CASE STUDY 3 - Public Health Accreditation Board · 2013-06-14 · Revised PHAB EDUCATION SERVICES...

PHAB EDUCATION SERVICES - Discussion Guide of 49

CASE STUDY 3

E-PHAB DOCUMENTATION ASSESSMENT

DISCUSSION GUIDE

Site Visitor Training

PUBLIC HEALTH ACCREDITATION BOARD Education Services

Revised – April 2013

NOTE: The documents used during Site Visitor Training are for training purposes

only and do not represent actual documentation, nor is it indicative that similar

documentation should be accepted or rejected by site visitors.

This guide is to be used for discussion about the training documents and does not

cover all aspects of document quality, nor how they would or would not meet PHAB

requirements.


DOCUMENTATION EXERCISE GUIDE Site Visitor Training

Documentation Exercise using e-PHAB

Here are the measures that are in the SVT Training Health Departments. The

documentation is also located on the flash drive distributed at the training.

1.1.2 T/L

2.1.2 T/L

2.3.2 A

3.2.2 A

4.1.1 A

5.1.3 A

6.2.3 A

6.3.5 A

7.2.1 A

8.1.1 T/L

8.2.1 A

9.2.1 A

9.2.2 A

10.2.2 A

11.1.1 A

11.1.2 A

12.1.2 A

12.3.2 A

Acronyms

ACHC – Acme County Health Center

EH – Environmental Health

OFI – Opportunity for Improvement

NOTE: Many of the Measures are either largely or slightly demonstrated for training

purposes. They are not designed to show that health departments would submit many

measures that would be assessed as such – most measures will likely be fully

demonstrated.


Measure 1.1.2 T/L

Domain 1: Conduct and disseminate assessments focused on population health status and

public health issues facing the community

Standard 1.1: Participate in or Conduct a Collaborative Process Resulting in a

Comprehensive Community Health Assessment

1.1.2 T/L: Complete a Tribal/local community health assessment

Required Documentation 1: A Tribal or local community health assessment dated within the last five years that includes:

Documentation that data and information from various sources contributed to the community health assessment and how the data were obtained

A description of the demographics of the population A general description of health issues and specific descriptions of population groups

with particular health issues A description of contributing causes of community health issues A description of existing community or Tribal assets or resources to address health

issues Example 1

Title – ACHC Community Health Assessment – Part 1

File – Acme 2010 CHA Volume One

File Description – This is the primary report of the ACHC CHA from 2010. Example 2

Title – ACHC Community Health Assessment – Part 2

File – Acme 2010 CHA Volume Two

File Description – Part 2 of the ACHC CHA from 2010 contains Environmental Health data.


Required Documentation 2: Documentation that the Tribal or local community at large has had an opportunity to review and contribute to the assessment

Example 1

Title – Website Comment for CHA

File – Measure 1.1.2 Website Comment

File Description – This document details the CHA posting on the ACHC website inviting comment and questions.

Example 2

Title – Press Release for CHA

File – Measure 1.1.2 CHA Press Release

File Description – This press release was sent on 6-9-2010 announcing the CHA reports and asking for comment.

Measure Narrative The documentation in this measure related to the CHA process that the ACHC undertook in 2010. We use the CHA protocols established by Healthy Carolinians at the State Division of Public Health (See 1.1.1 L). For this CHA, we collaborated with the NC Institute for Public Health, which facilitated the process. The report was issued in two parts. The first dealt with health care needs, demographics and health data. The second dealt with environmental health issues and data. The examples of distribution and seeking of input are but two of many - others are available upon request. The Board of Health also sought input at BOH meetings. The press release and website posting were two primary means of publicizing the reports and seeking input. Referenced in Narrative (1.1.1L) Required Documentation 3: Description of the process used to identify health issues and assets

Title – CHA Guide Book

File – Measure 1.1.2 CHA Guide Book

File Description – This is the guide book for the CHA process established by the Healthy Carolinians Branch at the NC Division of Public Health.


Assessment

1. While all the required components are most likely in the reports, none of the bullet points have been flagged or highlighted. (The first four bullets are in the documents. The fifth bullet is touched on throughout but is not fully developed.) Unless the Site Visitor wants review some 330+ pages in the reports, the health department should be asked to provide narrative on where the required elements can be found in the document.

2. These two examples are fine. A documentation OFI to make the documentation stronger would be to have a screen shot from the web site showing the info that was posted and to include a fax cover or email showing distribution of the press release.

Pre-Site Visit Assessment: Pending, until the required elements in the CHA are located.

The material does fully demonstrate with an Opportunity for Improvement to better delineate the available community resources.


Measure 2.1.2 T/L

Domain 2: Investigate health problems and environmental public health hazards to protect the community

Standard 2.1 Conduct Timely Investigations of Health Problems and Environmental Public

Health Hazards

2.1.2 T/L: Demonstrate capacity to conduct an investigation of an infectious or communicable disease Required Documentation1: Audits, programmatic evaluations, case reviews or peer reviews of investigation reports against protocols (2 examples) Example 1

Title – Evaluation of HepA Response

File – Measure 2.1.2 ACHC – Evaluation of HepA Response 03-2012

File Description – Example 2

Title – Acme OSWW Program Review 2008

File – Measure 2.1.2 Acme OSWW Program Review 2008

File Description – Here is a complete program review of the On-Site Wastewater (OSWW) program in Environmental Health at ACHC. This was conducted by the State OSWW Division and was conducted in February, 2008. The report was dated May 16, 2008 and details the evaluation of the program against protocols.

Title – OSWW Plan of Action 8-10-10

File – Measure 2.1.2 Plan of Action 8-10-10

File Description – Here is the Plan of Action developed by the ACHC in August of 2010. This follows up and is in response to the Program Review of 2008. Note high-lighted text.

Required Documentation 2: Completed After Action Report (AAR)


Title – Acme Shigella Outbreak Report

File – Measure 2.1.2 Acme Shigella Outbreak report-final 1-21-10

File Description – Here is the final report of the November 2009 Shigella Outbreak in the county and the response of ACHC. The report was finalized on 1-21-2010 and forwarded to the State Division of Epidemiology.

