authored & prepared by
www.redstar1.org
TRIBAL ACCREDITATION READINESS
GUIDEBOOK
& ROADMAP
SEPTEMBER 2013
Support for this guidebook was provided by a grant from the Robert Wood Johnson Foundation. www.rwfj.org.
1
CONTENTS
INTRODUCTION
INTRODUCTION.............................................................. pg. 3
Tribal Health Departments (THDs) are increasingly involved
in public health activities in rapid response to the changing
health needs of American Indian and Alaska Native communities. Tribes recognize that strengthening public health
infrastructure can generate resources and increase the efficiency and effectiveness of programs and services. A stronger Tribal public health infrastructure may lead to improvements in health outcomes and greater capacity to respond
to important public health issues.
BACKGROUND.............................................................. pg. 4-6
− What is public health?
− Tribal public health systems
− Benefits of Public Health Accreditation
− Eligibility for Public Health Accreditation
− PHAB Accreditation Application Process
WHAT’S IN THE GUIDE?............................................... pg. 7-9
− Readiness AREAS
− Readiness PHASES
− Readiness Areas and Phases - Three Sisters and the Harvest
− How To Use The Accreditation Readiness Roadmap
EARLY PHASE – INFORMATION GATHERING............. pg. 10-18
IMPLEMENTATION PHASE – PLAN INTO ACTION......... pg. 25-27
Organizational Readiness ........................................ pg. 10-11
− Accreditation Team
− Leadership Support
− Cost
− Electronic Filing System
Organizational Readiness............................................pg. 25
− Accreditation Team
− Leadership Support
− Cost
− Electronic Filing System
Public Health Performance....................................... pg. 12-15
− Self-Study
− Engaging Tribal Administration and Departments
− Quality Improvement
Public Health Performance..........................................pg. 26
− Self-Study
− Engaging Tribal Administration and Departments
− Quality Improvement
Improvement Planning............................................. pg. 16-18
− Community Health Assessment
− Community Health Improvement Plan
− Organizational Strategic Plan
Improvement Planning................................................pg. 27
− Community Health Assessment
− Community Health Improvement Plan
− Organizational Strategic Plan
PLANNING PHASE – DETERMINING THE APPROACH.... pg. 19-24
APPLICATION READY.................................................... pg. 28
Organizational Readiness............................................. pg. 19
− Accreditation Team
− Leadership Support
− Cost
− Electronic Filing System
Organizational Readiness............................................pg. 28
− Accreditation Team
− Leadership Support
− Cost
− Electronic Filing System
Public Health Performance....................................... pg. 20-21
− Self-Study
− Engaging Tribal Administration and Departments
− Quality Improvement
Public Health Performance..........................................pg. 28
− Self-Study
− Engaging Tribal Administration and Departments
− Quality Improvement
Improvement Planning............................................. pg. 22-24
− Community Health Assessment
− Community Health Improvement Plan
− Organizational Strategic Plan
Improvement Planning................................................pg. 28
− Community Health Assessment
− Community Health Improvement Plan
− Organizational Strategic Plan
Public health accreditation is a process by which a THD can
measure its performance against a set of national standards.
The accreditation process itself is an opportunity to advance
public health quality and performance within THDs; it provides
a way for THDs to identify performance improvement opportunities, bolster management practices, develop leadership, and strengthen important relationships in the community. The Public Health Accreditation Board (PHAB) is a
non-profit organization that serves as the accrediting body.
The vision of PHAB is a high-performing governmental public
health system comprised of accredited Tribal, local, and state
public health departments that will make the United States
a healthier nation overall. To achieve this vision, Tribal, state
and local health departments must work together to achieve
greater health outcomes.
The Tribal Accreditation Readiness Guidebook and Roadmap
is designed to help THDs navigate the multifaceted accreditation process. The approach described in this guidebook
was developed based on experience working with diverse
THDs nationwide and is designed to provide general recommendations. We recognize that THDs are diverse in terms
of size, structure, governance, population, jurisdiction and
partners, and adapting the recommended approach, or using
alternate approaches, may be preferable. The guidebook
includes references to information and technical assistance,
so you and your team can explore and use other tools and
resources to help your THD achieve its objective.
We hope this guidebook serves as a helpful tool to plan,
organize and benchmark your accreditation readiness
activities, and that the roadmap makes it easy to monitor
your progress through the phases of readiness.
This guidebook is intended to supplement PHAB’s materials
and documents, not to replace them. THDs are encouraged
to reference PHAB materials and documents often.
Public health accreditation is more than just a destination;
it’s a journey, and there are many ways to reach your journey’s
end. We hope the Tribal Accreditation Readiness Guidebook
and Roadmap will be a helpful companion along the way!
Pursuing public health accreditation is no small feat. It is a
complex process that includes many steps and requires a
significant investment of human and financial resources.
“Public health accreditation is more than just a destination; it’s a journey, and there are many ways to reach
your journey’s end. We hope the Tribal Accreditation Readiness Guidebook and Roadmap will be a helpful
companion along the way!”
CONCLUSION................................................................ pg. 29
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3
BACKGROUND
WHAT IS PUBLIC HEALTH
Public health is often defined as promoting, protecting and
improving the health of communities through education,
promotion of healthy lifestyles, disease prevention, and
surveillance and response. The field of public health has
evolved over the last few decades to include a framework of
essential services, and now, accrediting governmental public
health departments. In 1994, the Core Public Health Functions Steering Committee developed a framework for describing public health activities that should be addressed in all
public health systems. This framework is referred to as the
10 Essential Public Health Services. These essential services
are the basis for the Center for Disease Control and Prevention’s (CDC) National Public Health Performance Program, as
well as national public health accreditation.
10 ESSENTIAL PUBLIC HEALTH SERVICES 1
1.
Monitor health status to identify and solve
community health problems.
2.
Diagnose and investigate health problems and
health hazards in the community.
3.
Inform, educate, and empower people about
health issues.
4.
Mobilize community partnerships and action to
identify and solve health problems.
5.
Develop policies and plans that support individual
and community health efforts.
6.
Enforce laws and regulations that protect health and
ensure safety.
7.
Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable.
8.
Assure competent public and personal health care
workforce.
9.
10.
Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
Research for new insights and innovative solutions
to health problems.
Public health practice is most effective when it includes a
systems approach. A systems approach is one where
multiple stakeholders, governmental and non-governmental entities, work in partnership to assure conditions in
which people can be healthy. Such conditions often include,
but are not limited to, social, economic, educational and
environmental factors that either contribute to or hinder
community wellness.
It is important to identify and document such partnerships,
both internal and external to the Tribe; doing so is critical for
formalizing relationships, clarifying roles and responsibilities,
and describing the manner in which specific public health
functions are coordinated and carried out. Understanding
the Tribal public health system at the local level makes it
easier to identify the key partners you will want to engage
in various activities throughout the accreditation process.
TRIBAL PUBLIC HEALTH SYSTEMS
Tribal health services are often coordinated through
complex systems made up of various stakeholders. These
stakeholders may include local and state health departments, the Indian Health Service, Tribally Led Organizations,
such as Area Indian Health Boards and Inter Tribal Councils,
and Tribal Epidemiology Centers. The degree to which
services are coordinated with other stakeholders varies by
Tribe, region, and type of service or activity.
System partner engagement in the accreditation process is
critical because the standards address THD capacity to work
with its partners to provide a range of core public health
functions and services. Such functions include, but are not
limited to, environmental public health, health education
and promotion, chronic disease prevention and control,
communicable disease, injury prevention, material and child
health, access to clinical services, and public health laboratory services. Since many programs and services are delivered
in partnership and/or in coordination with others, it is important to include Tribal public health system partners in
planning and performance improvement activities. Keep in
mind that documentation explaining how the process,
program or intervention is delivered will be required; this
holds true whether public health activities are provided directly by a THD, or by a partner or stakeholder.
In Tribal public health systems, many entities work together to provide critical health functions and activities to
support community health (see Diagram 1). Given that
each Tribal system is unique, the scope and level of coordination that occurs between a THD and its partners will
vary. PHAB recognizes that public health activities may be
provided directly by the THD or by another organization
or entity through formal arrangements, such as contracts,
compacts or memoranda of understanding.
DIAGRAM 1.
TRIBAL HEALTH
SYSTEMS
Tribal
Gov
Tribal
Health
Dept/Clinic
TLOs/TECs
Community
Leaders
Many THDs provide services such as mental health, substance
abuse prevention and intervention, primary care, and human
and social services. Because these activities are not considered
core public health services under the Essential Public Health
Services framework used for accreditation purposes, PHAB’s
scope of accreditation authority does not extend to these
areas. Therefore, documentation from these program areas
is not generally accepted for public health accreditation. This
is also true for documentation from health care facilities,
professional licensing programs, and health care financing
systems (e.g., Medicaid).*
COMMUNITY
HEALTH
Tribal
Colleges
BENEFITS OF PUBLIC HEALTH ACCREDITATION
Public health accreditation is a voluntary process that seeks
to advance performance and improve quality within health
departments. Accreditation documents the capacity of a
THD to deliver the three core functions of public health—assessment, policy and assurance—as well as the Ten Essential
Public Health Services. Accreditation is based on a set of
standards and measures, which were developed in consultation with Tribes and Tribal representatives through a workgroup of Tribal public health professionals, the Tribal Public
Health Accreditation Advisory Board, as well as a national
Tribal call for input conducted by the National Indian Health
Board.
Public health accreditation offers many potential benefits,
including, but not limited to:
• Strengthening self-determination by providing a
frame work for Tribes to improve public health
infrastructure and build capacity
• Identifying and acting on improvement opportunities
in order to deliver high quality public health services to
all community members
• Strengthening leadership and employee performance within the THD
• Building stronger partnerships with the community, public health practitioners, and other essential
stakeholders
• Potential access to new funding sources for various activities (such as quality and performance
improvement) and opportunities to pilot new
programs and processes
Other benefits may be identified as the public health accreditation initiative grows and PHAB’s accreditation process
continues to develop and improve through its own continuous quality improvement efforts.
Federal
Agencies
Private
Industry
Local/State
Health
Depts
*For more information, review the PHAB’s Accepted Program Areas for PHAB Documentation, December 2012.
http://www.phaboard.org/wp-content/uploads/Accepted-Program-Areas-for-PHAB-Documentation-December-2012.pdf.
1. Centers for Disease Control and Prevention. National Public Health Performance Standards Program, 10 Essential Public Health Services.
http://www.cdc.gov/nphpsp/essentialservices.html (Accessed April 2013).
