Tribal Accreditation Readiness
Guidebook and Roadmap
June 12, 2013
NNPHI Open Forum
Aleena M. Hernandez, MPH
Apryl Krause, ND, MPH
TARGET Project:
Tribal Accreditation Readiness through Guidance,
Education and Technical Assistance
Red Star Innovations
Inter Tribal Council of Arizona, Inc.
California Rural Indian Health Board Tribal Epidemiology Center
Institute for Wisconsin’s Health, Inc.
Support for this project was provided by a grant from the Robert Wood Johnson Foundation
Objectives
• Have a basic understanding of accreditation
and its benefits
• Provide an overview of the Tribal Public
Health Accreditation Guidebook and Roadmap
– Including its development
• Discuss the early stages of readiness for
accreditation
Workshop Participants
We recommend that participants be:
• Familiar with public health accreditation
– Eligibility requirements
– Accreditation Process
– PHAB standards and measures
• If accreditation is new, we recommend you view
the PHAB Online Orientation in addition to this
webinar at www.phaboard.org
• This webinar will be recorded and available
online at www.redstar1.org.
What is Public Health Accreditation?
• Measurement of Tribal, state and local health
department performance based on a set of
national standards
• Issuance of recognition of achievement by a
nationally recognized entity
• Supports continuous quality improvement in
public health performance
Public Health Accreditation Board
PHAB: Non-profit, non-governmental
organization dedicated to advancing
continuous quality improvement of
Tribal, state, local and territorial public
health departments.
• Accrediting body for national public
health accreditation.
Vision: a high performing governmental
public health system that will make us a
healthier nation.
10 Essential Public Health Services
(www.cdc.gov)
The Essential Public Health
Services
1. Monitor health status
2. Diagnose and
investigate health
problems
3. Inform, educate and
empower people
4. Mobilize communities to
address health
problems
5. Develop policies and
plans
6. Enforce laws and
regulations
7. Link people to needed
health services
8. Assure a competent
workforce
9. Evaluate health
services
10. Conduct research for
new innovations
PHAB Standards and Measures
v1.0
• Based on the public health functions set forth
in the 10 Essential Public Health Services and
Core Functions (www.cdc.gov)
• 12 Domains
– Each domain has a set of standards and
measures
• Required documentation for each measure
TRIBAL PUBLIC HEALTH
SYSTEMS
Tribal
Government
Tribal
Health
Dept.
ITCs/Tribal
EpiCenters
Community
Tribal
Colleges
Community
Health
Local/
State
Health
Dept.
Federal
agencies
Private
Industry
Tribal Public Health Infrastructure
ITC’s/Epi
Centers
Communi
ty
Leaders
Tribal
Colleges
Tribal
Gov
Community
Health
Local/
State
Health
Depart
Tribal
Health
Dept/Clini
c
Federal
agencies
Private
Industry
Benefits and Opportunities
•
•
•
•
•
•
•
•
Strengthen self-determination
Identify and act upon improvement opportunities
High performance and quality improvement
Strengthen leadership and employee
performance
Build stronger partnerships and increase
communication and collaboration
Recognition, validation and accountability
Potential increased access to resources
It’s about communities
PHAB Resource Documents
•
•
•
•
Seven Steps to Accreditation
Guide to Accreditation
Standards and Measures 1.0
Other Accreditation Materials
– Glossary 1.0
– Readiness Checklists
– Statement of Intent and Application information
Readiness
Checklists:
Preparation
Planning and
Process
Readiness Checklists
Readiness Checklists are divided into four
sections:
1. Initial Checklist – eligibility and support
2. Prerequisite Checklist – 3 prerequisites are
current and complete
3. Process Readiness Checklist – recommended
processes in place to support accreditation
4. Organizational Checklist – accreditation
preparation tasks
Initial Checklist
• Is the health department eligible?
– Statutory authority to promote and protect health
• Do you have support from:
– Health Department Director?
– Appointing Authority of the Health Department Director?
– Board of Health or other governing entity?
• Has the Director considered the cost of apply and
budget implications?
• Have HD staff reviewed the 10 Essential Public Health
Services and determined the HD is providing all 10?
