1. Outline: Binders (walk through as doing training) Review contents Welcome Purpose: To train the Domain Team leads in the process of conducting team meetings, first steps, and expected outcomes/timelines Roles and Responsibilities Overview of timeline – update on status of pre-requisites General process overview Intro to the PHAB standards What are the Domains Basic structure of standards Key elements from documentation guidance document/AC Handbook Self Assessment Tool (review of original and use of new) Documentation Basics – PHAB ppt Preparing documentation – key elements Documentation selection – Assessing documentation what types should you look for Core Public Health Programs Tools to manage the documentation (PHAB spreadsheet) Accreditation SharePoint site 11/6/14 Division of Public Health Idaho Department of Health and Welfare

2. Accreditation Team Leads Training Traci Berreth and Dan Ward November 6, 2014  Purpose  Train the Domain Team Leads on the roles within your teams, the process of accreditation document review and collection, and expected outcomes/timelines Division of Public Health Idaho Department of Health and Welfare 11/6/14

3. Accreditation Structure 11/6/14 Division of Public Health Idaho Department of Health and Welfare

4. Roles and Responsibilities  Accreditation Coordinator:Traci Berreth  Oversee accreditation efforts  Process Manager:Dan Ward  Oversee processes & manage timelines  PHAB Nomenclature Team: Traci, Dan, Chris Ball, Katie Anderson, & Sonja Schriever  Define the process for documentation collection, establish structure for managing documentation  PHAB Management Team:Elke, Traci, Dan, Domain Team leads  Participate in and guide major steps, guide completion of pre- requisites, work on formalizing QIP and Workforce development plans; etc. Division of Public Health Idaho Department of Health and Welfare 11/6/14

5. Roles and Responsibilities  Domain Team Leads and Co-Leads:  Team 1: Dieuwke (Co-lead Elke, Traci)  Team 2: James (Co-lead Kris S.)  Team 3: Sonja (Co-lead Mary)  Team 4: Kathy (Co-lead Chris B.)  Develop in-depth knowledge of assigned domains and standards  Convene Domain Team meetings and manage overall process for the team  Assess documentation  Report on progress  Identify gaps in documentation and assign tasks to address  Approve the documentation for final review by PHAB MT Division of Public Health Idaho Department of Health and Welfare 11/6/14

6. Roles and Responsibilities  Team Members:  Develop in-depth knowledge of assigned domains and standards  Identify potential documentation for each measure  Assess documentation to ensure it meets the standard  Identify gaps in documentation and inform Team Lead  Assist in completing required documentation elements for e-PHAB  Participate in quality improvement initiatives to address opportunities for improvement within assigned domains Division of Public Health Idaho Department of Health and Welfare 11/6/14

7. Seven Steps of Accreditation- Step 1  1. Pre-Application (Division is officially here)  Preliminary work to assess readiness of the Department  Assign key roles and responsibilities  Complete online orientation  Begin outlining timelines and work plans  Complete and submit Statement of Intent  One year prior to submitting Application Division of Public Health Idaho Department of Health and Welfare 11/6/14

8. Seven Steps of Accreditation – Steps 2 & 3  2. Application  Submit on-line application via e-PHAB  AC attends in person training (access given to e-PHAB when training complete)  3. Documentation review and selection  Begin assessing and selecting documents following PHAB criteria  Implement process for accessing, reviewing and selecting documents prior to upload to e-PHAB  Submit documentation through e-PHAB Division of Public Health Idaho Department of Health and Welfare 11/6/14

9. Seven Steps of Accreditation – Step 4  4. Site Visit  PHAB team conducts completeness review of submitted documents, allows state 30 days to respond to requests for further clarification or additional information  2-3 day visit from PHAB Team  State participants will include: AC, Administrator, DHW Director and other governance, Domain Team leaders, other key division/department staff, and Community Partners  Visit includes: Entrance conference, Department walk-through, Interviews with key staff, Sampling and collection of additional information if requested, Exit conference  Within 2 weeks of visit and report will be issued  State will have 30 days to respond to factual errors  No response to corrective action plan at this time  Recommendation made to Accreditation Committee Division of Public Health Idaho Department of Health and Welfare 11/6/14

10. Seven Steps of Accreditation – Step 5  5. Accreditation Decision  PHAB Accreditation Committee convenes and determines status  Accredited or Not Accredited  If Not Accredited: State has 90 days to respond with “Accreditation Action Plan”  PHAB reviews and approves (1 year to complete, re-reviewed) Division of Public Health Idaho Department of Health and Welfare 11/6/14