Measure Narrative

ACHC has provided two examples of programmatic reviews. One was done by the state for

our On-Site Waste Water program. Another review was an internal review of our response

to a Hepatitis A outbreak. The AAR is from an investigation of a Shigella outbreak that the

ACHC responded to, mitigated and contacted those affected in the outbreak.

Assessment

1. There are two examples provided. The guidance specifies that the examples should be

related to the capacity to respond to outbreaks of infectious or communicable disease. Also

note that the guidance and the measure state that the documentation should be reviews of

investigation reports against protocols. Acme has provided two examples. The evaluation is

for a Hepatitis A outbreak. There is a need to have the protocol that was used as a part of

the evaluation and this should be asked for.

The OSWW example is a program review that is nonspecific to a particular outbreak

or disease situation. It could be possibly argued that the review does contain

information of work against protocol, and that improper disposal of sewage or a

system failure can cause an outbreak of disease, but this is a stretch and does not

meet the intent of the measure. This example would not be acceptable. There could

be a question with a reopen to ask for another example that has a focus of an

infectious or communicable disease.

2. The department does provide an AAR of a communicable disease outbreak and how the HD

conducted the response. This is acceptable evidence for this requirement. (Note that this

outbreak provides a means for developing documentation for the other requirement in this

measure. The AAR could be reviewed against the department’s communicable disease

response protocols to determine if the response was handled in the best way possible.

However do not ask for this specific type of evidence. However, you could mention this in

your comments regarding Opportunities for Improvement.

Pre-Site Visit Assessment: Largely Demonstrated


Measure 2.3.2 A

Domain 2: Investigate health problems and environmental public health hazards to protect the community

Standard 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.

2.3.2 A: Maintain 24/7 access to laboratory resources capable of providing rapid detection, investigation and containment of health problems and environmental public health hazards

Required Documentation 1: 1. Laboratory certification

Document 1

Title – ACHC Laboratory CLIA Certificate

File – Measure 2.3.2 ACHC CLIA Certificate File Description – This is the CLIA certificate showing that the department is authorized to conduct the listed laboratory testing.

Document 2

Title – NC State Lab CLIA Certification

File – Measure 2.3.2 NC State Lab CLIA Certification File Description – This is the CLIA certificate for the NC State Lab of Public Health, which serves as a main reference lab for the health department.

Required Documentation 2: 2. Policies and procedures ensuring 24/7 Coverage

Title – ACHC Emergency Operations Procedures

File – Measure 2.3.2 ACHC duties – EOP

File Description – See highlighted text showing our responsibility to have full time coverage of all major services and for response to public health emergencies.


Required Documentation 3:

3. Protocols for handling and submitting specimens

Document 1

Title – Clinical Laboratory & Clinical Lab Specimens

File – Measure 2.3.2 Clinical Laboratory & Clinical Lab Specimens

File Description – none

Document 2

Title – Laboratory Specimen Handling Policy

File – Measure 2.3.2 Laboratory Specimen Handling Policy


Document 3

Title – Laboratory Specimens Protocol

File – Measure 2.3.2 Laboratory Specimens Protocol


Measure Narrative Through our own laboratory services and the reference labs we use, we maintain the necessary capacity for both daily services and emergency or outbreak response. We maintain a moderate level CLIA certified lab (offsite) and provide basic support at the health department. All laboratory policies follow both the department protocol and CLIA protocols for review and revision.

Assessment

1. There are two CLIA certificates provided – one for ACHC and one for the State Lab.

The State Lab Certificate has expired, so a new one will need to be requested. Also,

the team should ask if there are any other reference labs used by the HD. This could

be done as a question thru e-PHAB, or could be noted by the team as a question

during the interview. In either case, if there are other labs, the team would decide if

those certificate copies will be asked for.


2. There is only one weak piece of evidence here. It is a HD duties section from the Co.

EOP that states that the HD will maintain 24/7 coverage for the lab. However there

is no policy or protocol included. This does not meet the documentation

requirement. The team could ask for the policy on how the HD maintains the

coverage of the lab.

3. There are three polices/protocols attached and all are named for laboratory

specimens. While between the three this element is demonstrated, there is a

definite opportunity for improvement. All three protocols have components of

specimen handling and three different policy formats. How does staff know which

one to refer to? Or would all three have to be referenced, if needed, when handling

specimens? These three should be consolidated into one protocol. Also, there are no

protocols for handling environmental health specimens. This could be a question

now or during an interview. The team would determine if it would reopen to

request environmental health specimen handling protocols.

Pre-Site Visit Assessment: Slightly Demonstrated


Measure 3.2.2 A

Domain 3: Inform and educate about public health issues and functions Standard 3.2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences. 3.2.2 A: Establish and maintain communication procedures to provide information outside the health department Required Documentation 1: Written procedures for communications, updated biennially, that include:

a. Disseminating accurate, timely, and appropriate information for different audiences b. Informing and/or coordinating with community partners for the communication of targeted and unified public health messages c. Maintaining a current contact list of media and key stakeholders d. Designating a staff position as the public information officer e. Describing responsibilities and expectations for positions interacting with the news media and the public, including, as appropriate, any governing entity members and any department staff member

Document 1

Title – Acme Media Policy

File – Measure 3.2.2 Acme Media Policy

File Description – Health Department media policy

Document 2

Title – ACHC Crisis Communication Policy

File – Measure 3.2.2 ACHC Crisis Communication Policy

File Description – This document demonstrates the appointment and role of the PIO

Document 3

Title – Acme County Emergency Pub Info Plan

File – Measure 3.2.2 Acme Co Emer Pub Info Plan

File Description – Contains communication procedures. See highlighted list of media contacts on page 24


Required Documentation 2: Dissemination of public health messages outside the health department

Example 1

Document 1

Title – Diabetes Press Release

File – Measure 3.2.2 Diabetes Press Release

File Description – 1st example of disseminated message Part 1

Document 2

Title – Diabetes Advocacy Day Press Release

File – Measure 3.2.2 Diabetes Advocacy Day Press Release

File Description – 1st example of disseminated message Part 2

Example 2

Document 1

Title – Heat Related Illness Press Release

File – Measure 3.2.2 Heat Related Illness Press Release

File Description – 2nd example of disseminated message

Measure Narrative

We submit our Crisis Communications Plan, our Media Policy and our Acme County

Emergency Public Information Plan, as referenced above, as examples of the department’s

ability to establish and maintain communications procedures to distribute timely

information in an appropriate fashion outside the agency.