THD Eligibility
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 SelfDetermination 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 Tribeʼs 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.
1As
evidenced by inclusion on the list of recognized Tribes mandated under 25 U.S.C. §
479a-1. Publication of List of Recognized Tribes.
Process Readiness Checklist
 Accreditation Coordinator (AC) designated
 Online orientation completed by AC, HD Director and
Accreditation Team
 Appointing authority and Board of Health engaged in
process
 Electronic capability to produce documentation
 Capability to establish internal electronic filing system
 Process to systematically review and revise policies and
procedures
 Evidence of collaboration with key stakeholders
Organizational Readiness Checklist
 Work plan to discuss and complete tasks; timeframes
to gather documentation
 Process for identifying appropriate documentation
 Review of standards and measures and PHAB
materials (Guide to Nat’l PH Dept Accreditation)
 Self-Study or initial review of standards and measures
 Identified areas for technical assistance
 Identified a target for submitting Statement of Intent
Prerequisite Checklist
Prerequisites must be complete and
current (within the past 5 years):
1. Community Health Assessment
2. Community Health Improvement Plan
3. Department Strategic plan
Purpose of the Guide
• Simplify a complex process
• Tool to plan, organize and prepare for
accreditation
• Create connections among various readiness
and preparation activities
• Provide additional references, resources and
tools for specific readiness activities
• Provide a “roadmap” or “scorecard” to
monitor progress and success!
Accreditation Guidebook
• Organizational Readiness
• Public Health Performance
• Community Health Improvement Planning
Based on PHAB Readiness
Checklists www.phaboard.org.
Corn: Organizational Readiness
•
•
•
•
Accreditation Team
Tribal Leadership Engagement
Cost
Electronic Filing System
Beans: Public Health Performance
• Self-Study (based on PHAB Standards and
Measures)
• Tribal Administration and Department
Engagement
• Quality Improvement
Squash: Community Health
Improvement Planning
• Community Health Assessment
• Community Health Improvement Plan
• Organizational Strategic Plan
Phases of Readiness
• Early Phase – Information gathering,
identifying models, training teams
• Planning Phase – Developing the plan of
action, identifying benchmarks and timelines
• Implementation Phase – Plan into action!
Monitoring progress, adjusting the plan
• Application Ready – Implementation has
concluded and a PHAB application
requirement has been met or completed.
Phases of Readiness
• Early
Phase
• Application
Ready
• Implementation
Phase
Harvest
Planting
the Seed
Growth
Germination
• Planning
Phase
ORGANIZATIONALREADINESS
Application Ready
Preparation Stage
Planning Stage
Early Stage
AccreditationTeam
Tribal Leadership EngagementandSupport
Tribal HealthDepartmentdeterminesif it is eligible for
Appropriategoverningauthorityandentit(ies) areinformedabout
accreditation. (12.1)
thepurpose, benefits, costs, andrequirementsof accreditation.
Tribal HealthDirectorsupportstheTHDseekingpublic health Governingauthority andentit(ies) affirmtheir supportforthe
accreditation.
Tribal HealthDepartmentseekingpublic healthaccreditation.
AccreditationCoordinator(s) is designatedtooverseeaccreditation
readinessandapplicationprocess.
Amultidisciplinary"AccreditationTeam"of keystaff is established
andledbytheAccreditationCoordinator(s).
Tribal HealthDirector, AccreditationCoordinator(s) andTeam
completethePHABonlineorientationandreviewetheGuideto
National Public HealthDepartmentAccreditation.
COMMUNITYHEALTHIMPROVEMENTPLANNING
PUBLIC HEALTHPERFORMANCE
Cost
Electronic FilingSystem
Self Study
EngagingTribal AdministrationandDepartments
Tribal HealthDirectorconsidersthecostsof applyingforPHAB AccreditationCoordinator, ordesignee, meetswiththe
AccreditationTeamreviewstheTenEssential Public AccreditationTeamand/orSelf-StudyTeamidentifies
accreditationandthebudgetimplications.
appropriateInformationTechnologystaff to discussaccreditation HealthServicesanddeterminestheTribal Health Tribal departmentsand/orprograms, external partners
•AccreditationCoordinatorandTeamconsiderresources,
requirementsandtheneedforanelectronic filingsystemthatwil be Departmentprovidesall ten.
andotherstoengagein theself-studuprocess.Ÿ
consultants, andtrainingsneededtopursueaccreditation.
arepositoryfordocumentation.