11. Seven Steps of Accreditation – Steps 6 & 7  6. Annual Reports  7. Re-accreditation process begins within 1 year of expiration Division of Public Health Idaho Department of Health and Welfare 11/6/14

12. Timeline Overview  7/1/14:Submit Statement of Intent (Completed 8/1/14)  7/1/15:Make application to PHAB (commit fees)  7/1/16:Documentation submission complete  12/31/16:Site visit completed, Division of Public Health Accredited! Division of Public Health Idaho Department of Health and Welfare 11/6/14

13. Detailed Timeline – First 6 months Division of Public Health Idaho Department of Health and Welfare 11/6/14 Oct-Dec 2014  Teams convened for first time  Team members receive initial training and assignments to review assigned domains. Jan-Mar 2015  Training on documentation review and uploading documents to SharePoint provided to each team  Teams complete PHAB Self-Assessment v1.5 to identify gaps  Team members begin collecting possible documentation examples that meet required standards of date, evidence of authenticity, version (draft or final), and criteria outlined in the Standards and Measures  Team leads report to PHAB MT

14. Overview of Team Process – Documentation Review and Selection Division of Public Health Idaho Department of Health and Welfare 11/6/14

15. PHAB Standards Introduction  Assessing Documentation Domain Standard Measure Required Documentation Guidance Division of Public Health Idaho Department of Health and Welfare 11/6/14

16. PHAB Domains and Standards Overview Division of Public Health Idaho Department of Health and Welfare 11/6/14 Domain 1. Conduct and disseminate assessments focused on population health status and public health issues facing the community 1.1 Participate in or conduct a collaborative process resulting in a comprehensive community health assessment 1.2 Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on the health status of the population 1.3 Analyze public health data to identify trends in health problems, environmental public health hazards, and social and economic factors that affect the public’s health 1.4 Provide and use the results of health data analysis to develop recommendations regarding public health policy, processes, programs or interventions Domain 2. Investigate health problems and environmental public health hazards to protect the community 2.1 Conduct timely investigations of health problems and environmental public health hazards 2.2Contain/mitigate health problems and environmental public health hazards 2.3 Ensure access to laboratory and epidemiological/environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards 2.4 Maintain a plan with policies and procedures for urgent and non-urgent communications

17. PHAB Domains and Standards Overview Division of Public Health Idaho Department of Health and Welfare 11/6/14 Domain 3. Inform and educate about public health issues and functions 3.1 Provide health education and health promotion policies, programs, processes, and interventions to support Prevention and Wellness 3.2 Provide information on public health issues and public health functions through multiple methods to a variety of audiences Domain 4. Engage with the community to identify and address health problems 4.1 Engage with the public health system and the community in identifying and addressing public health problems through collaborative processes 4.2 Promote the community’s understanding of and support for policies and strategies that will improve the public’s health Domain 5. Develop public health policies and plans 5.1 Serve as a primary and expert resource for establishing and maintaining public health policies, practices, and capacity 5.2 Conduct a comprehensive planning process resulting in a Tribal/state/community health improvement plan 5.3Develop and implement a health department organizational strategic plan 5.4Maintain an all hazards emergency operations plan

18. PHAB Domains and Standards Overview Division of Public Health Idaho Department of Health and Welfare 11/6/14 Domain 6. Enforce public health laws 6.1 Review existing laws and work with governing entities and elected/appointed officials to update as needed 6.2 Educate individuals and organizations on the meaning, purpose, and benefit of public health laws and how to comply 6.3 Conduct and monitor public health enforcement activities and coordinate notification of violations among appropriate agencies Domain 7. Promote strategies to improve access to health care services 7.1Assess health care service capacity and access to health care services 7.2Identify and implement strategies to improve access to health care services Domain 8. Maintain a competent public health workforce 8.1Encourage the development of a sufficient number of qualified public health workers 8.2 Ensure a competent workforce through the assessment of staff competencies, the provision of individual training and professional development, and the provision of a supportive work environment

19. PHAB Domains and Standards Overview Division of Public Health Idaho Department of Health and Welfare 11/6/14 Domain 9. Evaluate and continuously improve health department processes, programs, and interventions 9.1 Use a performance management system to monitor achievement of organizational objectives 9.2 Develop and implement quality improvement processes integrated into organizational practice, programs, processes, and interventions Domain 10. Contribute to and apply the evidence base of public health 10.1 Identify and use the best available evidence for making informed public health practice decisions 10.2 Promote understanding and use of the current body of research results, evaluations, and evidence-based practices with appropriate audiences Domain 11. Maintain administrative and management capacity 11.1 Develop and maintain an operational infrastructure to support the performance of public health functions 11.2Establish effective financial management systems Domain 12. Maintain capacity to engage the public health governing entity 12.1 Maintain current operational definitions and statements of public health roles, responsibilities, and authorities 12.2 Provide information to the governing entity regarding public health and the official responsibilities of the health department and of the governing entity 12.3 Encourage the governing entity’s engagement in the public health department’s overall obligations and responsibilities