We also have provided examples related to two programs – diabetes care from adult

health/chronic disease and heat related illness from community health promotion – to

demonstrate the implementation and following of our plans.

Assessment

1. The three documents include two department policies and a county plan. The

documentation listed is only part of what is needed. The attached policies do not


have the required elements. We do know that they have a PIO, so requirement d is

well covered. Some of requirement e is covered also. While there is a list of media

contacts, there is no list of key stakeholders included for requirement c.

Requirements a and b have some documentation in the county plan, but they are not

pointed out or highlighted, so the site visitor would have to read thru and pick out

what they think applies.

2. Here two examples are presented and one is a chronic disease - diabetes. The other

is within health promotion (injury prevention?). This section is met. An OFI would

be to include the email or fax cover showing that the releases went out.


The main deficiency is within required documentation 1.


Measure 4.1.1 A (NOTE: This documentation is the same as in 7.2.1)

Domain 4: Engage with the community to identify and address health problems

Standard 4.1 Engage with the Public Health System and the Community in Identifying and Addressing Health Problems Through Collaborative Processes

4.1.1 A: Establish and/or actively participate in partnerships and/or coalitions to address

specific public health issues or populations

Required Documentation: 1. Documentation of current collaborations that address specific public health issues or

populations Example 1

Document 1

Title –Access to Care Annual Report

File – Measure 4.1.1 Coalition Report File Description – This is an annual report on the Access to Care project of the ABO Health Care Coalition.

Document 2

Title – Agreement for Nurse Practitioner Services

File – Measure 4.1.1 Agreement for NP Services

File Description – This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner to serve at the ACHC clinic sites.

Example 2

Document 1

Title – Access to Care Action Plan 2010

File – Measure 4.1.1 Access to Care Action Plan

File Description – This is the action plan regarding access to care from the 2010 Community Health Assessment. Partners are highlighted (for required documentation 2).


Document 2

Title – Access to Care Talking Points

File – Measure 4.1.1 Access to Care Talking Points File Description – This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders.

2. List of partner organizations or representation in each collaboration

Title – List of Coalition Partners

File – Measure 4.1.1 List of Coalition Partners

File Description – Here is a list of partners for both coalitions, also highlighted in other documents in this measure.

3. Description of process used to mobilize the Tribal/state/local community

Title – Action Plan with process highlights

File – Measure 4.1.1 Access to Care Action Plan - process highlights

File Description – The efforts to engage coalition members and the community is highlighted through our marketing plans for the project.

Measure Narrative

The examples included demonstrate the active participation of the ACHC in the coalitions

submitted. The needs addressed by these efforts are supported through our CHA and

CHIP. We work to engage both our partners and the community in these efforts to address

public health needs.

Assessment

1. Though there are two examples the (ABO coalition and HealthNet), it appears that

the HealthNET project involves the ABO coalition and is one piece of their work.

Can you argue that there is a coalition between BestHealth and ACHC? No, the NP

contract is just that – a contract – and is a support to the HealthNet project.

Nonetheless, they both are working on the same public health issue – access to care,

so another example of a coalition is needed. This can be a question with a reopen if

desired.

2. Provided is a listing and both examples in required documentation 1 have the

partners highlighted in the documents.


3. This is the same document that was submitted for required documentation 1. That

is fine and the health department has highlighted different information in the

document. The work of the ABO coalition has some process listed in the Action Plan

– though weak and lacking in detail. The HealthNet report has no real info on

process at all. This required documentation is not present.



Measure 5.1.3 A

Domain 5: Develop public health policies and plans

Standard 5.1 Serve As a Primary and Expert Resource for Establishing and Maintaining

Public Health Policies, Practices, and Capacity

5.1.3 A: Inform governing entities, elected officials, and/or the public of potential public

health impacts, both intended and unintended, from current and/or proposed policies


Documentation of the health department informing policy makers and/or the public about

potential public health impacts of policies that are being considered or are in place

Document 1

Title – County Commissioner Agenda Abstract

File – Measure 5.1.3 BOCC Agenda Abstract July 12, 2010

File Description – This document is the abstract of what the Health Director presented to the Board of County Commissioners at their meeting on July 12, 2010.

Document 2

Title – County Commissioner Meeting Minutes

File – Measure 5.1.3 BOCC Minutes - 7-12-10

File Description – This document is a page from the meeting minutes of the Board of County Commissioners held on July 12, 2010. Highlighted is the Health Director’s report on policy changes in the Environmental Health Water Sampling Program.

Document 3

Title – Board of Health Agenda

File – Measure 5.1.3 BOH Agenda Dated August 17, 2010

File Description – This document is the agenda for the Board of Health meeting held on August 17, 2010. On the agenda is discussion of Environmental Health policies.

Document 4

Title – Board of Health Meeting Minutes


File – Measure 5.1.3 BOH Meeting Minutes Dated August 17, 2010

File Description – This document is the meeting minutes of the Board of Health for August 17, 2010. Highlighted are the two policy change discussions.

Document 5

Title – Environmental Health Water Sampling Policy

File – Measure 5.1.3 EH Water Sampling Policy

File Description – This is the Environmental Health water sampling policy discussed at the Board of Health and Board of County Commissioner meetings.

Measure Narrative

In the documentation requirement, “policies” is plural so two examples are needed. The

documents for this measure contain two examples of policy change - state immunization

policy and the ACHC Environmental Health water sampling policy. Presentations to policy

makers and processes for public notification are included.

Assessment

1. The documentation provided gets at what the measure is assessing but is disjointed.

It appears that the department did inform both the governing entity and elected

officials about the impact of a policy change. We are just unsure what the public

health impact is. There are two issues here – changes in immunizations and changes

to an EH policy. The Board of Health agenda and minutes are uploaded, but the

immunization fact sheet was not. That document is needed to help complete the

requirement.

For the EH policy, it is noted that the potential impact was discussed with the Board

of Health, but no detail is recorded. The policy is included but again, we do not

know what the changes are and how it could impact the community from a public

health perspective. Also, the impact was discussed with the Commissioners, but the

materials, comments presented or presentation itself needs to be added.