AccreditationTeamidentifiesandorientsTribal Health AccreditationTeamprovidesanorientationtoTribal
IT determinestheTribehasthecapabilitytoproduceelectronic Departmentstaff andothersto participateonateamto administrationanddepartmentstobeengagedin the
documentation.
conductaninitial self-studybasedonthePHAB accreditationreadinessprocess.
Tribal HealthDepartmentandIT determinethecapabilityto standardsandmeasures.
establishaninternal electronic filingsystemwithaseparatefile for Self-StudyTeamcompletesapreliminaryself-studyto Tribal departments mayinclude, butarenotlimitedto,
eachmeasure.
assessreadinessforaccredittion.
humanresources, finance, facilities, information
QualityImprovement
CommunityHealthAssessment(CHA)
CommunityHealthImprovementPlan(CHIP)
AccreditationCoordinatorengagesthePerformance AccreditationTeamidentifiesstaff andstakeholders AccreditationTeamidentifiesstaff andstakeholders
ImprovementManager, QI Managerorappropriate staff toparticipatein acollaborativeprocessforthe toparticipatein acommunityhealthimprovement
todevelopaQI Plantoaddressself-studypriorities, or developmentof aCHA. (CHAprocessmaybean planningprocessforthedevelopmentof aCHIP. (CHIP
tointegratethemintoanexistingplan.
acceptedTribal, stateornational model.)
processmaybeanacceptedTribal, stateornational
Appropriateapprovals toperformaCHAareobtained model).
fromtheTribal leadership, whichmayincludethe Staff andstakeholdersparticipatingin theCHIP are
governingauthorityand/orentit(ies).
trainedonCHIP processandPHABrequirements.
Staff andstakeholdersontheCHAplanningteamare
trainedontheCHAprocessandPHABrequirements.
Organizational Strategic Plan
AccreditationTeamidentifiesstaff andstakeholdersto
participatein strategic planningprocessforthe
developmentof aTribal HealthDepartment
Organizational Strategic Plan.
•Afacilitatoris identifiedandstrategic planning
approachhasbeendetermined.
•Staff andstakeholdersidentifiedtoserveonastrategic
planningteamareinformedof theplanningprocessand
PHABrequirements.
technology, healthinformationmanagement, the
attorneygeneral andpublic safety.
•AccreditationTeamreviewsPHAB's AccreditationReadiness •Governingauthorityandentit(ies)' role in theaccreditationprocess Acostanalysis of accreditationpreparationis completed, including, Tribal HealthDepartmentandIT identifi esandinstalls thechosen
Checklists
is discussedandastrategyfordemonstratingsupportis developed. butnotlimitedto, thefol owing:
electronic filingsystem, whichincludesaseparatefile foreach
An"AccreditationRoadmap"outliningmajoractivities, benchmarks
1) Completionof thethreeaccreditationprerequisites
measurein ordertoelectronically organizedocumentationbasedon
andtimelinesis developed
2) Technical assistanceneeds
thestandardsandmeasures.
•AccreditationTeamhasaclearunderstandingof their role and
3) Infrastructural needs(e.g. electronic filingsystem)
responsibilitiesin completingthemajoractivitiesoutlinedin the
4) PHABapplicationfee
AccreditationRoadmap.
•Accreditationteamassessesavailable resources, consultants, and
trainingsavailable to help withaccreditationreadinessefforts.
• AtargetdateforsubmittingaStatementof IntenttoPHABis
identified.