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BACKGROUND
ELIGIBILITY FOR PUBLIC HEALTH ACCREDITATION
One of the first questions to ask when considering
accreditation is: ”Is the THD eligible to be accredited?” PHAB’s
definition of an eligible THD is:
A Tribal health department is defined, for the purposes of
PHAB accreditation, as a federally recognized Tribal
government1, Tribal organization, or inter-Tribal consortium,
as defined in the Indian Self-Determination and Education
Assistance Act, as amended. Such departments have jurisdictional authority to provide public health services, as evidenced by constitution, resolution, ordinance, executive order,
or other legal means, intended to promote and protect the
Tribe’s overall health, wellness and safety; prevent disease;
and respond to issues and events. Federally recognized Tribal
governments may carry out the above public health functions
in a cooperative manner through formal agreement, formal
partnership, or formal collaboration.*
* As evidenced by inclusion on the list of recognized Tribes mandated
under 25 U.S.C. § 479a-1. Publication of List of Recognized Tribes.2
In other words, a THD, organization or consortium is considered eligible if it meets all of the following criteria:
• THD is a government function of one or more federally
recognized Tribes to provide public health services within its jurisdiction(s).
• THD has jurisdictional authority to promote and protect
the Tribe’s health, wellness and safety, prevent disease,
and respond to issues and events of public health importance.
• THD’s jurisdictional authority is evidenced through legal
action by the Tribe’s governing authority, such as a Tribal
Chair and/or an entity, such as Tribal Council.
WHAT’S IN THE GUIDE
A THD may be a government function as described above;
however, to be eligible for accreditation, its authority must
be formally evidenced, documented, or supported in the
Tribal constitution or other legal document (such as by
resolution, ordinance, executive order, or other legal
means). If such documentation does not exist, it must be
developed and approved as a legal document of the Tribe(s),
and then submitted with the accreditation application.
For more information about documentation of a THD’s
authority to conduct public health activities, reference
PHAB’s Standards and Measures Version 1.0, Domain 12,
standard 12.1, measure 12.1.1A.
PHAB ACCREDITATION APPLICATION PROCESS
The PHAB accreditation application process can feel overwhelming for many. The PHAB accreditation process includes seven primary steps: 1) Pre-Application, 2) Application, 3) Documentation Selection and Submission, 4) Site
Visit, 5) Accreditation Decision, 6) Reports, and
7) Reaccreditation3. For each step of the PHAB accreditation process, the THD must complete a set of activities. It
will be important to learn about the timing and requirements for each step in order to align the THD’s planning,
implementation and application readiness activities with
the PHAB accreditation process, especially for steps 1
through 4.
Planning and preparing for public health accreditation is a
complex process that includes many steps. The complexities
are due, in large part, to accreditation readiness not being a
linear process where one step follows another. On the contrary, many tasks need to be undertaken concurrently, and
in some cases, synergistically. By synergistically, we mean
tasks and/or activities completed cooperatively and in coordination, in order to achieve a better result than if they were
completed independently.
The guidebook is intended to supplement, not replace, PHAB’s
materials and documents describing the accreditation process
and requirements. THDs are encouraged to reference PHAB
materials and documents often.
The Tribal Public Health Accreditation Guidebook and
Roadmap will help a THD navigate the process of preparing
for accreditation by breaking it down into understandable
steps, identifying opportunities to bring synergy to your
planning and activities, and by providing ample guidance
along the way. We have included references throughout,
including sources of information, technical assistance and
tools that may be useful in achieving your objective.
• Organizational Readiness is the cornerstone to readiness
efforts. It focuses on Tribal Leadership and the resources you
will need to plan and prepare for accreditation. Leadership
support from the Tribal Health Department Director, Tribal
Council, and Health Committees, among others, is critical to
facilitating system-wide engagement in the process.
An important feature of this guidebook is the Accreditation
Readiness Roadmap, which divides the main activities you
must do to prepare for accreditation into three Readiness
Areas:
Organizational Readiness, Public Health Performance
and Improvement Planning
Each Readiness Area includes a description of the primary
activities, which are organized by Readiness Phases:
Early Phase, Planning Phase, Implementation Phase,
and Application Ready
The PHAB Guide to National Public Health Accreditation
provides a detailed description of activities associated with
each step, as well as the timing. Rather than describe that
process here, we encourage you to become familiar with
PHAB’s Guide and other supporting material.
The roadmap includes every activity listed in the PHAB
Readiness Checklists4 , as well as other activities that may be
helpful in preparing and organizing for accreditation. The
roadmap is not intended to prescribe what and how specific activities should be completed, but rather to offer THDs
an approach to planning and monitoring the completion of
accreditation readiness activities. THDs are diverse in terms
of size, structure, governance, population, jurisdiction and
partners, so adapting the recommended approach or using
alternate approaches altogether may be necessary.
2. PHAB (2011). Acronynms and Glossary of Terms Version 1.0. http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.02.pdf
3. PHAB (2011). Guide to National Public Health Department Accreditation. http://www.phaboard.org/wp-content/uploads/PHAB-Guide-to-National-Public-HealthDepartment-Accreditation-Version-1.0.pdf
RESOURCE!
A Tribal Public Health Code is a viable means for documenting authority. It can also be a good tool for addressing other standards and measures related to public health law. An excellent resource for developing a
public health code is: ‘The Turning Point Model State Public Health Act: A Tool for Assessing Public Health
Laws presented by the Public Health Statute Modernization National Excellence Collaborative.’
http://www.turningpointprogram.org/Pages/pdfs/statute_mod/MSPHAfinal.pdf
READINESS AREAS
The public health accreditation Readiness Areas, as used in
this guidebook, include three main categories where a THD
can focus its efforts when preparing for accreditation:
• Public Health Performance focuses on the THD infrastructure, including processes, competencies, relationships, and
resources. This infrastructure enables performance of public
health’s core functions and essential services in the community.
• Improvement Planning focuses on the three accreditation
prerequisites, a community health assessment (CHA), a community health improvement plan (CHIP), and an organizational strategic plan, as an overall improvement planning
process. The CHA provides information about health status
to inform the CHIP, and the strategic plan addresses improvements in the THD’s internal operational capacity.
4. PHAB (2011). National Public Health Department Accreditation Readiness
Checklists, Version 1.0. http://www.phaboard.org/wp-content/uploads/
National-Public-Health-Department-Readiness-Checklists.pdf
RESOURCE!
Visit the PHAB website to access the Guide to National Public Health Department Accreditation.
http://www.phaboard.org/wp-content/uploads/PHAB-Guide-to-National-Public-Health-Department-Accreditation-Version-1.0.pdf
6
7
WHAT’S IN THE GUIDE
• Application Ready occurs when planning and implementation efforts are completed and PHAB application requirements
have been met. Required documents are ready to be submitted to PHAB based on the accreditation application process
guidelines.
READINESS AREAS AND PHASES
THREE SISTERS AND THE HARVEST
The activities you will engage in as you prepare for accreditation are often interdependent and connected across Readiness
Areas. When connections between and among activities are
identified, and the connected activities are conducted in
coordination with one another, the outcome can lead to
Tribal public health functions and services that are more
meaningful, strategic and impactful.
THE COLUMNS
Each Readiness Area is divided into subcategories to help
you organize the many activities you will need to do for each
of the three main Readiness Areas. The chart below shows
these subcategories for each area.
ORGANIZATIONAL
READINESS
Squash provides the ground cover to ensure the corn and
beans have the nutrients and moisture required to thrive
and bear the most fruit. Likewise, Improvement Planning
is a process aimed at making community and organizational improvement decisions based on accurate and recent
data. Data-based decision making will ensure that programs
and services are meaningful, purposeful and strategic, thus
providing an environment that supports planned health
improvements efforts.
−
−
−
−
The three sisters are referenced throughout the guidebook
to remind us of the value of companion planting as a
metaphor for the value of creating synergy and coordination within our public health activities.
DIAGRAM 2. PHASES OF READINESS AND GROWTH CYCLE
Ea
rly
Harvest
Growth
−
−
−
Planting
the
Seed
Germination
IMPROVEMENT
PLANNING
Self Study
Tribal Administration and
Departments
Quality Improvement
USING THE GUIDEBOOK AND ROADMAP TOGETHER
The guidebook describes each benchmark outlined in the
roadmap. Topics in the guidebook follow the same order as
the roadmap, beginning with the first row, Early Phase, and
progressing through Organizational Readiness and its subcategories before going on to Public Health Performance.
Once the summary of Early Phase completes with the Improvement Planning, the guidebook topics begin explaining
the next row in the roadmap, which describes the Planning
Phase. The guidebook continues along in the same manner
through the Implementation and Application Ready Phases
of the roadmap.
e
as
Ph
n
y
ad
Re
Accreditation Team
Tribal Leadership
Cost
Electronic Filing System
REFERENCE ROADMAP FOLD OUT
LOCATED IN THE CENTER OF THIS GUIDE
PUBLIC HEALTH
PERFORMANCE
THE ROWS
Readiness Areas are divided into four Readiness Phases: 1)
Early Phase; 2) Planning Phase; 3) Implementation Phase;
and 4) Application Ready. Each Readiness Area subcategory
includes benchmarks with specific indicators for each Readiness Phase. You can use these benchmarks to monitor
progress through each phase, as well as the completion of
activities required throughout the PHAB accreditation preparation and application process.
The phases of planting, germinating, growing, and harvesting the three sisters is likened to the four Readiness Phases,
as illustrated in Diagram 2.
Imp
le m
en
ati
t
You might find the analogy of the three sisters – corn, beans
and squash – helpful in understanding what is meant by interdependent and connected. Many Tribes have a long
tradition of planting and harvesting the three sisters together because of the synergistic relationship between the
three. When planted and nurtured together, the three form
an interdependent relationship that allows them to thrive in
unison and provide higher yields that benefit community
health. This is commonly referred to as companion planting.
The harvest that results from companion planting is more
abundant than when the seeds are planted independently
and separately from one another.
Public Health Performance can be likened to beans, as their
vines grow up along the corn stalk, stabilizing the corn and
making it less vulnerable to weather and other elements.
Quality public health performance can provide opportunities to stabilize Tribal public health infrastructure, bolster
management practices, and develop leadership. Bean
plants also provide nitrogen to the soil used by the other
plants in the way the public health performance can benefit
and strengthen the organization and community health
improvement planning process.
se
• Implementation Phase is when plans are put into motion,
tasks are completed, and vital documents are developed,
gathered, and reviewed. Progress is monitored and plans
are modified as challenges and opportunities are encountered.
