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AmyBelflowerThomasHealthDirectors’LegalConference

April4,2018

ComplianceUpdate

PresentationOverview

1. Programupdates1. ReaccreditationwithHonors2. ConditionalAccreditationProtocol3. Onlineevidencesubmissionpilot

2. ReviewofStandardrevisionprocess1. Annualchanges2. ChangesrequiringRulesCommission

3. Humanservicesconsolidation4. Questionsandcomments*

*

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ProgramUpdates

ReaccreditationwithHonors

• LHDsthatmissoneorfewerActivitieswithineachoffiveStandards

• Congratstoinauguralclass:– AnsonCountyHealthDepartment– CatawbaCountyPublicHealth– Granville‐VanceDistrictHealthDepartment– MaconCountyHealthDepartment

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OperationalGuidelinesAdoption

• 20+policies/proceduresreorganizedtothreesetsofOperationalGuidelines:– AccreditationProcess– Board– SiteVisitTeam

RequestforReviewoftheSiteVisitReport

• Processclarifiedfor:– WrittenResponse: ifadepartmentdisagreeswithafinding.– ErrorofFact: ifthedepartmentfindsanerrorthatisquantifiable,objectiveandnotsubjecttointerpretationinitsmeaning.

• LHDmaysubmitaReviewAppealtoBoardifdisagreewithBoard’sactionforWrittenResponseorAccreditationAdministrator’sfindingsofErrorofFact.

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ConditionalReaccreditationRecommendationProtocol

Purpose: togiveanLHDanadditionalopportunitytosubmitevidencecompiledduringtheiraccreditationcycleinordertomeetaccreditationrequirements.

Thewrittenevidencecannotbenewlycreatedorreviseddocumentation.Itmaybeanydocumentationthatwasinplaceasofthebeginningofthesitevisit.

1. CarefullyreviewyourSiteVisitReportandseewhichStandardsyoumissed.2. ConsultpagenineoftheNCLHDAAccreditationProcessOperational

Guidelines.3. IfyouhaveevidencetosubmitforanActivitywithinamissedStandard,

followProtocolandrequestevidencebereviewed.4. SiteVisitTeamwillreviewmaterialoff‐siteandreassess.

1. IfevidencenowallowsenoughActivitieswithinStandardtobemet,recommendationischangedtoReaccreditation.

2. Ifrecommendationisnotchanged(eithermaterialnotresubmittedorstilldoesnotmeet),agencywilllikelybecomeConditionallyReaccreditedatBoardmeetingandhastwoyearstoreapplyforReaccreditation.

WhatifourRecommendationisforConditionalReaccreditation?

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OnlineEvidencePortalPilot

• Adaptingasystemfornotonlyreal‐timeevidencesubmissionandreview,butaccountability

• 2018pilots:– AlbemarleRegionalHealthServices– HydeCountyHealthDepartment– GreeneCountyHealthDepartment– Martin‐Tyrrell‐WashingtonHealthDistrict– WayneCountyHealthDepartment

StandardRevisionProcess

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NCLaw

• SenateBill804‐ GS130A‐34.1– EstablishedNCLHDABoardwithinNCIPH(17membersappointedbyNCDHHSSecretary)

– DirectsCommissiontoadoptrulesestablishingStandardsforLHDs– MandatesallLHDstoobtain(byDecember1,2014)andmaintainaccreditation

• 10ANCAC48B– Definesscoringrequirementsbycorefunction– DescribesBenchmarksandActivities

NCLaw

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NCLaw

• Boardcanassignthefollowingstatus:• Accredited• ConditionallyAccredited:periodofuptotwoyearswithagencyreapplyingwhenready

• Unaccredited:uponexpirationofconditionalaccreditation

• Beingaccreditedistiedtofunding:

OverallGoalofChanges

Improve LHD’s

Ability to Succeed

Provide training

Remove un-

necessary structural barriers

Provide clear and consistent guidance

Support sharing of

best practice

Make requirements

easier to meet

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• AnychangestomaterialsmadeonanannualbasiseffectiveJanuary1– Agenciesheldtowhatiseffectiveasoftheir90‐daynotification

• Allmaterialsonwebsite• Annualcolorschemeforchanges— 2018• ChangesalsodetailedinSummaryofChangesdocument

SummaryofChanges

• Providedwheneverchangesaremadetoassessmentdocuments(HDSAI,Interpretation)

• Listsanddetailschangesmadesincelastupdate

• Correspondstochangesmarkedinorangeinupdateddocuments

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HumanServices

Consolidation

Changesin2015

• 10ANCAC48BamendedApril1,2015duetoHB438

• ChangesweremadetoHDSAI/Interpretationeffective6.1.15:– Benchmark34shuffled,includingdeletingoneActivity– WhereAdvisoryCommitteeallowed,specificallyidentified(38.2,38.3,39.1,39.4,40.1,40.2,41.1,41.2,41.3)

– WhereConsolidatedHumanServicesDirectorapplicable,specificallyidentified(37.1,37.3,37.4,37.5,37.6)

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AretheNCLHDAStandards

achievableforaCHSA?

