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Working Toward Accreditation

Working Toward Accreditation. Joan Ellison, Public Health Director Mary Margaret Stallone, Director Center for Preventive Services Livingston County Department of Health. Conference of Environmental Health Directors / NYSACHO Meeting December 18, 2012. Be A Part Of Achieving Excellence

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Working Toward Accreditation

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  1. Working Toward Accreditation Joan Ellison, Public Health Director Mary Margaret Stallone, Director Center for Preventive Services Livingston County Department of Health Conference of Environmental Health Directors / NYSACHO Meeting December 18, 2012

  2. Be A Part Of Achieving Excellence Accreditation

  3. Seven Steps to Accreditation • Pre-application • Application • Documentation Selection and Submission • Site Visit • Accreditation Decision • Reports • Reaccreditation

  4. Steps Taken… • Pre-application • Online Orientation • Assess Readiness • Inform PHAB- Statement of Intent to Apply • Application • Community Health Assessment • Community Health Improvement Plan • Agency Strategic Plan

  5. Livingston County Department of Health Accreditation Timeline Through November 2011 By November 16, 2011 January 2012-May 2012 Prerequisites Documentation Selection and Submission to PHAB Submit Application to PHAB Pre-application Self Assessment Between June 2012 and November 2012 By February? 2013 Scheduled Site Visit- Could be 1-6 months after submission of all documentation Accreditation Decision

  6. Steps Taken… • Assemble Accreditation Team • Assign Domains to Domain Leader • Assemble Domain Teams

  7. Steps Taken… • Documentation Selection and Submission • Domain Team Meetings • Discussion • Gathering of materials/ documents

  8. Steps Taken… • Discussion of materials at Accreditation Team meeting

  9. Steps Taken… • Accreditation Coordinator attended Accreditation Training • Shared information with Accreditation Team • Discussed revision of process

  10. Steps Taken… • Public Health Director and Accreditation Coordinator met with Domain Leaders • Domain Leaders then met with their teams to discuss and revise information as needed

  11. Steps Taken… • Accreditation Team met again to discuss new information to determine if the standards were met

  12. Tracking Our Achievement

  13. Getting Ready to Push the Button

  14. Pushing the Button!

  15. Final Submission!

  16. Responding To Questions • Two Sets of Questions • Related to dates and signatures on documents • More information requested from site team

  17. Steps Taken • Site Visit 11/29/12 and 11/30/12

  18. Next Steps • Accreditation Decision • Review Accreditation Site Visit Report- within 14 days of the site visit • LCDOH has 30 days to respond • Report is sent to the PHAB Board for their review • LCDOH to be contacted in approximately two months regarding Board decision • If LCDOH does not get accredited, LCDOH has 90 days to take corrective action

  19. Next Steps • Accreditation Decision • Accreditation- good for five years • Site visit team recommends opportunities for improvement • Not Accredited • Must submit accreditation plan within 90 days • Must implement and provide proof of implementation of action plan with 12 months

  20. Next Steps • Reports • Department reports progress annually • Reaccreditation • Application for reaccreditation after 5 years

  21. Successes • Appointing an Accreditation Coordinator • Appointing Domain Leaders • Include Diverse Group of Staff • Ensure Adequate Time to Gather, Revise and Submit Information

  22. Successes • Staff Awareness and Involvement from the beginning • Staff Input – meeting the criteria • Creation of Several Policy and Procedures • Met Deadlines for Submission • Strive to Improve Various Areas • Strategic Plan

  23. Lessons Learned Regarding Required Documents • Comprehensive meeting minutes • Presentations to include date, time, place • Documentation of process • Proceed with Domain in Numerical Order

  24. What Are We Doing Differently? • Performance Management • Quality Improvement • Minutes • Documentation of process • Tracking systems in place • Identify who, what and where presentations are made

  25. Accreditation is the beginning Improve Improve Improve Improve Accreditation Re-Accreditation Improving the public’s health through continuous quality improvement NACCHO National Association of County & City Health Officials

  26. Questions

  27. Livingston County Department of Health 2 Murray Hill Drive Mt. Morris, NY 14510 585-243-7270 Dept-of-health@co.livingston.ny.us

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