The Accreditation Readiness Roadmap was designed to help
THDs monitor progress. Each segment of the roadmap includes benchmarks to identify progression through the
Readiness Phases by Readiness Area. Benchmarks listed in
the roadmap address all items included on the PHAB
Readiness Checklists.5
-
Community Health Assessment
Community Health
Improvement Plan
Organizational Strategic Plan
As you become more familiar with the guidebook and
roadmap, we recommend you do the following tasks:
− Read through the roadmap and understand the general
elements of each subcategory by Readiness Phase.
− Assess the THD against the benchmarks identified within
each subcategory at each phase of readiness.
− Implement or adapt the strategies identified in the guidebook.
− Monitor progress through each phase by subcategory and determine whether the THD has successfully transitioned from one phase to the next. (THDs will advance more quickly through phases in some
subcategories than others).
− Reference PHAB guidance materials often to ensure your
efforts address the requirements as identified by PHAB.
− Adjust plans and activities as needed.
Reading through the guidebook and roadmap will help a THD
understand the timing of particular readiness activities, how
to plan concurrent activities based on information gathered,
and how to identify and create connections within a complex
process.
ha
• Planning Phase is a time for developing plans to complete
activities that address accreditation requirements and benchmarks identified in the roadmap. Plans should include timelines for completion, person(s) responsible, and approaches
to monitoring progress.
HOW TO USE THE ACCREDITATION READINESS ROADMAP
gP
• Early Phase references a time of information gathering
and sharing. It is a time of learning about accreditation requirements and infrastructural needs. It includes, informing
and educating leadership, identifying who needs to be
engaged in the process, and forming teams to address specific readiness activities.
Like corn, Organizational Readiness can serve as a pillar
for public health performance. Engaging Tribal Leadership
will ensure that public health performance has the support
and resources it needs to formalize internal and external
partnerships, develop policies and plans, and develop an
infrastructure to support quality services that effectively
address the most pressing needs of the community.
Ap
pli
ca
tio
READINESS PHASES
Accreditation readiness activities are organized along a
continuum that is divided into four primary readiness phases:
on
Ph
ase
Pla
nn
in
8
5. PHAB (2011). National Public Health Department Accreditation Readiness Checklists, Version 1.0.
http://www.phaboard.org/wp-content/uploads/National-Public-Health-Department-Readiness-Checklists.pdf
9
EARLY PHASE INFORMATION GATHERING
ORGANIZATIONAL READINESS
ORGANIZATIONAL READINESS
The Early Phase of accreditation readiness focuses on gathering information and sharing it with others. During this phase,
key THD staff and leadership learn about the accreditation
requirements, as well as the THD’s infrastructural capacity
and current public health performance activity. Be sure to
share information with Tribal Leadership, THD staff, and other
programs within the Tribe to garner support and plant the
seed for future engagement. Also, be sure to identify who to
engage in the accreditation process, how to engage them
and when. We strongly recommend working as a team
because it facilitates greater commitment and accountability among the staff to complete the accreditation readiness
process resulting in shared success.
ORGANIZATIONAL READINESS
Organization Readiness is the cornerstone to accreditation
readiness efforts. It is similar to corn in that it provides the
structure for public health performance just as corn stalks
provide the structure for beans to climb. Organizational
Readiness includes four primary components:
1) Accreditation Team
2) Leadership Support
3) Cost
4) Electronic Filing System
Choosing the right people to do the job, ensuring leadership
support, allocating financial resources, and putting the appropriate electronic filing system in place will help provide
the structure needed to address public health performance
improvement needs and facilitate a community health and
organizational improvement planning process.
Accreditation Team
Once a THD decides to pursue accreditation, we recommend
that the director appoint an Accreditation Coordinator(s) to
oversee and coordinate the accreditation process and lead
the Accreditation Team. Be sure to give the name and contact
information of the Accreditation Coordinator to PHAB, as he/
she will serve as the primary point of contact.
Next, the THD director and the Accreditation Coordinator
need to identify the health department staff members who
will comprise the multidisciplinary accreditation team.
Establishing an Accreditation Team to oversee and monitor
accreditation readiness activities is strongly recommended.
The formation of an Accreditation Team usually occurs
after the THD has gathered enough information to understand the purpose, requirements, benefits and costs of the
process. This team may include members of senior management, middle management, and frontline program
employees. This is the perfect time to take account of the
talents, strengths, and skills of THD staff. When building
your team, consider individuals who are objective, organized, and effective communicators, as well as those who
have strong leadership and credibility with staff, are effective delegators, and are subject matter experts. The Accreditation Coordinator(s) is responsible for leading the
team and planning the various activities throughout the
Readiness Phases.
executive. The appointing authority must provide a letter of
support to include with the PHAB application when it is ready
for submission.
The definition of a governing entity is “the individual, board,
council or other body with legal authority over the public
health functions of a jurisdiction, region, district or reservation as established by state, territorial, or Tribal constitution
or statute, or by local charter, bylaw, or ordinance as authorized by state, territorial, Tribal, constitution or statute.” 6
For THDs, this may be the Tribal Council, health oversight
committee or other health board. We strongly encourage
that members of the governing entity view the PHAB online
orientation. If that is not possible, an alternative approach
would be to provide an in-house orientation.
Cost
There are costs associated with preparing for accreditation,
including an application fee. The application fee for accreditation is based on the size of the population the THD serves
and can be paid all at once, or in incremental payment plans.
The THD determines the population size. Unlike counties
and states where the population is based on those
individuals who reside within a geographic boundary, some
Tribes will have unique considerations that may be dependent
on a number of factors (such as jurisdictional area, which
may or may not be defined solely by Tribal lands) and who
they serve (i.e. Tribal members, Tribal members and spouses,
non-Tribal members who access services).
Tribal Leadership
It is essential to engage Tribal Leadership in accreditation
efforts from the beginning. During the early stages be sure
to inform them about accreditation, its purpose, benefits,
costs and general requirements. Tribal Leadership support
will be important as you a) engage stakeholders who are
both internal and external to the Tribe, b) formalize partnerships through memoranda of understanding, c) document the role of governance in public health, and d) request
THD budget allocations to cover the costs associated with
accreditation (e.g. PHAB application fee, infrastructure
development to address accreditation requirements, and
technical assistance for various aspects of accreditation
preparation).
In addition to the application fee, the Accreditation Team
and THD director must consider other costs, such as the cost
for technical assistance, training, information technology,
and infrastructure development. These costs will be largely
dependent on the THD’s current capacity, infrastructure and
the in-house expertise available for addressing the
accreditation requirements. The team will most likely have
a better sense of the resources it needs as it completes the
Planning Phase.
Electronic Filing System
PHAB requires that all documentation and other application
materials be submitted electronically. Thus, THDs must be
able to organize and store documentation based on the PHAB
standards and measures within an electronic filing system.
To determine whether the Tribe has the infrastructure and/
or capacity to develop this filing system, we recommend that
the Accreditation Coordinator meet with IT staff to discuss
the requirements of accreditation. Explain the need for an
electronic filing system that can serve as a repository for
documentation. Electronic files will typically be in Word,
Excel and PDF formats and must be accessible during the
accreditation readiness process, and also during the PHAB
site visit. There may be other requirements to explore with
the IT department, such as whether to purchase a filing
system, such a Microsoft Sharepoint, or the need for a secure
server where files can be safely stored and accessed by
multiple users.
PHAB uses the terms “appointing authority” and “governing entity” to refer to the administrative and legislative
aspects of governance. Appointing authority is typically
the person(s) who has the authority to appoint the THD
director. In most cases, this will be the Tribal Chair or chief
RESOURCE!
PHAB has developed a coordinator handbook to help determine who is best suited for the position.
http://www.phaboard.org/wp-content/uploads/PHAB-Accreditation-Coordinator-HandbookVersion-1.0.pdf
10
6. PHAB (2011). Acronynms and Glossary of Terms Version 1.0.
http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.02.pdf
11
EARLY PHASE INFORMATION GATHERING
PUBLIC HEALTH PERFORMANCE
Public health performance refers to the THD’s capacity to
leverage resources and coordinate services, alone and in
partnership with their system partners. It also includes, the
THD’s ability to effectively and efficiently deliver core functions and essential services of public health in the community. Accreditation is based on the premise that a high-performing governmental public health system leads to better
health outcomes. Just as bean vines stabilize the corn plants,
making them less vulnerable to wind and other elements,
public health performance improvement can stabilize Tribal
public health infrastructure, bolster management practices,
develop leadership, and strengthen important relationships
in the community. The components addressing public health
performance in this guide include:
1) Self-Study
2) Engaging Tribal Administration and Departments
3) Quality Improvement
A self-study is an effective way for a THD to evaluate its
performance, functions and services based on PHAB’s standards and measures. Engaging key stakeholders, such as
Tribal administration and other departments, in the self-study
process is essential to understanding how the system partners
are working together as a whole to deliver important services. Through the self-study process, the health department’s
strengths and opportunities for improvement are easily
identified. In addition, improvement areas requiring a quality
improvement (QI) process can be incorporated into the development of a QI plan.
Self-Study
An important element of the accreditation process is conducting an organizational self-study based on the PHAB standards
and measures. The self-study is an excellent way to identify
strengths and opportunities for improvement in THD performance. Although this process can be intimidating for some,
it is an excellent way for the Accreditation Team and other
participants, to become familiar with the PHAB standards
and measures. It can also give the team a better sense of
whether the THD is ready to consider accreditation as a
short- or long-term goal.
PUBLIC HEALTH PERFORMANCE
Planning for a self-study is critical to its success and is a
starting point for documenting the capacity of the THD
through a collaborative process. Determining who will
participate and the approach on how to engage in self-study
are important first steps. We recommend that the Accreditation Team identifies the most appropriate individuals to participate in the self-study based on the general
content of each of the PHAB domains.
creditation preparation. The spreadsheet is not designed to be a long-term management or document
organization tool, but it can be used until your own
internal system is created.
The Self-Assessment Workbook for Tribal Health Departments is an Excel based tool and is a great instrument for facilitating a collaborative approach to reviewing the standards and measures. It also useful
for identifying and noting potential documentation,
Based on our experience conducting self-studies with
various THDs, we have found individuals tend to work in
areas that cut across certain domains. As a result, we have
identified common “domain groupings” to help guide your
planning. This is a great way to identify small teams (or
domain teams) who can take the lead in addressing the
standards and measures within their assigned domain. In
the case of a small THD, where it may not be possible to
have multiple teams, conducting a review by domain groupings, rather than sequentially, can facilitate the process by
allowing the team to focus on similar content areas and
public health functions.
TABLE. 1 - SAMPLE DOMAIN GROUPINGS
See Table 1. Sample Domain Groupings, which shows how
a THD can group the domains. When creating groupings,
consider the THD’s organizational chart, positions within
the department, and the roles and responsibilities of participating staff members. Again, this is just an example.