Questions could be asked to define the impacts from the EH policy. The measure

could be reopened to request the missing documentation.


Missing documentation and no cohesive documentation about the EH policy impact


Measure 6.2.3 A

Domain 6: Enforce public health laws

Standard 6.2 Educate Individuals and Organizations On the Meaning, Purpose, and Benefit of Public Health Laws and How to Comply 6.2.3 A: Provide information or education to regulated entities regarding their responsibilities and methods to achieve full compliance with public health related laws Required Documentation 1: Written record of the provision of information or education to regulated entities concerning their responsibilities for compliance with public health laws

Example 1

Title – ACME Well Rules

File – Measure 6.2.3 - ACME Well Rules 2008

File Description – Acme County Well Rules adopted in 2008

Example 2

Title – Effective Date of Well Rules

File – Measure 6.2.3 - Effective Date of Well Rules

File Description – Board of Health authorization on when the well rules will take effect.

Example 3

Title – Open Forum Agenda

File – Measure 6.2.3 - Open Forum Agenda

File Description – Open forum for well-drillers regarding the well rules held March 15, 2008.

Example 4

Title – Open Forum Minutes

File – Measure 6.2.3 - Open Forum Minutes

File Description – Minutes from the open forum held March 15, 2008.


Example 5

Title – Proposed time line for well rules

File – Measure 6.2.3 - Proposed time line for well rules 10-07

File Description – Timeline for the adoption of the well rules

Measure Narrative

These documents relate to the adoption of county well rules in 2008 and the sharing of the

information with those who would be most impacted – well drillers who work in the

county. A copy of the rules are included as well as the information regarding a forum held

to inform the well drillers. The rules and the timeline were distributed at the forum.

Assessment

1. First, there is only one example here and two are needed. This is something that the

AS will check for when doing the completeness check. They would notify the

department that only one example has been provided (though there are multiple

documents for that one example.

Should something like this make it through the completeness review, the team

would ask for another example since two are required by the health department.

2. There was some good evidence here but it applies to one example. Since the rules

are signed and dated, there is no need for the effective date document, which isn’t

signed anyway. Just disregard this document – it adds nothing. The minutes give the

number of attendees. The guidance states an attendance list, so an OFI would be to

include the list of participants or sign in list as a part of the minutes.

The time line document doesn’t really add anything here either and is just extra

documentation. While it does show plans for the open forum, the minutes and

agenda are stronger evidence.

Pre-Site Visit Assessment: Pending

Leave as pending since two examples are required


Measure 6.3.5 A

Domain 6: Enforce public health laws

Standard 6.3 Conduct and Monitor Public Health Enforcement Activities and Coordinate Notification of Violations among Appropriate Agencies 6.3.5 A: Coordinate notification of violations to the public, when required, and coordinate the sharing of information among appropriate agencies about enforcement activities, follow-up activities, and trends or patterns Required Documentation 1:

Communication protocol for interagency notifications

Title – ACHC Notification Policy

File – Measure 6.3.5 ACHC Notification Policy interagency

File Description – This is the health center’s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for interagency notifications.


Protocol for notification of the public when required

Title – ACHC Notification Policy

File – Measure 6.3.5 ACHC Notification Policy public

File Description – This is the health center’s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for public notifications.

Required Documentation 3: Documentation of notification of enforcement actions, and sharing information concerning enforcement activities

Title – Environmental Health Notice of Violation

File – Measure 6.3.5 EH Notice of Violation

File Description – Here is an example of a Notice of Violation that is a part of the Environmental Health rules. This sample was delivered in person by Environmental Health to the owner of the septic system that had failed.


Title – HIV Isolation Order

File – Measure 6.3.5 HIV Isolation Order

File Description – This is a copy of an HIV Isolation Order that was given to an individual in July of 2009. This follows enforcement action as detailed by State Statute (listed in the letter). The individual information has been blacked out.

Measure Narrative

The communication protocols for both interagency and public notifications are included in

the same policy. This policy is submitted for required documents 1 & 2, with sections

highlighted to demonstrate how it contains that requirement. There are a number of

communication protocols that are define by rule and statute. ACHC adopts those by

reference as we are the agent of the state that enforces those regulations.

ACHC has attached two examples of notification that we do as a part of our Environmental

Health and Communicable Disease programs. Both follow the guidelines established by

law and State Government.

Assessment

1 & 2. The health department submitted the same document for both requirements. It is

fine to have both required elements in the same document and they have

highlighted the differences. Note that there are several references to statute.

Guidance requires the submission of these laws. Thus the need to have the

reference that includes lists of communication requirements in law or rule. This is a

case of “I said so”, but the Site Visitors will not know the rules that the health

department must operate by.

While there are 4 other possible documents about protocols for interagency

communications on the flash drive, none of the documents really deal with

notification of violations.

• Measure 6.3.5 ACHC Communication and Media Protocols • Measure 6.3.5 ACHC Crisis Communication Policy • Measure 6.3.5 Acme co Emer Pub Info Plan • Measure 6.3.5 Acme Media Policy

These other protocols fit better in Measure 3.2.2

3. The department did provide two examples of enforcement letters that was sent

from the department. Both are fine examples of enforcement of laws, but notice that


this correspondence goes to individuals and not the public or other agencies. So

while the documents fulfill the requirement, they do not fulfill the measure.

Remember to put the documentation requirement in the context of the measure. If

these had been examples that 1) went to other residents in the mobile home park

regarding the sewage leak, and; 2) the issuance of the isolation order had been

communicated to the state public health department; then the requirement would

have been demonstrated. This is an OFI for this measure and the note in the

conformity box.



Measure 7.2.1 A (NOTE: This documentation is the same as in 4.1.1)

Domain 7: Promote strategies to improve access to health care services

Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services

7.2.1 A: Convene and/or participate in a collaborative process to establish strategies to improve access to health care services Required Documentation 1: Documentation that a coalition/network/council is working on collaborative processes to reduce barriers to health care access or gaps in access

Document 1

Title – Access to Care Action Plan 2010

File – Measure 7.2.1 Access to Care Action Plan

File Description – This is the action plan regarding access to care from the 2010 Community Health Assessment. This document supports both required elements of documentation.