20. Standard Structure Division of Public Health Idaho Department of Health and Welfare 11/6/14

21. Documentation Selection  Consider selection options and programs:  Best reflects health department operation  Meets specifics of the Required Documentation  Demonstrates conformity with measure (Context and intent of M & S & D)  A variety of programs Division of Public Health Idaho Department of Health and Welfare 11/6/14

22. Documentation Selection  Current & in use when submitted  Draft documents not accepted  No confidential information  2 examples within past 5 years unless otherwise required (based on submission to PHAB)  Paperless process  –“hard copy” submitted electronically in e-PHAB  Submit in acceptable file formats Division of Public Health Idaho Department of Health and Welfare 11/6/14

23. Documentation Selection  Documents may be used for more than one measure  –i.e., Can use same document more than once  Continuity versus across department  Several documents may be needed to demonstrate conformity  Don’t confuse # of examples with # of documents Division of Public Health Idaho Department of Health and Welfare 11/6/14

24. Evidence of Authenticity Evidence of Authenticity = Signature  All documents must show evidence of authenticity. That is, the document must have a logo, signature, email address, or some other evidence that the document is “authentic” to the applicant health department. The purpose for this requirement is to provide PHAB site visitors with evidence that the documentation does in fact “belong” to the health department being reviewed.  Evidence of Authenticity is a best practice Division of Public Health Idaho Department of Health and Welfare 11/6/14

25. Evidence of Authenticity Examples:  Documentation could be a written policy and include the signature of a governor, mayor, or health department director.  With email; the "To" and "From" and the email addresses will serve as evidence that the document is "official" health department business.  A department logo will provide the evidence that the document is an official health department document.  A brochure will not have the health department or program director's signature, but it will include the department's logo.  Meeting minutes are usually signed but may include the department’s logo instead, noting that it is an “official” document. Division of Public Health Idaho Department of Health and Welfare 11/6/14

26. All Documents Must be Dated  All documentation used to demonstrate conformity with measures must be dated within the timeframe indicated in the Guidance. The date indicates when the document was created, adopted, reviewed, revised, etc.  The specificity of the date on the document will depend on the documentation requirement and the type of document.  Emails provide the full date and time  Policies may include the month, day, and year.  Reports may include the month and year.  A brochure may include only the year. In most cases the month and year will be required  Dating on documents is a best practice Division of Public Health Idaho Department of Health and Welfare 11/6/14

27. Step 1 – Dates and Signatures Review your existing documents:  Policies  Procedures  Plans  Directives  Public Information  Protocols  Dates:  Created date  Revised date  Reviewed date  Amended date  Effective period  Signatures:  (“Evidence of authenticity”) HD logo  HD Director signature  HD Abbreviation  HD e-mail address  Membership list 11/6/14 Division of Public Health Idaho Department of Health and Welfare FOR

28. Not Prescriptive  Look for “What” is in place, not “How” it got there or “Who” developed it  Documentation may be developed, e.g.,  By the health department  By another level of government (an umbrella agency, the state or local HD)  By another governmental agency  By a community partner, non-profit org  By a contractor (e.g., consultant, academic)  By a partnership (evidence of membership) 11/6/14 Division of Public Health Idaho Department of Health and Welfare

29. Core Public Health Programs  access to clinical services  chronic disease prevention and control  communicable disease  community health  environmental public health  governance  health education  health promotion  injury prevention  management /administration  maternal and child health  public health emergency preparedness  public health laboratory services 11/6/14 Division of Public Health Idaho Department of Health and Welfare

30. NOT used for PHAB Accreditation  mental health  substance abuse  primary care and other health care (No individual or personal health services)  human services  social services (including domestic violence)  health care facilities  professional licensing programs  health care financing systems (e.g., Medicaid)  PHAB’s scope of accreditation authority does not extend to these areas. Documentation from these program areas will generally not be accepted for public health department accreditation. 11/6/14 Division of Public Health Idaho Department of Health and Welfare

31. Tools & Resources 11/6/14 Division of Public Health Idaho Department of Health and Welfare  Team Binder  Accreditation SharePoint site  Domain Team Work Plan  Self-Assessment  PHAB.org