THDs may create different groupings depending on how
the THD is structured and the roles and responsibilities of
key staff.
If you do decide to form domain teams, be sure to designate
a lead who will be responsible for convening the team and
reporting back to the Accreditation Team. Depending on
the size of the THD, some individuals may serve on more
than one domain team. After participants are identified,
it will be important to share the THD’s interest in accreditation and orient them to the accreditation process.
Domains 1 and 2: Surveillance, Investigation
and Environmental Public Health Hazards
Domains 3, 4, 7, 10: Health Education,
Promotion, Prevention and Evidence-Base
• Domain 1: Conduct and disseminate
assessments focused on population health
status and public health issues
• Domain 2: Investigate health problems and
environmental public health hazards to
protect the community
• Domain 3: Inform and educate about public
health issues and functions
• Domain 4: Engage with the community to identify and address health problems
• Domain 7: Promote strategies to improve
access to health services
• Domain 10: Contribute to and apply the
evidence base of public health
Domains 5, 6, 12: Policies, Plans, Laws
and Governance
Domains 8, 9 and 11: Workforce, Performance
Management, QI and Administration
• Domain 5: Develop public health policies
and plans
• Domain 6: Enforce public health laws
• Domain 12: Maintain capacity to engage the
public health governing entity
PHAB has created a PHAB Standards and Measures Version
1.0 Document Selection Spreadsheet in Excel. The spreadsheet is an excellent tool for managing the process of
documentation selection during the early stages of ac-
RESOURCE!
There are two self-study tools based on the Tribal standards and measures:
- Self-Assessment Workbook for Tribal Health Departments (Excel format)
www.http://www.instituteforwihealth.org/tribal.html
- Tribal Health Department Self-Study Tool: Tribal Health Department Capacity Assessment for
Accreditation Preparation (Fillable PDF format)
and/or partners to engage in the process. The workbook includes a field where the self-study team can
input a score to rate a THD’s capacity to address each
measure. After completing the self-study, the Excel
file automatically calculates the average score for each
domain and standard, and produces a radar chart illustrating the overarching strengths and areas of
improvement identified by domain.
• Domain 8: Maintain a competent public
health work force
• Domain 9: Evaluate and continuously im
prove processes, programs and
interventions
• Domain 11: Maintain administrative and
management capacity
RESOURCE!
The resources listed below should be used in conjunction with the full PHAB Standards & Measures and the PHAB Guide to National Health Department Accreditation.
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-DocumentationSelection-Spreadsheet-Version-1.01.xlsx
12
13
EARLY PHASE INFORMATION GATHERING
PUBLIC HEALTH PERFORMANCE
DIAGRAM 3. Self-Assessed Capacity by PHAB Domain
DIAGRAM 3. Self-Assessed Capacity by PHAB Domain is a
sample radar chart based on a health department’s self-study
scores. Based on the chart, this health department was
strongest in the areas of community engagement, access to
services, and administrative capacity. Areas of greatest need
include investigation, community education, law enforcement
and using evidence-based practices. The information collected in self-study can be used to inform the development
of the THD’s strategic plan, a prerequisite for accreditation.
It can also be used to identify QI projects to include in a QI
Plan, which is a requirement in Domain 9. This is discussed
in more detail in the Planning Phase of the guidebook.
Engaging Tribal Administration And Departments
Engaging departments and programs outside of the health
department, but within the Tribe, is critical during the early
stages of accreditation preparation. Not only is bringing in
individuals from outside the THD necessary when addressing
various standards and measures, it can help other departments better understand and appreciate how working in
partnership can strengthen services, improve coordination,
achieve shared goals, leverage resources and increase overall
productivity.
PUBLIC HEALTH PERFORMANCE
Participation of Tribal administration and/or departments in
the self-study should be based on experience and expertise,
as well as their role as a public health system partner. Understanding their roles and functions can help a THD determine where it is best to engage them by aligning their role
with the content and documentation requirements of the
standards and measures. The more familiar the Accreditation
Team is with the PHAB standards and measures, the easier
it will be to determine the appropriate partners to engage
and where they can contribute most. Some examples of
departments and programs that a THD may choose to engage
are human resources, finance, facilities, IT, Tribal attorney
general, and public safety.
QI is increasingly used in the field of public health as a means
to improve performance and increase efficiencies. Creating
an organizational culture of QI can transform a THD’s shared
attitudes, beliefs, values and practices. Creating an organizational culture that embraces QI as a common practice for
performance improvement requires: leadership commitment;
the appropriate infrastructure to support QI, (such as a performance management system and QI plan); employee commitment; a customer focus; teamwork and collaboration;
and continuous process improvement.8 QI facilitates a team
approach to grow a strong community and customer focus,
and integrate purposeful, data based improvement processes within the THD.
It is a good idea to provide an orientation for participating
Tribal administration, departments and programs, so they
understand the purpose of accreditation, its benefits, their
role in supporting the effort, and the potential benefits to
the community at large. We recommend you give each
participant a written request to participate in the accreditation process. The request should include a clear and concise
description of the request, roles, responsibilities, and potential time commitment.
While QI is not a specific requirement of the accreditation
application process, it is addressed in Domain 9, which is
dedicated to performance management and QI. Standard
Quality Improvement
Quality Improvement (QI) is foundational to public health
performance improvement efforts and accreditation. QI in
public health can be defined as ‘the use of a deliberate and
defined improvement process…which is focused on activities
that are responsive to community needs and improving
population health. It refers to a continuous and ongoing effort
to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and
other indicators of quality in services or processes which
achieve equity and improve the health of the community.” 7
8. NACCHO (2013). Roadmap to a Culture of Quality Improvement: A Guide to Leadership and Success in Local Health Departments.
http://qiroadmap.org/culture-to-qi/foundational-elements-for-building-a-qi-culture/. Accessed August 12, 2013.
If, on the other hand, no organized QI effort exists, the
Accreditation Team will need to identify training opportunities, resource materials, and if necessary, a consultant
who can help initiate the process.
RESOURCE!
There are many high-quality resources available to help with QI efforts. We have had great luck with
“Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook”, developed by the
Michigan Public Health Institute. It provides an overview of QI fundamentals and a step-by-step approach
that uses the Plan-Do-Check-Act cycle. It also includes case studies from local health departments,
discusses how to build a culture of QI, and provides multiple resources for QI.
http://www.accreditation.localhealth.net/guidebook.htm
Other resources include:
•
•
•
7. Riley, W. et. al. (201). Defining quality improvement in public health. Journal of Public Health Management and Practice, 16 (1), 5-7.
RESOURCE!
For additional guidance, refer to the Tribal Health Department Self-Study Guide available at adapted from
NACCHO’s Guide to Organizational Self Study. www.redstar1.org/resources/
www.naccho.org/topics/infrastructure/accreditation/upload/Organizational-Self-Study-Guide.pdf
9.2 and its corresponding measures require the development and implementation of a QI Plan. Many THDs have
experience conducting QI within their clinical services and
may even have QI plans to maintain accreditation with
other accrediting bodies, such as Accreditation Association
for Ambulatory Health Care or Joint Commission on Accreditation of Healthcare Organizations. If this is the case,
you may need to expand QI efforts to include public health
services. It will be important to engage the manager or
staff responsible for THD performance improvement and/
or QI in accreditation readiness efforts, and in the development of a QI Plan.
•
•
14
NACCHO Roadmap to a Culture of Quality Improvement - http://www.qiroadmap.org/culture-to-qi/
National Network of Public Health Institute Public Health Performance Improvement Toolkit http://nnphi.org/tools/public-health-performance-improvement-toolkit-2
Association of State and Territorial Health Officials www.astho.org/Programs/Accreditation-and-Performance/Quality-Improvement/
Public Health Foundation www.phf.org/focusareas/pmqi/pages/default.aspx
Public Health Quality Improvement Exchange www.phqix.org
Each of these sites links to additional resources, training opportunities, case studies, samples from other health departments, and technical assistance offerings.
15
EARLY PHASE INFORMATION GATHERING
IMPROVEMENT PLANNING
For purposes of this guidebook, Improvement Planning includes the prerequisites for public health accreditation: 1)
community health assessment 2) community health improvement plan, and 3) organizational strategic plan. While the
three prerequisites are often discussed as three separate
documents, they also work together as a comprehensive
improvement process that positively affects community health
and the overall work of the THD. Much like squash provides
the ground cover to ensure the corn and beans have the
nutrients and moisture required to thrive and bear the most
fruit, Improvement Planning is a process aimed at improving
both community health outcomes and THD performance.
The CHA provides information about health status to inform
the CHIP, and the strategic plan addresses the THD’s internal
operational capacity building to support overall improvement
planning efforts. Viewing the three prerequisites as an overall
process ensures that decisions are based on current data,
and that programs and services are meaningful, purposeful
and strategic; thus providing a rich environment for planned
improvements to transpire. Such a process can help ensure
that:
1) Services provided are leading to better health outcomes
2) Programs and services are focused on health priorities that are aligned with Tribal, state and national priorities
3) Infrastructure and processes are in place to ensure high performance
4) Policies are in place to support health improvement
objectives
5) Stakeholders and leadership are engaged in the planning
and implementation of health improvement efforts
The three prerequisites must be completed in order to apply
for public health accreditation. Prerequisites must be current
and have been updated within the last five years. Be sure to
submit documentation of the three prerequisites along with
the PHAB application for accreditation. After the application
and prerequisites are submitted, PHAB will review the documents for completeness. Later, during the site visit and review
process, the prerequisites are reviewed again to determine
whether they meet the requirements as outlined in their
respective standards and measures.
IMPROVEMENT PLANNING
Engaging Tribal Leadership is an important part of the CHA
process. Be sure to inform leadership and seek the appropriate approvals, as needed, after you select a CHA model and
determine the approach you will be using. Obtaining appropriate approvals from Tribal Leadership may be required
because the CHA process often includes the collection of
primary data in the form of community surveys, focus groups
and interviews. The team may also collect secondary data
from various Tribal departments and partner agencies and
organizations. Having Tribal Leadership approvals will help
ensure the appropriate community protections are in place,
and also prevent potential challenges to accessing data,
data-sharing across programs and agencies, and/or reporting
data. Both the ITCA and Northwest Portland Area Indian
Health Board toolkits include guidance material for obtaining
Tribal Leadership approval and/or support.