Document 2

Title – Access to Care Talking Points

File – Measure 7.2.1 Access to Care Talking Points File Description – This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders.

Required Documentation 2: Development of strategies through the collaborative process to improve access to health care services

Document 1

Title – Access to Care Annual Report

File – Measure 7.2.1 Coalition Report File Description – This is an annual report on the Access to Care project of the ABO Health Care Coalition.


Document 2

Title – Agreement for Nurse Practitioner Services

File – Measure 7.2.1 Agreement for NP Services

File Description – This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner (NP) to serve at the ACHC clinic sites. Contraction for a NP is one of our strategies to address access to care issues.

Measure Narrative

These documents demonstrate the efforts of the ACHC and community partners, including

local medical providers and partners to increase and improve access to care. Through a

regional coalition and the CHA, we are working to increase access by providing services

and staffing, by contracting for NP services onsite at the ACHC, to meet identified needs.

Assessment

Is it OK to use the same material for different measures? Yes, but remember that the

contents must conform to the requirements of the measure. If using documents more

than once, there should be different elements in the documentation that meets the

requirements for the separate measures. However, the documentation is a better

match in this measure than in 4.1.1

1. There is evidence of a collaborative process here in the action plan. The talking

points would be better under Required Documentation 2, since it gets at strategies.

2. While there is documentation of strategies being used (and the HD submits that

contracting for a NP is one), there is only sketchy evidence of how the strategies

were developed by the coalition partners. This would be an OFI. The Annual Report

has soon elements that could be highlighted for Required Documentation 1.

While the documentation could be better arranged in the submission process, that’s

OK for assessing as what is needed is here.

Pre-Site Visit Assessment: Fully Demonstrated


8.1.1T/L

Domain 8: Maintain a competent public health workforce

Standard 8.1: Encourage the Development of a Sufficient Number of Qualified Public

Health Workers

8.1.1 T/L: Establish relationships and/or collaborations that promote the development of future public health workers Required Documentation 1: Documentation of relationships or collaborations that promote public health as a career

Document 1

Title – Internship Learning Agreement

File – Measure 8.1.1 Learning Agreement

File Description – This document is a copy of an agreement to place an intern from Bowman University at the ACHC.

Document 2

Title – Acme Comm College Contract

File – Measure 8.1.1 Acme Comm College Contract signed

File Description – This is our agreement with the local community college regarding placing students in the Health Center for internships or practicums.

Measure Narrative

Included are two samples of agreements or contracts used by the ACHC to give students an

opportunity to experience public health and gain exposure to a possible career choice.

There are executed contracts on file at the department that can be reviewed on request.

Assessment

1. There are two documents and only one example is needed. The Acme Community

College contract has been signed and appears to be in place. Based upon the

narrative, there are records at the Health Department demonstrating the use of the

contract. The learning agreement is an executed document showing how a student is


working in the health department for an internship. Again the narrative insinuates

that there may be other contracts at the Health Department as well.

While both are excellent in developing future public health workers, an OFI (based

on guidance) would be for the Health Department to also document instances of

making presentations to a university, college, high school or club about public health

as a career.



8.2.1

Domain 8: Maintain a competent public health workforce

Standard 8.2: Assess Staff Competencies and Address Gaps by Enabling Organizational and Individual Training and Development 8.2.1 A: Maintain, implement and assess the health department workforce development plan that addresses the training needs of the staff and the development of core competencies Required Documentation 1: Health department workforce development plan that includes:

a. Nationally adopted core competencies b. Curricula and training schedules

Document 1

Title – Workforce Development Policy

File – Measure 8.2.1 Workforce Development Policy File Description – This document is the ACHC Workforce Development Plan that was adopted in 2008 and revised in 2010

Document 2

Title – Training Calendar 2011

File – Measure 8.2.1 Training Calendar 2011 File Description – This is the schedule of trainings for ACHC staff held in 2011

Required Documentation 2: Documentation of implementation of the health department workforce development plan

Title – Workforce Development Implementation Report

File – Measure 8.2.1 Workforce Development Implementation Report File Description – This is the 2010 report showing implementation of the Workforce Development Plan.


Measure Narrative

The documentation included for this measure are the workforce development policy and

plan for the ACHC. The plan was initially adopted in 2008 and has been guiding our

workforce development since. It was revised in 2010 and has the support of the Board of

Health. The implementation report and the training schedule are completed each year and

are used in review and needed revisions of the plan.

Assessment

While the basics seem to be here, the documentation is weak.

1. There is a plan present. While the plan has a short paragraph on using the national

core competencies, there is no real link to any of the implementation or training

plans. Also, the plan just mentions using the competencies without any supporting

detail about how they will be used for staff. There is a training calendar but it is

very limited. There is no info on who is targeted, what the topic might cover and

who is responsible. Also, some of the trainings are listed as updates and may just be

info sharing versus an educational session.

2. There is an implementation report with a number of trainings listed. This will work

but what is needed is the agenda, participant list and materials for two of the

sessions to show who attended and the elements covered in the training and how

those trainings relate back to the Workforce Development Plan.



Measure 9.2.1

Domain 9: Evaluate and continuously improve health department processes, programs, and interventions

Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions

9.2.1 A: Establish a quality improvement program based on organizational policies and

direction.

The following documentation (2 files) and descriptions have been uploaded into this

measure.


A written quality improvement plan

Example 1

Document 1

Title – ACHC Quality Improvement Plan (Example 1)

File – Measure 9.2.1 Quality Improvement Policy and Plan


Document 2

Title – ACHC Quality Improvement Plan (Example 2)

File – Measure 9.2.1 Quality Improvement Policy and Plan with highlights

File Description – The QI Plan has highlights to note how the plan correlates

to the guidance for the measure.

Document 3

Title – Companion to ACHC QI Plan (Example 2a)

File – Measure 9.2.1 Companion to QI Plan

File Description – This companion document is the key that supplements the

highlights in the QI Plan. This document is color-coordinated to match with

the QI Plan in highlighting the key elements.