AretheNCLHDAStandardsclearfordifferentconsolidationscenarios?

IsitharderforaCHSAtobe

reaccredited?

WhatdoIdoifmyagencyis

consolidatinginthefuture? HowdoItalktomy

countyleadersaboutNCLHDA?

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Recentdata ToolswithinInterpretation

Guidance Thingstoconsiderfor

consolidatedagencies TrainingsandGuidance

documents

ReaccreditationDataAssessment

• 131Reaccreditations2011‐2018*– 17initialConditionalReaccreditationrecommendations(13%)

• HealthAgencyConsolidationallowedin2012– 24Reaccreditationsforconsolidatedagencies

• 13GovernedbyBoardsofCountyCommissioners• 11GovernedbyConsolidatedHumanServicesBoard

– 107ReaccreditationsforBoardofHealth‐governedagencies

107

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Governance Structure of Local Health Agency Reaccreditations, 2011-2018

Traditional Consolidated - BOCC Consolidated - CHS*Includesspringsitevisitreports,butnotfallfor2018

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ReaccreditationDataOverview

• 131ReaccreditationSiteVisits,2011‐2018

1 1

7 6 63

8 10

1313

15

13

20

15

0

5

10

15

20

25

30

2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018

Nu

mb

er o

f A

gen

cies

Fiscal Year of Reaccreditation

Reaccreditation Site Visits (n=131) by Governance Structure, 2011-2018

Traditional (n=107)

Consolidated (n=24)

SummaryofActivitiesNotMet

• Ofthe131ReaccreditedLHDs:

– ActivitiesNotMetrangedfrom0to19Activities

– Mean=4.3Activities

– Median=3Activities

311 6 4

10

66

24

61

0

10

20

30

40

50

60

70

80

0 1-5 6-10 11-15 16-20

Nu

mb

er o

f A

gen

cies

Number of Not Met Activities

Traditional (n=107)

Consolidated (n=24)

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ActivitiesNotMet,2011‐2018

13%11%

23%

41%

13%11%

16%

29%

33%

12%

0

5

10

15

20

25

30

35

40

45

50

Assessment Policy Development Assurance Facilities &Administrative Services

Board ofHealth/Governance

% A

ctiv

itie

s M

isse

d

Activities Not Met, by Standard & Governance TypeFY2011-2018 LHD Reaccreditations (n=131)

Traditional (n=107)

Consolidated (n=24)

SummaryofActivitiesNotMetByConsolidationStatus

• Onaverage,consolidatedagenciesmissedanaverageofonlyonemoreActivitythantraditionalLHDs– 5.4vs4.1Activities

• Thisfindingisnotstatisticallysignificantduetolimitedsamplesize,butstillnotable

0

5

10

15

20

Traditional(n=107)

Consolidated (n=24) Overall(n=131)

Act

ivit

ies

No

t M

et

Box Plot of Activities Not Met, by Consolidation Status2011-2018 LHD Reaccreditations (n=131)

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SummaryofActivitiesNotMetByAgencyGovernance

• ConsolidatedagenciesgovernedbyaCHSboardaveraged2.5moreActivitiesmissedcomparedtotraditional– 6.7vs4.1Activities

• ConsolidatedagenciesgovernedbyaBOCCwerecomparabletotraditionalagencies– 4.2vs4.1Activities

• Smallsamplesizes,butstillmeaningfulresults 0

5

10

15

20

Traditional(n=107)

Consolidated -BOCC(n=13)

Consolidated - CHS(n=11)

Overall(n=131)

Act

ivit

ies

No

t M

et

Box Plot of Activities Not Met, by Governance Structure2011-2018 LHD Reaccreditations (n=131)

ToolswithinInterpretationGuidanceSections

AddedGuidanceforConsolidatedHumanServicesAgenciesforeveryActivity

• Helpswithspecificscenarios• RemindsaboutwhetherAdvisoryBoardcanaddress

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WhatGoestoLocalBoardofHealth

IfBOCChasassumedpowers/dutiesoftheBoardofHealth,wheneverBOHisreferredto,itequatestoBOCC(e.g.,Activity2.4— diseaseincidence/trendreport).