Community Health Assessment
A Community Health Assessment (CHA) can be defined a
number of ways. Most definitions describe it as collaborative
process that includes regular and systematic collection,
analysis and dissemination of information on the health of
a community. PHAB describes CHA as:
“… a collaborative process of collecting and analyzing data and information for use in educating and mobilizing communities, developing priorities, garnering resources, and planning actions to improve
the population’s health.” 9
CHAs involve a multi-step process that engages Tribal and
community leadership, as well as the community at-large, in
identifying health concerns, prioritizing important health
issues based on data, and documenting and communicating
the results. Data collected and analyzed for the CHA, provide
important information about a community’s health status.
Data should include Tribal demographics, socioeconomic
characteristics, quality of life, behavioral factors, the environment (including the built environment), morbidity and mortality, and other social, Tribal, community, or state determinants of health status. It is important to note that CHA results
will serve as the basis for the Tribal community health improvement plan.
Once the appropriate approvals are obtained, the Accreditation Team can identify staff and stakeholders to serve on a
CHA Planning Team and/or participate in the CHA process.
Partners and/or stakeholders to consider are departments
and programs within the Tribe, as well as county, city, state,
and federal governmental agencies, non-profit organizations,
community coalitions, and others that work with the THD to
address health issues. Subcommittees or workgroups may
also be developed to focus on particular aspects of the
process, such as data collection and community engagement.
Once identified, it will be important to provide the team with
training on the chosen model, the overall approach, and the
PHAB CHA requirements.
When preparing to conduct a CHA, first identify the most
appropriate CHA model for the THD to use throughout the
process. Many models, approaches and toolkits exist for
conducting a CHA; however, few are specific to Tribes and
Tribal communities. Table 2. CHA Models (pg. 18) lists examples of models that can be used to guide the CHA planning
and implementation process. The first two listed in the table
are Tribally specific. The Inter Tribal Council of Arizona’s
(ITCA) Community Health Assessment for Public Health Accreditation: A Practical Guide and Toolkit was designed to
guide Tribes through the CHA process based on the PHAB
Standards and Measures Version 1.0. Whichever model you
choose, be sure to reference the measures and required
documentation that address CHA in Domain 1. Not all models
address the specific PHAB requirements. (See PHAB standard
1.1, measure 1.1.1 T/L for additional models)
Community Health Improvement Plan
Community health improvement planning is a collaborative
process that describes how the THD will work with its
partners to achieve measureable health improvements in
the community. PHAB defines a community health improvement plan (CHIP) as:
“…a long-term, systematic effort to address public health problems on the basis of the results of community health assessment
activities and the community health improvement process. This
plan is used by health and other governmental education and
human service agencies, in collaboration with community partners, to set priorities and coordinate and target resources. ” 10
It is a good idea to begin conceptualizing the CHIP approach
during the final stages of completing the CHA. Since setting
priorities is a critical component required in the development of both the CHA and CHIP, it is a good idea to identify strategies to engage community in priority setting for
both. This way you can dovetail community health priority setting for both the CHA and CHIP to support the
completion of both prerequisites. Refer to the PHAB Standards and Measures, Measure 5.2.1. for examples of models
that can be used.
Once the model and approach for the CHIP process has
been selected, the Accreditation Team can identify staff
and stakeholders to participate in the process. Emphasis
is placed on collaborating with public health system partners (outside of the health department) for planning. This
not only brings different perspectives into the process, but
it encourages a shared sense of responsibility during implementation. It also can foster stronger partnerships and
greater coordination of services, which leads to better
health outcomes. Regardless of which model you use, be
sure to provide the team with training on the chosen model
(including the overall approach) and the PHAB CHIP
requirements.
10. PHAB (2011). Acronynms and Glossary of Terms Version 1.0. http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.02.pdf
9. PHAB (2011). Public Health Accreditation Board Standards and Measures Version 1.0.
RESOURCE!
A nice tool for tracking progress and maintaining necessary quality during these processes is the document
“Recommendations on Characteristics for High-Quality Community Health Assessments and Community
Health Improvement Plans” developed by NACCHO. This resource includes a detailed checklist of tasks to
complete, as well as suggestions for writing the report narratives.
http://www.naccho.org/topics/infrastructure/CHAIP/chachip-online-resource-center.cfm
RESOURCE!
A community-friendly model that we find easy to follow is the Guide and Template for Comprehensive Health
Improvement Planning Version 2.1 developed by the Connecticut Department of Public Health, Planning and
Workforce. http://www.ct.gov/dph/lib/dph/state_health_planning/planning_guide_v2-1_2009.pdf
16
17
EARLY PHASE INFORMATION GATHERING
PLANNING PHASE GERMINATION
ORGANIZATIONAL READINESS
IMPROVEMENT PLANNING
The Planning Phase begins after you have planted the initial
seeds, gathered and shared information, obtained leadership,
and identified which models you will use. The THD is now
ready to determine its approach and make its plans as the
accreditation readiness seeds are germinating and taking
root. During the Planning Phase, a THD develops an overarching plan. This plan should include the benchmarks identified
in the Readiness Roadmap, as well as plans that address
specific activities, such as performance improvement, community health assessment, and quality improvement. Plans
that are developed during this time should include timelines
for completion, person(s) responsible, and approaches to
monitoring progress.
TABLE. 2 - CHA MODELS
Model
Organization
Community Health Assessment for Public Health Accreditation:
A Practical Guide and Toolkit
Inter Tribal Council of Arizona - www.itcaonline.com
Indian Community Health Profile Project Toolkit
Northwest Portland Area Indian Health Board
http://www.npaihb.org/images/resources_docs/Toolkit_Final.pdf
Mobilizing for Action through Planning and Partnerships (MAPP)
National Association of County and City Health Officials:
http://www.naccho.org/topics/infrastructure/mapp/
Community Health Assessment and Group Evaluation (CHANGE)
Centers for Disease Control and Prevention - http://www.cdc.gov/
healthycommunitiesprogram/tools/change.htm_
The Community Tool Box
University of Kansas http://ctb.ku.edu/en/tablecontents/chapter_1003.aspx
ACHI Community Health Assessment Toolkit
Association for Community Health Improvement
http://www.assesstoolkit.org/
Strategic Plan
Many THDs are familiar with the strategic planning process,
which often includes developing a vision, mission, goals and
objectives. PHAB’s ‘Glossary of Terms’ explains that,
The strategic plan must link with the THD CHIP and QI Plan.
An approach for creating such linkages is addressed in the
Planning Phase - Improvement Planning section of this guidebook.
“a strategic plan results from a deliberate decision-making
process and defines where an organization is going. The plan
sets the direction for the organization and, through a common
understanding of the mission, vision, goals, and objectives,
provides a template for all employees and stakeholders to
make decisions that move the organization forward.” 11
Much like the CHIP, the Early Phase of developing a strategic
plan includes identifying appropriate staff and stakeholders
to participate in the process. In some cases, all or some of
these participants may also be on the Accreditation Team.
You may want to consider engaging the governing entity, or
its members, in the planning process as it may help align the
strategic planning process with any efforts being undertaken
more broadly by the Tribe. After you identify who will participate, it may be helpful to find a facilitator who can assist
with the strategic planning process.
The planning process considers broad based information that
is based on assessments of the larger environment in which
a THD operates. Such assessments can include information
gathered in the self-study, community health assessment,
and an environmental scan of external events, trends and
other factors that may impact the THD or community health.
ORGANIZATIONAL READINESS – Accreditation Team
After completing the tasks listed in the Roadmap’s Early Phase
of Readiness, the Accreditation Team needs to revisit and
review the PHAB Guide to Accreditation and PHAB Readiness
Checklists, including 1) Initial Checklist, 2) Prerequisite Checklist, 3) Process Readiness Checklist, and 4) Organizational
Checklists. All elements listed in these four readiness checklists are included in the roadmap. As previously mentioned,
review these documents often. They provide important guidance on completing the various accreditation requirements.
As the Accreditation Team moves into the Planning Phase,
they can begin creating an “Accreditation Work Plan” that
outlines major activities, benchmarks and timelines for accountability and which also identifies who is responsible for
completing specific tasks. Once the Accreditation Team
creates a work plan and has a clear understanding of the
roles and responsibilities of various teams and individuals,
it is important to assess whether resources are available to
complete these activities. The Accreditation Team should
work with other teams and staff to identify technical assistance resources, training, consultants, and tools needed to
complete identified tasks. As resources are being secured,
and the THD Accreditation Work Plan is being developed,
the Accreditation Team can set a target date for submitting
the Statement of Intent (SOI) to PHAB. There is one (1) year’s
time between when a THD submits its SOI and when it must
submit its PHAB online application. If after one year, the THD
is not ready to submit the application, it will need to resubmit an SOI when it is ready to begin the accreditation process.
11. PHAB (2011). Acronynms and Glossary of Terms Version 1.0. http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.02.pdf
RESOURCE!
For additional guidance, refer to the Developing a Tribal Health Department Strategic Plan:
A How-To-Guide, adapted from the NACCHO Developing a Local Health Department Strategic Plan:
A How-To Guide. www.redstar1.org/resources.
www.naccho.org/topics/infrastructure/accreditation/upload/StrategicPlanningGuideFinal.pdf
See Application Ready section of this guide for more information about setting target dates to submit the various PHAB
application process requirements.
18
Tribal Leadership
Assuming the initial self-study was conducted, the Accreditation Team will have a better understanding about
the role of the governing entity in the accreditation process
and what documentation is needed to address the standards and measures. The Accreditation Coordinator should
work with the THD director to meet with the governing
entity and discuss its role. Be sure to inform members of
the governing entity where their support and/or approval
is needed, including, but not limited to, securing financial
resources for accreditation readiness activities, addressing
performance objectives, engaging internal and external
partners, and formalizing partnerships with federal, state
and local agencies. The THD will need to document ongoing
communication with Tribal Leadership, as well as information about policies that need to be developed or updated.
Cost
In the Early Phase of accreditation readiness, the easiest
cost to determine was the PHAB application fee. Now,
however, a great deal of information has been gathered
and planning has taken place. The Accreditation Team
most likely has a better understanding of the resources
needed to support accreditation readiness activities. It
may be helpful at this time to conduct a simple cost analysis to determine costs required to address the following:
1) Completion of the three accreditation prerequisites
2) Technical assistance needs
3) Infrastructural needs (e.g. electronic filing system)
4) PHAB application fee
There may be other costs not listed here that the THD must
consider. After assessing the projected costs, the Accreditation Team can create a budget for pursuing accreditation.
The health department director and/or other appropriate
staff can present this budget to Tribal Leadership with a
request for funding. Other potential funding sources, such
as grants, should be explored as well.