Self-StudyTeamidentifie sandprioritizesmeasures Tribal departmentsparticipatein theidentifcationand APerformanceManagementCommittee/Team CHATeamdevelopedaplantoconductaCHAthat
requiringimprovement.
prioritizationof measuresrequiringimprovement. developsaperformancemanagementsystem; or includes, butis notlimitedto, thefol owing:
PerformanceImprovementManager, Qi Manageror Tribal departmentsagreetobeengagedin the reviewsanexistingperformancemanagementsystemto °Communityengagement
appropriatestaff workswithSelf-StudyTeamtoidentify improvementprocessandparticipatein planning. determinewhetherit meetsaccreditationrequirements. °Identificationandprioritizationof healthindicators
processesordocumentationdevelopmenttoincludein
QI Planis developedtoaddressdeficienciesidentified °Datacollection, analysis, andreporting
aQI Plan.
in theself-study; orneededimprovementsare °Identificationof healthpriorities
Self-StudyTeamdevelopsaprocesstoselectand/or
integratedintoanalreadyexistingTribal Health °Reportingof results
developdocumentationforeachmeasure.
DepartmentQI Plan. Ÿ
Self-StudyTeamcreatesapreliminarytimelineto
addressspecific areasforimprovement.
• AccreditationTeammeetsregularly andprogressis monitoredand • Governingauthorityandentit(ies) providesthenecessarysupport Resourcesaresecuredtocovercostsassociatedwithaccreditation
documented.
toengageinternal andexternal partners, formalizepartnershipswith readinessactivities, application, andannual accreditationfees.
•AccreditationTeamhasprocuredproperdocumentationof Tribal federal, stateandlocal agencies, andcoordinateservicesand
HealthDepartmenteligibility.
functionswithotherTribal administrativedepartments.
Documentationof thegoverningentity's engagementin theTribal
HealthDepartment's overall obligationsandresponsibilities,
includingcommunicationsaboutimportanthealthissues, policies,
andprioritiesis developedandgathered.
•Governingauthoritywritesandsignsaletterof support.
Tribal administrationanddepartmentsareactively QI Planis implementedandactivitiesaredocumented. CHAPlanis implementedandprocessis documented. •CHIP describeshealthpriorities, objectives,
Thestrategic plancontainsamissionandvision
engagedin accreditationreadinessactivitiesbyworking AccreditationCoordinatoris monitoringthe
•Communityengagementhasoccurredatmultiple strategies, andtime-framedperformancemeasures. statement, andidentifiesgoals, objectives, strategies
collaboratively toaddresstheapplicable measures. completionandorganizationof documentation. pointsduringtheCHAplanningprocess.
Stakeholdershaveacceptedresponsibilityfor andtargetsthatmeetthePHABrequirementsand link
•Technical assistanceis soughtandsecuredtoaddress
•DatacollectedduringtheCHAprocessis analyzedand implementingstrategies.
totheCHIP andQI Plan.
opportunitiesforimprovementasneeded.
sharedforinputandinterpretation.
•Policychangesneededtosupporttheplanare
Strategic planis completeandreadytobeadopted
•Thereis evidenceof collaborationwithTribal, stateor
•ACommunityHealthProfile is createdandsharedwith identified.
andimplemented.
communitypartnersandstakeholdersin planning,
thetribal communityand partners.
Measurable healthoutcomesorindicatorstomonitor
policydevelopmentandotherpublic healthfunctions.
•Healthprioritiesareidentifiedwithinputfrom progressareidentified
•Documentswerereviewedforcompletion.
communityandsystempartnersandstakeholders. CHIP alignswithTribal, national, andstatepriorities
•CHIP is completeandis readytobeimplemented.
PHABprovidesTribal HealthDepartmentaccesstothe DocumentsareuploadedintotheTribal Health QI Plananddocumentationof QI activitiesare
CHAis uploadedwiththePHABapplication.
CHIP is uploadedwiththePHABapplication.
Strategic Planis uploadedwiththePHABapplication.
e-PHABDocumentationSubmission.
Department's electronic filingsystem.
uploadedinto electronic filingsystemforDomain 9.
Accreditationand/orCHIP Team(s) aremonitoring Accreditationand/orStrategic PlanningTeam
Tribal HealthDepartmentuploadsandsubmits
progressin meetingperformancemeasuresidentifiedin completesatleastoneannual reportof progress
documentationtoPHAB.
theCHIP andis evaluatingprogresstowardsaddressing towardsgoals andobjectivescontainedin thestrategic
identifiedhealthindicators.
plan, includingmonitoringandconclusionsonprogress.