WhatCanGotoAdvisoryCommittee

GuidancewillbeclearaboutwhethertheAdvisoryCommitteecanfulfillrole(e.g.,Activity38.2— CHAreview).

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BOCCisActingonBehalfofTheirRoleasBOH

IfBOCChasassumedpowers/dutiesoftheBOH,evidencemustshowthatcertainActivitiesaredonefirmlyintheirroleasaBOH(e.g.,Activity14.4— draftingordinancesandrules).

WhoNeedstobeTrained

IfBOCChasassumedpowers/dutiesoftheBOH,theymustbetrainedonroles/responsibilitiesofBOH.YoucanchoosetotrainyourAdvisoryCommittee,butthatisnotrequired.

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WhoHiresaHealthDirectorandWhoSupervises

Assurethattheappropriateperson(BOHorconsolidateddirector)inthechainofoversightisidentified(e.g.,Activity37.1— qualifiedLHD).Thisappliestohiringaswellasthingslikesigningoffonperformanceevaluationsandjobdescriptions.

TrainingsandGuidanceDocuments

Slidesandfour‐pageguideonwebsite(updated1.1.18)

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ResourcesandTraining

Opportunities

Accreditation101:NewAACBi‐annualTraining

SavetheDate:September18from9to4

HiltonCharlotteUniversityPlaceFee:$60

RegistrationavailableinJune

NexttrainingwillbeSpring2019inEasternN.C.

Audience:NewAACs,Co‐AACsorBackupAACs

PleasenotethisisNOTforexperiencedAACs.

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Accreditation101:Team‐basedTraining

• Offeredbyrequestatyourlocalsite(Jan.‐MayandOct.‐Nov.only)

• Forgroupsof15‐20• STRONGLYencouragepartneringwithneighboringLHDs

• Request“NCLHDAtechnicalassistance”fromyourlocalAHEC

AnnualSkills‐buildingWorkshop

SavetheDate:BuildingYourAccreditationToolboxAugust14‐15,2018SheratonImperialinDurham

RegistrationwillopeninJulywithanexpectedfeeof$150andstaterateguaranteeattheSheraton.

Sessions focused on sharing best-practice models and

addressing common challenges.

While aimed at AACs of all levels of experience, local

accreditation team members are also invited.

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AllcountiesinNorthCarolinahavebeenaccredited,andbyMay2018,all85willhavebeenreaccreditedatleastonce.

! Questions&Discussion?

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Thankyou.

AmyBelflowerThomas,MHA,MSPH,CPHNCLHDAAdministratoramy.b.thomas@unc.edu

(919)843‐3973

TheNorthCarolinaLocalHealthDepartmentAccreditationProgramispartoftheNorthCarolinaInstituteforPublicHealthattheGillings SchoolofGlobalPublicHealthattheUniversityofNorthCarolinaatChapelHill.

Activity30.6Cleaning,DisinfectionandMaintenance

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Activity30.6Cleaning,DisinfectionandMaintenance

Activity30.6Cleaning,DisinfectionandMaintenance

Language has been added to clarify that the Activity pertains to clinical, laboratory and environmental health field equipment.

Language was added to the Intent to clarify that the local health department must demonstrate they have the capacity to maintain accurate environmental health field equipment.

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Activity30.6Cleaning,DisinfectionandMaintenance

• Clarifies that a comprehensive equipment list should be included as part of the policies and procedures documentation.

• Types of equipment to include are listed, but it is ultimately up to the LHD to catalogue.

Activity30.6Cleaning,DisinfectionandMaintenance

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Activity30.6Cleaning,DisinfectionandMaintenance

Also, clarifies that training records should show where applicable staff were trained on the policies and procedures.

Activity30.6Cleaning,DisinfectionandMaintenance

Clarifies: what should be included in the policy/procedure:

relevant items to include,

who is responsible for cleaning and maintenance of each item,

how cleaning and maintenance will be performed,

when cleaning and maintenance will be performed, and

which and how staff are trained on requirements.

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Activity30.6Cleaning,DisinfectionandMaintenance

Key points: You can use whatever mechanism/method you

want to demonstrate cleaning/disinfection/ maintenance- just make sure it is evidence-based, per manufacturer recommendation, or based on common industry practice.

Who and how you train is up to you.

Activity30.6Cleaning,DisinfectionandMaintenance

Basically:1. Catalogue what equipment/service areas

you have

2. Have an (informed) plan for cleaning/disinfecting/ maintaining it, including who does it, when, how, etc.

3. Train relevant staff on your plan and keep the documentation

4. Do what your plan says and keep the documentation