Electronic Filing System
With the help of IT staff the THD can create or acquire the
needed software and filing systems. The filing system will
serve as a repository for documentation and should be
organized so that each domain has a file for each standard,
and each standard has a file for documentation of each
measure. The filing system is critical as this is where all
documentation relating to accreditation will be filed, stored
and reviewed.
19
PLANNING PHASE GERMINATION
PUBLIC HEALTH PERFORMANCE
Public Health Performance – Self-Study
Once the self-study is completed, you can identify strengths
and methodically prioritize opportunities for improvement.
There is no right or wrong way to prioritize improvement
areas; however, identifying and agreeing on the criteria you
will use for prioritization can be helpful in guiding the process.
Examples of criteria include: 12
• Time (e.g. requiring the least or most amount of time to
address)
• Importance (as communicated by Tribal Leadership and
self-study participants)
• Scope of the problem (e.g., number of community members affected)
• Seriousness (e.g., leading causes of death)
• Trends (e.g., increase in prevalence among specific age
groups or gender)
• Equity (e.g., health inequities and disparities)
Using a scale of 1 to 5, you can prioritize an improvement
area using a criterion of time by assigning it a rating that you
define. For example, you can decide that a 5 means it requires
the most amount of time and a 1 is the least amount of time.
Whether you start with the improvement areas that can be
addressed easily and/or quickly, or areas that will require
more time, coordination, and resources is up to the team.
However, before you begin the prioritization process, just be
sure to establish the criteria, the rating scale and a basis for
decision-making.
Another approach to prioritization is to first look at the
domains that require the most improvement. Since many
of the standards and measures relate to one another, starting
at the domain level can help a THD look at specific public
health functions that can be improved. Then within each of
the domains identified, begin looking at the standards requiring the most improvement. The Self-Assessment Workbook
for Tribal Health Departments includes a formula to calculate
a mean score for each standard, which can be used to identify standards requiring the most improvement (See page 12
PUBLIC HEALTH PERFORMANCE
of this guidebook). Again, because the standards tend to
relate and build upon one another, you may find that your
improvement areas are primarily focused on one or two
standards. By identifying common improvement areas and
how they are linked, the THD can identify ways to address
them in clusters rather than separately. Once you have reviewed the domains requiring the most improvements, as
well as the corresponding standards, you can prioritize using
the predetermined criteria.
THDs are required to develop, implement and monitor
an organizational strategic plan. If the self-study results
are used as a basis for identifying strategic priorities, then
implementation of the plan will address Standard 5.3: Develop and implement a health department organizational
strategic plan, while also addressing other standards and
measures as identified in the self-study. This approach allows you to potentially address multiple standards and/or
measures at the same time you are preparing for accreditation.
Once you have reviewed performance improvement opportunities at the domain and standard levels, you can drill
down further and review the specific measures. The measures
also relate and build upon one another within each standard.
Based on predetermined criteria, you can prioritize which
measures to address. In addition, as you review each measure,
you may want to identify which improvement areas can be
addressed using QI. Improvement areas requiring QI can be
included in the THD QI Plan.
Improvement areas identified in the self-study can also
be integrated into the THD’s QI Plan in much the same
way. Since the QI plan must also be implemented and
monitored, this is an opportunity to foster a culture of
quality improvement and address accreditation requirements while preparing for accreditation. See Standard 9.2:
Develop and implement quality improvement processes integrated into organizational practice, programs, processes
and interventions.
After prioritizing your improvement areas, you need to
develop a process to identify, select and/or develop documentation for each measure. There is a section in the PHAB
Standards and Measures Version 1.0 (pp 3-4) that provides
some basic guidelines for documentation. We recommend
you read through this section. If the THD has established
domain teams, then team leads are responsible for working
with team members to identify documentation and either
a) file it in the THD’s electronic filing system, or b) submit it
to the Accreditation Coordinator for filing into the system.
Whatever process is identified, be sure to document the
process and identify mechanisms for accountability. Examples
of mechanisms include consistent and ongoing communication, regular meetings, written reports, and a timeline for
completion. A timeline for addressing specific measures and
performance improvement initiatives will keep the improvement effort consistently moving forward. You may want to
develop or adapt a form to track documentation as it is
completed.
Quality Improvement
Developing, implementing and monitoring a QI plan is a
requirement for accreditation. The guidance in PHAB’s
standard 9.2 lists many ways to document the process of
determining what the QI plan will address. Ultimately, the
plan will include QI training for health department staff;
well thought out goals, objectives and measures with
time-framed targets; a monitoring and evaluation plan;
and a plan on how to communicate QI activities to THD
staff and engage them in its implementation. We recommend the QI plan be developed in the Planning Phase of
accreditation readiness.
If you have taken the suggested approach of identifying
performance improvement opportunities in the self-study
for inclusion into the QI plan, it will be much easier to link
the QI plan to the organizational strategic plan, as required.
The QI plan must also link to the THD CHIP, which is covered
in the next section.
Engaging Tribal Administration and Departments
In the early Readiness Phases, Tribal partners were identified
to participate and were informed about accreditation. You
may or may not have invited them to participate in the selfstudy; however, if you did not, we recommend you invite
them to review the results and assist with prioritizing improvement areas. It is critical that you involve internal partners at
this point in the accreditation process because many of the
measures require documentation of public health activities
that the THD leads. Measures may also require documentation of functions, programs or services led by other Tribal
administration and departments outside of the THD so it will
be important to involve them in the conversation.
12. PHAB (2011). Acronynms and Glossary of Terms Version 1.0. http://www.
phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-TermsVersion-1.02.pdf
“Whether you start with the improvement areas that can be addressed easily and/or quickly,
or areas that will require more time, coordination, and resources is up to the team.”
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21
PLANNING PHASE GERMINATION
IMPROVEMENT PLANNING - COMMUNITY HEALTH ASSESMENT
Planning a CHA often takes more time than many
people anticipate. If done well, a CHA plan outlines
the step-by-step process to be used (based on the
model that you choose). Having a well-designed plan
can help clarify roles and responsibilities of the CHA
Planning Team and other workgroups or subcommittees. It can also determine key benchmarks and timelines for completion and eliminate or minimize challenges caused by poor planning. CHA plans often
include the following components:
• Community Engagement – defining community
and identifying who will be engaged and what
strategies will be used to engage them
• Identification Of Health Indicators – what mea
sures will be used to determine overall
community health status
• Data Collection – Analysis And Reporting – what
data will be collected, methods for collection, how it will be analyzed, and methods for sharing
results, as well as obtaining input on those results
• Health Priority Setting – what strategies will be
used to review data and identify health areas for
immediate improvement planning
• Reporting Of Results – what data will be included
in a summary report for dissemination to
community and stakeholders
A collaborative approach to conducting a CHA is
critical to ensure that the process is community driven.
Community participation fosters greater collaboration
and coordination of services to address community
needs, because it engages partners in both identifying
and solving important community health concerns. It
also builds community capacity and a sense of ownership around improving health outcomes. Important
elements to consider and define when planning a
collaborative approach include:
•
•
•
•
•
IMPROVEMENT PLANNING - COMMUNITY HEALTH IMPROVEMENT PLAN
Who to engage in the community
Ways to engage members of the community
Strengths of the community
Potential contributions to the process
Reason for engagement – what are the desired
outcomes
Health and wellness is a cultural value for many Tribal
communities. For this reason, prioritizing can sometimes be a challenge, because community members
may feel as if they are deciding that one health issue
is more important than another. We recognize that all
health issues are important in Tribal communities, and
it is likely that prevention programs and services provided extend beyond the priorities, objectives and
strategies listed in a CHIP. However, the general purpose
of the CHIP is to focus on health concerns that have
the greatest impact on the Tribe, so that a THD can
make measureable improvements on the overall health
and wellness of the community. Reassuring community members that services will not be limited to the
CHIP, may help address any issues that arise during the
prioritization process.
Community Health Improvement Plan
While the entire process of developing a CHIP is considered “planning”, this particular section of the guidebook focuses on addressing the documentation requirements for Measure 5.2.1: Conduct a process to
develop a Tribal community health improvement plan.
The process used to develop a community health
improvement plan will need to include broad participation by Tribal public health system partners.
Partners and/or stakeholders to consider including
are departments and programs within the Tribe, as
well as other groups that work with the THD to address
health issues (such as governmental agencies, nonprofit organizations, and community coalitions). Many
of these stakeholders and partners may be the same
as those engaged during the CHA process. A benefit
of participants being the same, is that the community health improvement planning process becomes
a natural progression from working together to assess
health status to planning for health improvement.
There are several tools that can be used to prioritize
health issues. Such tools include, but are not limited
to, brainstorming sessions, multi-voting, nominal group
technique and an affinity diagram. Check out the resource below. Or conduct an Internet search using any
of these terms to generate a list of tools for prioritizing
and building consensus. The CHIP team will need to
choose which method they feel will work the best for
them.
The community health improvement planning process
must be documented. Refer to the PHAB Standards
and Measures Version 1.0 for required documentation
and guidance.
Be sure to review data and information gathered
during the CHA and self-study while developing your
CHIP. While the CHA results will tell you about community health status, the self-study results can provide
information to identify issues, themes, assets and
resources available in the community to support community health improvement efforts. From this point,
stakeholder and partners can provide meaningful
input because prioritization of health issues will be
based on a variety of information sources and data.
“The Early Phase of accreditation readiness focuses on
gathering information and sharing it with others.”
RESOURCE!
For information on priority-setting techniques, visit NACCHO’s First Things First:
Prioritizing Health Problems. http://www.naccho.org/topics/infrastructure/accreditation/upload/
Prioritization-Summaries-and-Examples.pdf
RESOURCE!
The ITCA Tribal Community Health Assessment for Public Health Accreditation: A Practical Guide and Toolkit
has a sample CHA plan that THD’s can use. http://itcaonline.com/wp-content/uploads/2011/03/Tribal-CHAToolkit-for-Public-Health-Accreditation-Pilot-Version.pdf
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23
PLANNING PHASE GERMINATION
IMPLEMENTATION PHASE GROWTH
ORGANIZATIONAL READINESS
IMPROVEMENT PLANNING - STRATEGIC PLAN
Strategic Plan
As part of the departmental strategic planning process, be
sure to review the self-study results, as well as the THD’s
CHIP and QI plan. Reviewing these documents will ensure
that when you conduct the strengths, weaknesses, opportunities, and threats (SWOT) analysis, it will be based on
performance and health data rather than individual observation or opinion. Stakeholder analysis of assessment data and
planning can be very helpful to the process and can encourage buy-in and support during the implementation of the
plan. It is crucial that you document the strategic planning
process, including meetings, agenda and methods used.