Example 2

Title – ACHC Quality Initiatives 2011-12

File – Measure 9.2.1 ACHC QI Initiatives for FY 2011-2012

File Description – This is a work plan for the three initiatives from 2011-2012.

Measure Narrative

The ACHC QI Plan has been adopted to provide the guidance in developing and

implementing a strong QI plan at the health department. The Plan was initially adopted in

2008 and has been used in strategic planning and in programs review. It is reviewed

annually by both the leadership of the ACHC and the Board of Health. A copy is on file in

the County Manager’s Office.

Also included is the worktable of the QI initiatives undertaken at ACHC during the most

recent Fiscal Year (July, 2011 to June 2012).

Assessment

NOTE: The examples are two representations of what could be submitted. The department

would not submit both examples, but either 1 or 2.

For example 1, the plan is OK, but would be frustrating and time consuming to review. The

plan needs to have key elements highlighted or detailed so the site visitors can easily locate

as they review the file. So it is fine to send a question to the health department asking them

to point out the elements in the plan as listed in the guidance.

For example 2 & 2a, the plan has highlighted the key elements as listed in the guidance.

This plan is acceptable, though site visitors may fine some opportunities for improvement

for some areas that need more detail, for example identifying and selecting projects.

Also, there are the goals for the last year, but since a new year has started there should be a

new work plan that can be included. It is fine to ask for this document (it must have been

written prior to hitting the submit button) or offer it as an OFI. Note: the date uploaded

date is not the submitted date. OFI – add in elements of the process that is being studied

for QI.



Measure 9.2.2

Domain 9: Evaluate and continuously improve health department processes, programs, and interventions

Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions 9.2.2 A: Implement quality improvement activities The following documentation (3 files) and descriptions have been uploaded into this

measure.

Required Documentation 1: Documentation of quality improvement activities based on the QI plan Document 1

Title – QI Team Notes for Media Relations Initiative

File – Measure 9.2.2 Media Relations 2010

File Description – This document is one of the working records of the QI Team. It demonstrates working through the QI process.

Document 2

Title – Family Planning Storyboard

File – Measure 9.2.2 Acme QI Storyboard

File Description – Storyboard of the ACHC project to decrease Family Planning waiting time – results of the project are demonstrated. See highlighted areas in text to show project participants as well as actions taken and follow-up meeting QI plan guidelines.

Required Documentation 2: Demonstrate staff participation in quality improvement activities based on the QI plan Document 3

Title – QI Team Minutes for July 2011

File – Measure 9.2.2 QIT Minutes July 2011

File Description – Minutes of the Quality Improvement Team showing actions of the group and the members of the team, thus demonstrating staff participation in QI – see highlighted text.


Measure Narrative

These three documents show how the QI Team at the ACHC are workings to implement the

QI plan and bring meaningful change to the department through the involvement of both

leadership and frontline staff.

Assessment

1. There are two examples provided. The storyboard is a good example, but needs

some narrative to meet the required elements stated in the guidance. Based on the

storyboard alone, site visitors cannot discern what is asked for in the guidance -

what the problem was, what the process was, etc.

The media project certainly has some QI aspects, but seems to focus on workforce

development around specific staff, versus an administrative process. If there is

documentation on how this is a QI project – such as what is the problem regarding

media exposure, how can it be improved, what are the steps, etc. – it may be more

acceptable. Also as a team report, it’s written in a manner that only the HD can

understand and doesn’t clearly answer the questions that the examples must

demonstrate.

Also, the HD is submitting this as an administrative QI project. It really needs to be

tossed and select another project with a focus on the administrative processes of the

health department. One question with a reopen could be to ask for such a project.

2. The HD has provided a set of minutes with the QI Team members present. Both

projects also list participants. However for the projects, it is not clear who actually

participated in the project. The storyboard list the QI Team, but no project

personnel.



Measure 10.2.2 A

Domain 10: Contribute to and apply the evidence base of public health

Standard 10.2 Promote Understanding and Use of Research Results, Evaluations, and Evidence-based Practices with Appropriate Audiences 10.2.2 A: Maintain access to expertise to analyze current research and its public health implications Required Documentation 1: Documentation of availability of expertise (internal or external) for analysis of research

Title – CV of Vincent Dude

File – Measure 10.2.2 Dude CV – data expert

File Description – Mr. Dude serves as our expert for data and research analysis. He is employed by the state Division of Public Health. He resides in the local public health regional office and serves a number of counties including Acme.

Measure Narrative

No entry

Assessment

1. There is a CV that looks like a person who can provide the expertise is available to

Acme. However according to guidance, since he is outside the HD some type of MOU

is needed and should be developed by the HD/State and uploaded here. The MOU or

documentation containing a description of this person’s expertise and training

would make the evidence stronger. Also, we don’t know if there is a set amount of

time dedicated to Acme County or if it is on an as needed basis. The MOU could be

asked for in a reopen.


Since the CV is nothing more than that without the MOU


Measure 11.1.1 A

Domain 11: Maintain administrative and management capacity

Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the

Performance of Public Health Functions

11.1.1 A: Maintain policies and procedures regarding health department operations,

review policies and procedures regularly, and make them accessible to staff


Policy and Procedure Manual or individual policies

Document 1

Title – Admin Policy Manual Table of Contents

File – Measure 11.1.1 Admin Policy Manual Table of Contents

File Description – This document list the policies in the ACHC administrative policy manual. The full manual is available online and is available upon request or onsite.

Document 2

Title – ACHC Dress Code Policy

File – Measure 11.1.1 Dress Code Policy

File Description – This policy is an example from the department’s administrative policy manual.

Document 3

Title – ACHC Orientation Policy

File – Measure 11.1.1 Orientation Policy

File Description – This policy is an example from the department’s administrative policy manual.



Health department organizational chart

Title – ACHC Organizational Chart

File – Measure 11.1.1 ACHC O-chart 07-11

File Description – This is the most recent organizational chart for the ACHC.


Reports of review at least every five years or proof of regular updating process

Document 1

Title – Policy on Policies (Revising Policies)

File – Measure 11.1.1 Policy on Policies - review & revise

File Description – This is the ACHC policy on policies with sections highlighted that define how the department reviews and revises policies.

Document 2

Title – Admin Policy Manual Signature Page

File – Measure 11.1.1 ACHC Policy Manual Signature Page

File Description – This is the signature page for the Administrative Policy Manual showing annual review.


