1. Domain Champion Updates New Mexico Department of Health

2.  Shannon Barnes-Accreditation Coordinator  Anne Barraza-Accreditation Document Librarian Introductions

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

4. PHAB Accreditation Process Map

6. Documentation Submission: Measure Page

7. Uploading a document in EPHAB

8. Description Box

9.  Use the description boxes to help provide the link between the Measure and the uploaded document for the Site Visitors  Character Limit: 150 words  Describe how document demonstrates conformity  Identify specific location within the document  Describe the author, if not a HD document Description Boxes

10. Measure Narrative PHAB does not recommend going to 10,000 characters. If so, the Site Visitors will NOT read the document. (Read 5 minutes and move on) Do not enter charts, web links, or images in the measure narrative

11.  Use the measure narrative to explain to the Site Visitor the reason for selecting ALL documents submitted for the measure  Size limit: 10,000 Characters  Give context to the evidence  Describe how all evidence demonstrates conformity  Explain why the HD is using the documents Measure Narrative

12. Consider selection options and programs:  Best reflects health department operation  Meets specifics of the required documentation  Demonstrates conformity with measure (Content and intent of M, S, D)  A variety of programs Documentation Selection

13.  Current and in use when submitted  Draft documents not accepted  No confidential information (Mark Out)  Within past 5 years unless otherwise required  Paperless process  Submit in acceptable file formats General Guidance

14.  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 (ex: Consultant, Academic)  By a partnership (evidence of membership) Documentation may be developed:

15.  Use PDF’s when possible  Open uploaded documents to check for readability (No sideways or upside down PDF documents)  No blank signature lines Remember to make the job of the Site Visitors as easy as possible! More General Stuff

16.  Review your:  Policies  Procedures  Plans  Directives  Public information  Protocols Dates and Signatures Dates: Created Date Revised Date Reviewed Date Amended Date Effective Period Signatures: (Evidence of authenticity) HD Logo HD Director Signature HD Abbreviation HD Email Address Membership List -FOR-

17. Acceptable File Formats

18.  Four Questions  What do I have?  How does it demonstrate conformity?  What do I want this to say?  How would it be assessed? Assessing Documentation Don’t think of your documentation as good or bad What’s the best we can show?

20. How long will it be from when our department submits documentation to when we have our site visit?

21. Pre-Site Visit  Review documentation  Conference calls  Request additional documentation Site Visit  Conduct meetings and interviews  Reach consensus Site Visit Report  Team assesses measures and inputs comments  Team Chair submits report Site Visit Process Post Site Visit  Team Chair available to Accreditation Committee

22.  2 days (Usual)  PHAB will set and provide Site Visit agenda to HD prior to visit  Organized by Domain  HD selects staff for participation  Include specific sessions to meet with:  Members of governance entity  Community partners  HD Director PHAB Tip to Site Visitors: Do your best to put the health department at ease Site Visit

23. NMDOH is on track… Updated Timeline Coming Soon!

24.  Do you have an action plan?  Do you have a timeline?  How can we support you? Major Gaps in Documentation?

25.  Questions?  Need assistance? SharePoint Overview