DIAGRAM 4. Performance and Health Assessment and
Improvement Planning
Self-Study
(assesment)
Community
Health
Assesment
QI PLAN
DEPARTMENTAL
STRATEGIC
PLAN
The THD organizational strategic plan must link with the CHIP
and the QI plan. We strongly recommend thinking of all three
plans as part of the strategic planning process. Performance
and Health Assessment and Improvement Planning illustrates
the relationship between the self-study and community
health assessment to the development of the QI, community health improvement and strategic plans. Using the data
from both assessments to develop the plans will ensure that
planning is data-based. It will also make it easer to link the
plans together by addressing common issues and themes in
performance and health improvement in each of the plans.
PLAN INTO ACTION
During the Implementation Phase, you will begin to turn your
plans into action. The seeds have been planted and the three
sisters are well established and growing! As a THD goes
through the Implementation Phase, it is important to monitor
progress and make adjustments as new information is gathered and challenges are identified and overcome.
Accreditation Team
As the accreditation effort progresses, the team collects dated
documentation that evidences accreditation activities as
specified in the various PHAB standards and measures. These
documented areas include, but are not limited to: leadership
support, infrastructural needs, performance improvement
activities and the three prerequisites. Be sure to track completed activities in the THD Accreditation Work Plan and use
the PHAB Readiness Checklists. Review PHAB Readiness
Checklists regularly and monitor advancement and completion. Remember that, although the information found in the
PHAB Readiness Checklists is included in the roadmap, these
two tools are organized differently and the same information
may appear in a different order.
Much like community health assessment informs the development of the CHIP, the self-study results can be used to
identify improvement areas requiring quality improvement.
Areas identified for QI can then be integrated into the THD’s
QI plan. Since the QI plan must also be implemented and
monitored, this is an opportunity to address accreditation
requirements while preparing for accreditation. Since performance improvements can also enhance and support efforts
to improve health, links can be made from the QI plan to the
CHIP.
The strategic plan can then be linked to the QI plan and CHIP
by referencing self-study and community health assessment.
You can use results from the two assessments to
identify themes, issues, strengths, and weaknesses, which form the basis for setting
strategic priorities and goals. Using assessCHIP
ment results ensures that your strategic
planning efforts are data-based and that
they support the THD’s QI plan and CHIP.
Since the standards and measures associated
with strategic planning also require that the strategic plan be implemented and monitored, linking the three
plans and monitoring their implementation ensures that the
THD is addressing accreditation requirements at the same
time it is addressing performance improvement initiatives.
By this time, documentation of THD eligibility for accreditation should be available and ready for you to submit.
Tribal Leadership
The support and engagement of Tribal Leadership has likely
evolved throughout the accreditation activities. At this point
in the process, they may be lending their support by reviewing and approving the formalization of partnerships with
outside agencies through memoranda of understanding.
They are engaged in THD activities, policy making and priority setting. The THD should be documenting this engagement
and working with the governing entity to ensure a structure
is in place for ongoing communication as described in Domain
12: Maintain Capacity to Engage the Public Health Governing
Entity.
Once the THD is ready to submit the PHAB application and
fee, the Appointing Authority, who may be the Tribal Chair
or chief executive, signs a letter of support to include with
the application.
Review PHAB standard 12.2-3 often to ensure the appropriate documentation is collected and that each of the requirements is being addressed.
Cost
During the Implementation Phase, a THD will want to be
sure resources are available to support accreditation
readiness technical assistance, training, and infrastructure
needs as identified earlier in the planning process. Resources should also be available to include the PHAB application fee, at a minimum, for the first year.
Electronic Filing System
The THD electronic filing system should now be in place.
We recommend that the Accreditation Team, and any
others responsible for filing documentation, be trained on
how to organize and file documents. The Accreditation
Coordinator should monitor the completion and organization of the files. Now is the time to consult with IT again
to ensure the system can support the PHAB site visit, which
will occur after all documentation is submitted to PHAB.
RESOURCE!
Resource! Visit the Association for State and Territorial Health Officials website for additional accreditation
and performance resources and tools.
http://www.astho.org/accreditation-and-performance/resources-and-tools/
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25
IMPLEMENTATION PHASE GROWTH
PUBLIC HEALTH PERFORMANCE
The Accreditation Team and all those involved are now
working on performance improvement opportunities according to the priorities and timeline developed in the Planning
Phase. As documentation is being identified, adapted or
created, the Accreditation Coordinator, or designated staff,
should monitor progress to ensure completeness. After
documentation is complete, it should be filed, or submitted
to the Accreditation Coordinator for filing, according to the
internal process identified by the THD. Documents should
be reviewed for completeness. A completed document must
adequately address the standards, be dated with the month
and year of review, and be placed into the appropriate electronic folder(s).
Tribal Administration and Departments
By now, Tribal administration, departments and programs
should be actively engaged in accreditation readiness and
performance improvement activities, as appropriate. Most
likely, there will be several different efforts moving forward
at the same time, based on the various domains, standards
and measures being addressed. Collaboration should be
IMPROVEMENT PLANNING - THREE PREREQUISITES
documented, and policies and protocols should be developed as needed. The Accreditation Team can encourage
accountability by having Tribal partners report regularly
on progress and challenges. Regular meetings can provide
a forum for general support and inform the team of adjustments to plans and timelines as needed.
CHA activities are now underway! Community is engaged in
a collaborative process to collect and gather information and
data on the community’s health status. Data collected during
the CHA process is analyzed and shared for input and interpretation. Community Health Profiles are often used to
summarize and share the CHA process and findings. Be sure
to share these summaries with the community and organizational partners and with stakeholders. Communicate and
disseminate CHA findings through various media techniques
such as newsletters, listening sessions, local radio stations,
and Tribal newspapers. All findings, including lessons learned,
should be communicated in a timely and understandable
manner.
Documentation should continue to be developed, gathered,
categorized, checked for accuracy, and placed into the
appropriate electronic folders according to the process
identified by the THD.
Quality Improvement
Once a QI plan is established, activities and progress must
be documented and tracked. This includes documenting
how an action plan was developed, any problem solving
and/or adjustments made to the approach being used,
and how QI results were evaluated. Review PHAB standard
9.1.2 to ensure the appropriate documentation is collected and requirements are being addressed.
After findings are shared, engage community stakeholders
and partners in priority setting. Health priority setting based
on CHA outcomes marks a transition point in the community health improvement process. You are transitioning from
collecting and reporting data to informing the development
of the CHIP. Outcomes from community input on health
priorities that are gathered in a systematic way, such as
forums, focus groups, and/or community meetings, should
be shared with stakeholders who were involved in developing the CHIP. Doing so ensures that community perspectives
are included in the planning.
It is important to document the CHA process, including, but
not limited to, meeting agendas and summaries, data collection methods and tools, community engagement activities
and outcomes, and dissemination activities.
Remember to review PHAB Standard 1.1. often to ensure the
appropriate documentation is collected and requirements
are being addressed. By the end of the Implementation
Phase, the community health assessment will be complete
and ready for submission to PHAB!
Community Health Improvement Plan
It is now time to produce a CHIP as indicated in Measure
5.2.2. A CHIP should include: Tribal health priorities, measurable objectives, improvement strategies and targeted, timeframed performance measures. The time-framed performance targets can be contained in a separate, internal
document, such as an annual work plan, that must be submit-
ted to PHAB as a supplement to the CHIP. Be sure to note
any policy changes that are needed to meet identified
health objectives. It is also be important to identify individuals, programs and/or organizations that are responsible for implementing strategies identified in the plan.
Formal agreements regarding responsibilities to implement
the plan are not required. By the end of this phase, the
CHIP will be complete and ready for submission to PHAB!
Keep in mind that the CHIP must be submitted with the
PHAB application, along with the CHA and the organizational strategic plan. The THD should begin implementing CHIP during the application process, since implementation of the plan is addressed in Measure 5.2.3. As
objectives are completed or new priorities are identified,
you may need to revise the original plan. Documenting
these changes and why they were deemed necessary
is just as important as tracking the original goals and
objectives.
Strategic Plan
At this point in the strategic planning process, the THD is
ready to adopt and implement a department strategic plan,
as described in measure 5.3.2 and 5.3.3. A strategic plan
should include the mission, vision and guiding principles,
strategic priorities, goals and objectives with measurable
time-framed targets. Results from the SWOT analysis and
analysis of external trends, events and factors should be
described.
Once adopted, you are ready to implement the plan. Keep
in mind that you will need to create annual reports that
track your progress toward goals and objectives. Reports
must include how targets are monitored, conclusions on
progress, and any revisions or adjustments to the plan
based on work completed. Review PHAB standard 5.3.1-3
often to ensure the appropriate documentation is collected and each of the requirements is being addressed.
By the end of this phase, the departmental strategic plan
will be complete and ready for submission to PHAB!
Review PHAB standard 5.2 often to ensure the appropriate documentation is collected and all requirements are
being addressed.
RESOURCE!
Documentation that the CHIP is in alignment with Tribal, state and national objectives is required. We
recommend that THDs visit the Healthy People 2020 objectives at www.healthypeople.gov and the National
Prevention Strategy at http://www.surgeongeneral.gov/initiatives/prevention/strategy/. THDs may also
want to review Government Performance Results Act (GPRA) measures to identify any measures that could
be included as improvement measures in the CHIP.
“ The Accreditation Team can encourage accountability by having Tribal partners
report regularly on progress and challenges.”
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27
APPLICATION READY HARVEST
CONCLUSION
It is now time to harvest the fruits of all that you have done!
You have prepared the THD organizationally, addressed THD
public health performance, and engaged in a community
health and THD improvement planning process. It is time to
apply for accreditation! At this point, it is likely your Tribal
Accreditation Readiness Guidebook and Roadmap is dogeared and worn from continual reference, as are your copies
of the PHAB Standards and Measure Version 1.0, PHAB
Readiness Checklists, and PHAB Guide to National Public
Health Department Accreditation. Let this be an indicator
and reminder of the hard work and effort being put forth on
behalf of your community.
There is one (1) year’s time between when a THD submits
its SOI and when it must submit its PHAB online application.
If after one year, the THD is not ready to submit the application, it will need to resubmit an SOI when it is ready
to begin the accreditation process. Six (6) months after
the THD submits the SOI and PHAB notifies the THD that
the SOI is complete and accepted, PHAB will provide access
to the e-PHAB application portal. Once access is granted,
the THD can electronically submit the application. The
THD must submit the application no more than six (6)
months from receipt of access to the application portal.