Statementof IntentsignedbytheTribal HealthDepartment Letterof supporttouploadedwithPHABapplicationandfee.
Directoris submittedtoPHAB.
•PHABnotifiedTribal HealthDepartment's applicationis complete
PHABdeterminesStatementof Intentis complete.
andfeewasreceived.
PHABprovidedtheTribal HealthDepartmentaccesstoe-PHAB
application
•AccreditationCoordinatorattendsPHAB's in-personaccreditation
processtrainingafterapplicationsubmission.
Electronic filingsystemis utilizedtoorganizedocumentationfor Accreditationand/orSelf-StudyTeamsaddressesall
eachmeasure.
identifiedimprovementopportunities.
AccreditationCoordinatoris monitoringthecompletionand Requireddocumentationis developed, gatheredand
organizationof documentation
preparedforuploadingintotheTribal Health
AccreditationCoordinatoris consultingwiththeappropriateIT staff Department's electronic filingsystem.
toensurethetechnologyis in placetosupportasitevisit.
FundsareallocatedtocoverthecostsassociatedwiththePHAB Electronic systemcontainsall necessarydocumentationfor
applicationfee.
submissionandreviewbyaccreditation sitevisit team.
PHABapplicationandfeearesubmitted(withdocumentationof
eligibilityandthreeprerequisites).
Thereis documentationof broadparticipationfrom Participantsin thestrategic planningprocessreview
Tribal public healthsystemstakeholders
theCHA, CHIP, Self-Studyresults, andtheQI Plan.
CHIP participantsreviewed dataandinformation Strategic planningprocessis documentedandthe
resultingfromthecompletedSelf Studyand/orCHAand methodsusedforreviewof majorelementsby
sharedit withparticipants/stakeholders
stakeholders. Ÿ
Issuesandthemesareidentifiedbystakeholders ASWOT(strengths, weaknesses, opportunitiesand
Assetsandresourcesareidentifiedandusedaspartof threats) analysis andanenvironmental scanare
theCHIP process. Ÿ
conductedandtheprocessis documented.
CHIP planningprocessis well documentedaccording
toPHABrequirements.
Roadmap Development
• Placed all items from the Readiness Checklists on
small sticky notes
• Organized them by theme
• Organized them into chronological steps
• Identified additional steps based on experience
and using the standards and measures
• Reviewed and refined
• Three sister analogy was born
Early Stage – Planting the Seed
Organizational Readiness – Information Gathering
•
•
•
•
•
Determine eligibility documentation
THD Director support
Identify the Accreditation Coordinator(s)
Establish a multidisciplinary Accreditation Team
Review PHAB online orientation and materials,
especially Guide to Accreditation
Early Stage – Planting the Seed
Organizational Readiness – Information Gathering
• Inform Tribal Leadership about the purpose,
benefits, cost and requirements
– Public health policy and laws
– Formalize partnership – MOUs/MOAs
– Engagement of other Tribal Departments
– Governance domain
– Budget requests/resource allocation
Early Stage – Planting the Seed
Organizational Readiness – Information Gathering
• Cost – Accreditation application fees and
associated costs
– Technical assistance – consultants, others
– Training – registration, travel
– Infrastructure – IT system, communications
meetings, software
– Prerequisites – facilitators, consultants, meetings,
travel, survey development
of the full application. Invoices will be provided by PHAB to the applicant health
department based on the type of payment schedule they select.
