence Accreditation

Seven Steps to Accreditation 1. Pre-application 2. Application 3. Documentation Selection and Submission 4. Site Visit 5. Accreditation Decision 6. Reports 7. Reaccreditation

Steps Taken… 1. Pre-application Online Orientation Assess Readiness Inform PHAB- Statement of Intent to Apply 2. Application Community Health Assessment Community Health Improvement Plan Agency Strategic Plan

Livingston County Department of Health Accreditation Timeline Through November 2011 Prerequisites Pre-application Self Assessment By November 16, 2011January 2012-May 2012 Submit Application to PHAB Documentation Selection and Submission to PHAB Between June 2012 and November 2012 Scheduled Site Visit- Could be 1-6 months after submission of all documentation By February? 2013 Accreditation Decision

Steps Taken… Assemble Accreditation Team Assign Domains to Domain Leader Assemble Domain Teams

Steps Taken… 3. Documentation Selection and Submission Domain Team Meetings Discussion Gathering of materials/ documents

Steps Taken… Discussion of materials at Accreditation Team meeting

Steps Taken… Accreditation Coordinator attended Accreditation Training Shared information with Accreditation Team Discussed revision of process

Steps Taken… Public Health Director and Accreditation Coordinator met with Domain Leaders Domain Leaders then met with their teams to discuss and revise information as needed

Steps Taken… Accreditation Team met again to discuss new information to determine if the standards were met

Tracking Our Achievement

Getting Ready to Push the Button

Pushing the Button!

Final Submission!

Responding To Questions Two Sets of Questions 1.Related to dates and signatures on documents 2.More information requested from site team

Steps Taken 11/29/12 and 11/30/12 4. Site Visit

Next Steps 5. Accreditation Decision Review Accreditation Site Visit Report- within 14 days of the site visit LCDOH has 30 days to respond Report is sent to the PHAB Board for their review LCDOH to be contacted in approximately two months regarding Board decision If LCDOH does not get accredited, LCDOH has 90 days to take corrective action

Next Steps 5. Accreditation Decision Accreditation- good for five years Site visit team recommends opportunities for improvement Not Accredited Must submit accreditation plan within 90 days Must implement and provide proof of implementation of action plan with 12 months

Next Steps 6. Reports Department reports progress annually 7. Reaccreditation Application for reaccreditation after 5 years

Successes Appointing an Accreditation Coordinator Appointing Domain Leaders Include Diverse Group of Staff Ensure Adequate Time to Gather, Revise and Submit Information

Successes Staff Awareness and Involvement from the beginning Staff Input – meeting the criteria Creation of Several Policy and Procedures Met Deadlines for Submission Strive to Improve Various Areas Strategic Plan

Lessons Learned Regarding Required Documents Comprehensive meeting minutes Presentations to include date, time, place Documentation of process Proceed with Domain in Numerical Order

What Are We Doing Differently? Performance Management Quality Improvement Minutes Documentation of process Tracking systems in place Identify who, what and where presentations are made

Accreditation is the beginning Improve Accreditation Improve Re- Accreditation Improve Improving the public’s health through continuous quality improvement NACCHO National Association of County & City Health Officials

Questions

Livingston County Department of Health 2 Murray Hill Drive Mt. Morris, NY