The application must include:
In the introduction of the guidebook, we reviewed the PHAB
accreditation process, which includes seven primary steps:
1) Pre-Application, 2) Application, 3) Documentation Selection
and Submission, 4) Site Visit, 5) Accreditation Decision, 6)
Reports, and 7) Reaccreditation.13 Each step of the PHAB
accreditation process has a set of activities a THD should take
to prepare. It will be important to learn about each step and
the timing of each activity in order for the THD to align and
incorporate them into the THD’s planning, implementation
and application readiness process, specifically for steps 1
through 4.
• Completed application form – electronic signature from the THD director
• Letter of support from the THD Appointing Authority
• Three prerequisites – current (updated within the last 5 years) community health assessment, community health improvement plan and strategic plan
• Formal verification of eligibility
• Application fee
ORGANIZATIONAL READINESS
PERFORMANCE IMPROVEMENT
IMPROVEMENT PLANNING
The Application Ready Phase is where the synergetic, cooperative and interdependent relationship among the three
sisters – Organizational Readiness, Performance Improvement,
and Improvement Planning – will result in a high-performing
THD that provides quality services aimed at supporting a
healthy Tribal community. Since the THD will arrive at the
Application Ready Phase at different times for each of the
Readiness Areas subcategories, it is important to align the
application readiness with the steps of the PHAB accreditation
application process.
PHAB Application Process
The first official action a THD will take to begin the PHAB
accreditation process will be to submit the PHAB Statement
of Intent (SOI). This submission occurs after the THD has
gathered all the necessary information, conducted a self-study
against the PHAB standards and measures, and has addressed
the majority of items listed in the PHAB Readiness Checklists.
The SOI is not binding and does not commit a THD to submit
an application. The primary purpose of the SOI is to inform
PHAB of your intention to submit an application.
For many, the overall health and wellness of Tribal communities is a cultural value. THDs are seeking opportunities to address
the public health needs of the communities they serve. In the era of healthcare reform and greater accountability, Tribes recognize the importance of strengthening public health infrastructure as a way to generate resources and increase the efficiency
and effectiveness of programs and services. We believe the public health accreditation process will lead to a stronger Tribal
public health infrastructure aimed at improvements in healthy communities for this generation and the next.
We hope the Tribal Accreditation Readiness Guidebook and Roadmap will be a helpful companion along your journey in public
health performance improvement and public health accreditation. We look forward to seeing Tribal Health Departments announced on the PHAB list of accredited health departments in the near future!
Once PHAB notifies the THD that the application is complete
and the fee has been received, the Accreditation Coordinator will attend an in-person 2-day training. After this training is complete, PHAB will grant access to the online system
for submitting documentation.
ACKNOWLEDGMENTS
Red Star Innovations is grateful for the support provided through a grant from the Robert Wood Johnson Foundation to support
Tribal Health Departments preparing for public health accreditation. We appreciate the support of our partners on the grant:
Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center, California Rural Indian Health Board, Inc. Tribal Epidemiology
Center and the Institute for Wisconsin’s Health, Inc. The Tribal Accreditation Readiness Guidebook and Roadmap was reviewed
by a national panel of public health professionals. We are grateful for the thoughtful recommendations and feedback provided
by the following individuals: (listed alphabetically by last name)
Jeffrey Brock, MPH
Performance Officer
Health Department and Systems Development Branch
Division of Public Health Performance Improvement
Office for State, Tribal, Local and Territorial Support
Centers for Disease Control and Prevention
As soon as a THD receives access to PHAB’s online system,
documentation can be uploaded. The THD has one (1)
year from the time it receives access to PHAB’s online
system to submit all documentation to PHAB. In total, there
is a two-year time period available from the time a THD
submits SOI to submitting the final application and all
documentation. All documentation should be maintained
in the THD internal electronic filing system until it is reviewed for completeness. Completeness includes an internal determination that it addresses the requirements of
the measures and that all documents are dated. Once the
review is complete, the Accreditation Coordinator can
upload the documentation submission to PHAB.
Karen Cook, FNP
Community Wellness Director
Yellowhawk Tribal Health Center
Confederated Tribes of the Umatilla Indian Reservation
Liza Corso, MPA
Senior Advisor for Public Health Practice and Accreditation
Division of Public Health Performance Improvement
Office for State, Tribal, Local, and Territorial Support
Centers for Disease Control and Prevention
Laverne Dallas, MSW
Director of Health Resource Department
Gila River Indian Community
Appendix 1 and 2 of the PHAB Guide to National Public
Health Accreditation in the PHAB Seven Step Accreditation
Process Summary and the PHAB Accreditation Process
Map. Both documents are great resources for understanding the accreditation process steps and activities and the
time-frame for completing each activity.
Jim Pearsol
Chief Program Officer, Performance Team
Association of State and Territorial Health Officials
Lorrie Sheppard, RN
Community Health Department/In Home Care Program
Director Health and Wellness Center
Forest County Potawatomi
Jessica Solomon-Fisher, MCP
Director, Accreditation Preparation & Quality Improvement
National Association of County and City Health Officials
Kathryn Wehr, MPH
Program Associate
Robert Wood Johnson Foundation
Robin Wilcox
Chief Program Officer
Public Health Accreditation Board
The contents of this guidebook are solely the responsibility of the authors and do not necessarily represent the official views
of the Robert Wood Johnson Foundation, the national review panelists listed above, or their employers.
http://www.phaboard.org/wp-content/uploads/PHABGuide-to-National-Public-Health-Department-Accreditation-Version-1.0.pdf.
For more information, please contact us at Red Star Innovations at (520) 407-6307 or info@redstar1.org.
Visit our website at www.redstar1.org.
13. PHAB (2011). Guide to National Public Health Department Accreditation, Version 1.0.
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RESOURCES
ORGANIZATIONAL READINESS
IMPROVEMENT PLANNING
• PHAB (2011). National Public Health Department Accreditation Readiness Checklists, Version 1.0.:
http://www.phaboard.org/wp-content/uploads/National-Public-Health-Department-Readiness-Checklists.pdf
• PHAB (2011). Acronyms and Glossary of Terms Version 1.0.:
http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.02.pdf
• PHAB Coordinator Handbook:
http://www.phaboard.org/wp-content/uploads/PHAB-Accreditation-Coordinator-Handbook-Version-1.0.pdf
• PHAB Guide to National Public Health Department Accreditation:
http://www.phaboard.org/wp-content/uploads/PHAB-Guide-to-National-Public-Health-Department-AccreditationVersion-1.0.pdf
• PHAB’s Accepted Program Areas for PHAB Documentation, December 2012:
http://www.phaboard.org/wp-content/uploads/Accepted-Program-Areas-for-PHAB-Documentation-December-2012.pdf.
Turning Point Model State Public Health Act: A Tool for Assessing Public Health Laws presented by the Public Health Statute Modernization National Excellence Collaborative:
http://www.turningpointprogram.org/Pages/pdfs/statute_mod/MSPHAfinal.pdf
CHA
• NACCHO Recommendations on Characteristics for High-Quality Community Health Assessments and Community Health
Improvement Plans: http://www.naccho.org/topics/infrastructure/CHAIP/chachip-online-resource-center.cfm
• ITCA Tribal Community Health Assessment for Public Health Accreditation: A Practical Guide and Toolkit:
http://itcaonline.com/wp-content/uploads/2011/03/Tribal-CHA-Toolkit-for-Public-Health-Accreditation-Pilot-Version.pdf
CHIP
• Guide and Template for Comprehensive Health Improvement Planning Version 2.1 developed by the Connecticut
Department of Public Health, Planning and Workforce:
http://www.ct.gov/dph/lib/dph/state_health_planning/planning_guide_v2-1_2009.pdf
• NACCHO’s First Things First: Prioritizing Health Problems: http://www.naccho.org/topics/infrastructure/accreditation/
upload/Prioritization-Summaries-and-Examples.pdf
Strategic Plan
• Tribal Health Department Strategic Plan: A How-To Guide. (Adapted from NACCHO Strategic Planning Guide):
www.redstar1.org/resources
• Developing a Local Health Department Strategic Plan: A How-To-Guide
www.naccho.org/topics/infrastructure/accreditation/upload/StrategicPlanningGuideFinal.pdf
Other
• Resource! Visit the Association for State and Territorial Health Officials website for additional accreditation and
performance resources and tools. http://www.astho.org/accreditation-and-performance/resources-and-tools/
• Healthy People 2020 Objectives: www.healthypeople.gov
• National Prevention Strategy: http://www.surgeongeneral.gov/initiatives/prevention/strategy/
PUBLIC HEALTH PERFORMANCE
• PHAB Standard & Measures Version 1.0
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf
• PHAB Standards and Measures Documentation Selection:
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Documentation-SelectionSpreadsheet-Version-1.01.xlsx
Self Study
• Self-Assessment Workbook for Tribal Health Departments (Excel format): www.instituteforwihealth.org/tribal.html
• Tribal Health Department Self-Study Guide available at www.redstar1.org/resources/
• NACCHO’s Guide to Organizational Self Study:
www.naccho.org/topics/infrastructure/accreditation/upload/Organizational-Self-Study-Guide.pdf
Quality Improvement
• Michigan Public Health Institute, Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook:
http://www.accreditation.localhealth.net/guidebook.htm
• NACCHO Roadmap to a Culture of Quality Improvement: http://www.qiroadmap.org/culture-to-qi/
• National Network of Public Health Institute Public Health Performance Improvement Toolkit:
http://nnphi.org/tools/public-health-performance-improvement-toolkit-2
• Association of State and Territorial Health Officials:
• www.astho.org/Programs/Accreditation-and-Performance/Quality-Improvement/
• Public Health Foundation: www.phf.org/focusareas/pmqi/pages/default.aspx
• Public Health Quality Improvement Exchange: www.phqix.org
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TRIBAL ACCREDITATION READINESS
GUIDEBOOK & ROADMAP
This guidance document was supported by a grant from the Robert Wood Johnson Foundation. Red Star is grateful for this
support and the support of its partners on the grant: Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center, California
Rural Indian Health Board, Inc. Tribal Epidemiology Center and the Institute for Wisconsin’s Health, Inc. Red Star Innovations
thanks the following team members who contributed to this guidance document:
Aleena M. Hernandez, MPH, Executive Director
Apryl Krause, ND, MPH, Intern
Judy Beaudette, Professional Editor
Click Magnet Internet Marketing, Graphic Design Team
THE MISSION OF RED STAR INNOVATIONS is to advance community wellness by supporting self-determination and
public health capacity development among indigenous governments, organizations and programs through purposeful
planning, action and leadership.
www.redstar1.org // PO Box 86645 Tucson, AZ 85754 // (520)407-6307 // info@redstar1.org
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