Health
Department
Category
Category 1
Category 2
Category 3
Category 4
Category 5
Category 6
Category 7
Category 8
Population
Size of the
Jurisdiction
Served
Less than
50,000
50,000 to
100,000
>100,000 to
200,000
>200,000 to
1 million
>1 million to
3 million
>3 million to
5 million
>5 million to
15 million
Greater than
15 million
Year 1
Payment
Year 2
Payment
Year 3
Payment
Year 4
Payment
Year 5
Payment
$ 3,180
$ 2,385
$ 2,385
$ 2,385
$ 2,385
$ 5,168
$ 3,876
$ 3,876
$ 3,876
$ 3,876
$ 6,758
$ 5,068
$ 5,068
$ 5,068
$ 5,068
$ 7,950
$ 5,963
$ 5,963
$ 5,963
$ 5,963
$ 11,925
$ 8,944
$ 8,944
$ 8,944
$ 8,944
$ 15,900
$ 11,925
$ 11,925
$ 11,925
$ 11,925
$ 19,875
$ 14,906
$ 14,906
$ 14,906
$ 14,906
$ 23,850
$ 17,888
$ 17,888
$ 17,888
$ 17,888
Approved May 2011
Early Stage – Planting the Seed
Organizational Readiness – Information Gathering
• Electronic Filing System
– Meeting with IT to discuss capacity
– Electronic filing system to organize documentation
by domain, standard and measure
– Access to the filing system
– Early discussions about what might be needed in
the future
– Capability to produce electronic documentation
Early Stage – Planting the Seed
Public Health Performance – Information Gathering
• Self Study based on standards and measures
– THD provides all 10 essential services
– Identified a tool to conduct the self-study
– Conduct preliminary self-study
• Identify who will participate in the self-study
• Tribal Administration and Departments
• Engage QI or Performance Improvement
Manager for development of QI Plan
Tribal Self-Assessment
Workbook
Created by the
Institute for Wisconsin’s Health through
Wisconsin’s Public Health Quality Initiative
Early Stage – Planting the Seed
Community Health Improvement Planning – Information
Gathering
• Community Health Assessment
• Community Health Improvement Plan
• Strategic Plan
Community Health Assessment (CHA)
• A collaborative process that is conducted in
partnership with other organizations
• Involves the systematic collection and analysis of
data and information
• Provides a snapshot of information that can then be
followed in the future
• Results in a report about community health status
that is shared with the community at-large
• Basis for development of a community health
improvement plan
Type of Data Collected
•
•
•
•
•
Demographics
Socioeconomic characteristics
Quality of life
Behavioral factors
The environment (including the built
environment)
• Morbidity and mortality
• Other social, Tribal, community, or state
determinants of health status
Basis-Use-Benefits
• Data-based decision making and action
• Informs priority setting and action planning
• Provides a baseline to measure changes in
health over time
• Engages stakeholder/community in defining
its strengths and needs
• Increases collaboration/coordination among
stakeholders to address identified needs
Systematic Process
•
•
•
•
•
•
•
•
Develop an assessment plan
Systematically engage the community
Define the community/population
Identify community health indicators
Collect data
Analyze the data
Identify health priorities
Report results
Community Health
Improvement Plan (CHIP)
• A long-term, systematic plan to address issues identified
in the community health assessment
• Describes how the health department and the
community it serves will work together
• Must include participation of a broad set of stakeholders
and partners
• Planning and implementation process is communitydriven
• Addresses the needs of the population residing within
the Tribe's jurisdiction
Elements of a CHIP
• Tribal health priorities, measurable objectives,
strategies, performance measures, and time
• Policy changes needed to accomplish objectives
• Individuals and organizations responsible (does not
have to be formal)
• Measureable health outcomes/indicators to monitor
progress
• Alignment with state and national priorities (HP 2020)
• Plan implementation (reporting, monitoring,
evaluating progress)
Department Strategic Plan
• Process for defining an organization's roles, priorities,
and direction over 3-5 years
• What an organization plans to achieve, how it will
achieve it, and how it will know if it has achieved it
• Guide for allocating resources and pursuing priorities
• Focus on the entire health department
• Program-specific strategic plans may complement
and support the department strategic plan
• Links to CHIP and quality improvement plan
Performance and Health
Improvement
Self-Study
(assessment)
Community
Health
Assessment
QI Plan
CHIP
Departmental
Strategic Plan
Resources and Tools
• Inter Tribal Council of Arizona (CHA)
• Northwest Portland Area Indian Health Board (CHA)
• Mobilizing for Action through Planning and
Partnerships (MAPP)
– Covers CHA and CHIP; very comprehensive
• NACCHO www.naccho.org
– Local health department samples and tools
• ASTHO www.astho.org
– State samples and tools
Questions/Comments
Thank You!
Guidebook will be available at:
www.redstar1.org