Description of methods for staff access to policies

Title – Policy on Policies (Employee Access)

File – Measure 11.1.1 Policy on Policies - employee access

File Description – This is the ACHC policy on policies with sections highlighted that define employee access to departmental policies.


Measure Narrative

Provided is the table of contents for the administrative policy manual for the department. A couple of examples of policies from the manual have been included. All policies are initially approved and signed off, then the manual as a whole is reviewed and annually signed and dated by the health director.

The department has a policy on policies that defines the process for developing, approving, revising and accessing policy. This has been included under required documentation 3 & 4 with the appropriate sections highlighted demonstrating both the revision process and employee access. Assessment Documentation is fine for this measure. The Administrative Policy Manual is available online and should be reviewed. This is a measure that uses visual observation to verify the submissions. Look for locations of policies during the facility review (if hard copies are used for employee access). Also interviews could be used to ask about accessing policies or the review process. Pre-Site Visit Assessment: Fully Demonstrated


Measure 11.1.2

Domain 11: Maintain administrative and management capacity

Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the

Performance of Public Health Functions

11.1.2 A: Maintain written policies regarding confidentiality, including applicable HIPAA requirements Required Documentation 1: Confidentiality Policies

Document 1

Title – HIPAA Manual – Table of Contents File – Measure 11.1.2 ACHC HIPAA Policy Manual Table of Contents Description – This is the Table of Contents from the department’s HIPAA Policy

Manual. The full manual, including all forms used by the ACHC for privacy is

electronic and is available for review upon request or on-site.

Document 2

Title – Maintaining Privacy Policy File – Measure 11.1.2 Maintaining Privacy of Individuals Description – This policy details how the department will maintain privacy of

individuals who are receiving services through the ACHC.


Training content and staff participants Document 1

Title – Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In Description – This is the sign-in roster for the HIPAA training of 04-30-09.


Document 2

Title – Makeup Training Sign-In File – Measure 11.1.2 HIPAA Training Sign-In – Makeup Description – This is the sign-in roster for the makeup HIPAA training of 05-12-09.

Document 3

Title – HIPAA Training Agenda File – Measure 11.1.2 HIPAA_Training_Agenda 04-09 Description – Here is the agenda used for the HIPAA training, and makeup session.

This was the last department wide training. HIPAA training is now conducted

individually during orientation for each new staff member.

Required Documentation 3: Signed employee confidentiality forms, as required by policies

Document 1

Title – ACHC Confidentiality Statement File – Measure 11.1.2 Confidentiality Statement Description – This is a copy of the Confidentiality Statement that is signed by every

employee. As noted on the agenda copy, copies are kept in personnel files and

signed copies are available for review on site.

Measure Narrative

As demonstrated by these documents, the ACHC takes confidentiality of clients and of

information very seriously. Our manuals and training regarding HIPAA and confidentiality

are very thorough and every employee is responsible for following protocol. This is shared

among all staff and leadership. Failure to comply can invoke the disciplinary process.

Better

The HIPAA manual and privacy policy are examples of how ACHC approaches

confidentiality of both medical information and program activities. Policies for HIPAA and

privacy are well-defined and available to all staff. Training begins with orientation and all

new employees are trained on confidentiality of clients in all programs. The training

records are an example of one such training. The confidentiality statement, updated or

reviewed with the employee during the annual evaluation, is kept in every personnel file.


Assessment

1. The HD has provided 2 documents to show their privacy policies. One is the table of

contents for the HIPAA manual. Ask to see that on-site. The other policy deals with

other privacy issues. These are fine.

2. A training roster, along with the make-up, and the training agenda has been

submitted. However, this is only for HIPAA and there is no evidence of training content (if any was available). There is also no training records for the other privacy policy and that needs to be requested.

Here you can be specific and asked if there is any evidence of training for the

Maintaining Privacy of Individuals policy.

3. The form has been included. A statement that all have signed the form and the

copies can be seen upon request has been put in the description. This may be a

visual observation when on site – during the tour, you could ask to see where the

statements are kept. Or you could ask to see a couple of signed copies. If there is a

need for an interview on Domain 11, you could ask during that time.



Measure 12.1.2

Domain 12: Maintain capacity to engage the public health governing entity

Standard 12.1 Maintain Current Operational Definitions and Statements of the Public Health Roles, Responsibilities, and Authorities 12.1.2 A: Maintain current operational definitions and/or statements of the public health governing entity’s roles and responsibilities The following documentation (3 files) and descriptions have been uploaded into this

measure.


Authority of the governing entity

Document 1

Title – General Statutes for the Board of Health

File – Measure 12.1.2 BOH public health statutes - 130A

File Description – This document list the NC statutes that define the makeup and

duties of the local board of health, as well as the appointment of the director (which

is a BOH role).


Description of governing entity

Document 2

Title – Board of Health Operating Procedures

File – Measure 12.1.2 BOH Operating Procedures 9-21-2010

File Description – This document defines the operating guidelines of the Board, such

as officers, meeting times and agendas.

Document 3

Title – Board of Health Overall Operations

File – Measure 12.1.2 BOH Overall Operations Policy 7-17-2009


File Description – Based upon statute, this document details the overall operations,

duties & responsibilities of the BOH including appointments, training, rule-making

authority and policy development.

Measure Narrative

The three attachments for this measure demonstrate that the roles, responsibilities and

authorities of the board are well defined in both statute and in policy. Board Members are

oriented and regularly trained on this content. This evidence shows that the Acme BOH

takes serious its responsibility to represent the county, the department and our residents

in setting and supporting public health policy.

Assessment

Three documents are provided. The statutes provided are about the authority and make-

up of the Board of Health. There are two documents that provide operational guidelines for

the Board of Health. There is an OFI to combine the documents into one operations

protocol.

Overall, info is what is needed and is complete.



12.3.2

Standard 12.3 Encourage the Governing Entity’s Engagement in the Public Health Department’s Overall Obligations and Responsibilities 12.3.2 A: Track actions taken by the governing entity 1 file uploaded Required Documentation 1: Review issues discussed, actions taken, and policies set by the governing entity at least annually

Title – Board of Health Meeting Minutes

File – Measure 12.3.2 BOH Meeting Minutes 09-21-2010

File Description – This is a copy of the Board of Health minutes from September 21, 2010. There are two highlighted sections addressing the requirements of the measure.

Measure Narrative

None

Assessment

1. The minutes provided do show a summary of actions taken and notes that the

review of the Board Manual includes info the Board needs to know. Also the

minutes show that there was discussion and review on EH policies. However, there

is not clear documentation on a review of issues discussed or on all policies set by

the governing entity. There is also missing documentation as recommended by the

guidance. The evidence here needs much more development.

Pre-Site Visit Assessment: Slight-ly Demonstrated


Exercise Handouts


The National Challenge phab.demo.eaccreditation.org/login

SVT Chair – Sandra Willow

o Assign Domains to Team Members

Team Member Domains

Sandra Willow 2, 3, 8, 12

Larry Magnolia 1, 5, 6, 11

Don Frasier 4, 7, 9, 10

Open Measure 8.1.1 L (T/L)

o In “Build Site Visit Report” in the “Areas of Excellence” text box, add the

comment, “The health department has a very strong partnership with the

universities and colleges in the state. It is impressive that 60% of all

internship opportunities result in hiring full time public health employees.”

(remember to click save).

o Select “Reviewed” as the Pre-Site Visit Review Status for the measure.

o Choose “Fully Demonstrated” as the Pre-Site Visit Assessment for the

measure.

o Click “Accepted by Chair”.

Open Measure 8.2.1 A

o Select “Reopen” as the Pre-Site Visit Review Status for the measure (it is

required to write a request for another document). Your request could

be, “Please provide evidence of an annual update; the competency

documents are dated in 2010.”

o Choose “Slightly Demonstrated” as the Pre-Site Visit Assessment for the

measure.

o Click “Accepted by Chair”.



SVT Member – Larry Magnolia

Open Measure 1.1.2 L (T/L)

o In “Build Site Visit Report” in the “Opportunities for Improvement” text

box, add the comment “The health department acknowledges a future

effort to seek input on the CHA before actual publication.” (remember to

click save).

o Type a note in the Site Visitor Notes section and select the Chair as the

“user to alert” (remember to click post). The note to the Chair could be,

“The health department stated the committee meets quarterly, but the

last meeting was from 2011, should we ask for an example from 2012

even though the documentation is within the PHAB timeframe so we are

sure the collaboration is still current?”


o Choose “Largely Demonstrated” as the Pre-Site Visit Assessment for the

measure.


o In “Build Site Visit Report” in the “Conformity” text box, add the

comment, “The health department provided documentation in multiple

formats, web-based, FAQs, PowerPoint, each demonstrating a written

record of efforts to inform and educate regulated entities on their

compliance with public health law”. (remember to click save).

o Select “Reopened” as the Pre-Site Visit Review Status for the measure (it

is required to also submit a request/question). Your request could be,

“How often are your web-based fact sheets updated?”

o Choose “Largely Demonstrated” as the Pre-Site Visit Assessment for the

measure.



SVT Member – Don Frasier


o In “Build Site Visit Report” in the “Areas of Excellence” text box, add the

comment, “The health department has a very strong partnership with the

universities and colleges in the state. It is impressive that 60% of all

internship opportunities result in hiring full time public health employees.”


o Select “Reviewed with Questions” as the Pre-Site Visit Review Status for

the measure (it is required to also submit a request/question). Your

question could be, “It is unclear how recruitment activities are organized.

Does the youth council or the health department take the lead for the

Tobacco Coalition?”


measure.


o In “Build Site Visit Report” in the “Conformity” text box, add the

comment “The partnership between the health department and the Tribal

Leaders health coalition has met on an annual basis. The strategies

summarized in the 2009 report were clearly implemented in 2011.”


o Type a note in the Site Visitor Notes section and select Larry Magnolia as

the “user to alert” (remember to click post). The note to Larry could be, “I

remember you saying you used to be the WIC Coordinator. Could you take

a look at the Maternal infant health meeting strategies and let me know

what you think?”



measure.


DOCUMENTATION ASSESSMENT & RATING

demo.phab.eaccreditation.org/login

As you review the documentation – both individually and at your table (team), remember the four questions: 1. What documents/evidence do I have?

o Look at the documentation that has been uploaded into e-PHAB.

2. What does the Health Department want this to say? o Does the documentation appear appropriate to the measure? o Are the documents supported by the guidance? o What information has been submitted in the file descriptions and

measure narrative?

3. How does it demonstrate conformity? o How does the documentation compare to the requirements and the

guidance for the measure? o Are you able to locate the required elements?

- If not, what’s the documentation missing? - What questions should I ask the health department?

4. How would it be assessed & rated?

o What rating would you give the measure? o What are strengths within the documentation? o What are opportunities for improvement within the documentation?

Go over as a group:

Measure 3.2.2 A 1. Read the measure and the documentation requirements. 2. Look at the file descriptions (scroll the mouse over the document title). 3. Look at the measure narrative (beneath the required documentation). 4. Answer the four questions. 5. Draft a conformity statement.


Participants complete and report out: 1. Read the measure and the documentation requirements. 2. Look at the file descriptions. 3. Look at the measure narrative. 4. Answer the four questions.

- Open & review the documentation submitted - Make notes & send questions (if desired) - Assess the measure noting areas of strength & improvement - Individually review the assigned documents and then discuss your

findings with your ‘team’ 5. Write up a conformity statement. 6. Write up areas of excellence and opportunities for improvement, as needed.

SVT Chair – Sandra Willow

Measure 2.1.2 L (T/L) Measure 12.1.2 A

SVT Member – Larry Magnolia

Measure 5.1.3 A Measure 11.1.2 A

SVT Member – Don Frasier

Measure 9.2.1 A o First, open Example 1 and try to find the required elements o Then open Example 2 & 2a and note the required elements

Measure 9.2.2 A

CASE STUDY 3 - Public Health Accreditation Board · 2013-06-14 · Revised PHAB EDUCATION SERVICES...

Documents

Transcript of CASE STUDY 3 - Public Health Accreditation Board · 2013-06-14 · Revised PHAB EDUCATION SERVICES...