Getting Started: Orienting the Staff, Forming a Team and Developing a Plan

1. Getting Started: Orienting the Staff, Forming a Team and Developing a Plan Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series Coalition of Local Health Officials

2. Objectives for this Webinar • Planning and Considerations: • Assigning an Accreditation Coordinator • Engaging and Orienting Staff • Forming an Accreditation Team • Developing a Work Plan • Conducting a Self-Assessment • Documentation Review • Quality Improvement Planning • Prerequisite Planning • Developing a Plan for Engaging Community Partnersand Leadership • Review helpful resources for getting started

3. Why Now? • Training & TA resources available to counties • Grant opportunities • Potential to become more competitive applicant for other funding opportunities • Potential for a stronger voice at the table in CCO conversations • Important to show what PH does as all these transitions occur. • Important to focus on efficiency and quality improvement in current economic environment.

4. Step 1: Learning about PHAB • PHAB Online Orientation: http://www.phaboard.org/education-center/phab-online-orientation/ • NACCHO in-person presentations • NACCHO Answers to FAQs • NACCHO webinars: http://www.naccho.org/topics/infrastructure/accreditation/webcasts.cfm • PHAB Readiness Checklist: • http://www.phaboard.org/accreditation-process/accreditation-materials/

5. Assigning an Accreditation Coordinator • Recruit or appoint an Accreditation Coordinator • Coordinator provides leadership as needed while overseeing the self-assessment & accreditation process • Possible for the Health Director to take on this role • Fits somewhere naturally? • Example: Cross-programs, WIC Coordinator • Sample Accreditation Coordinator Duties

6. Plan for Engaging the Staff • Every member of the agency’s staff will be involved at some point in the process • For the process to be successful, not only must the Health Director visibly and actively support the process, but the health departments’ staff at all levels must be committed to the work. • Overview and on-going communication

7. Orienting the Staff • Department-wide orientation • Overview, purpose, time commitment, steps and activities involved in the process, importance of accreditation and how it will impact the agency • NACCHO has ‘ready-made’ training materials including a PPT presentation and presenter’s guide designed to inform LHD staff about accreditation and its importance to the agency. http://www.naccho.org/topics/infrastructure/accreditation/trainings.cfm • Ongoing communication is critical

8. Forming an Accreditation Team • Staff throughout the LHD need to be involved • Representatives from all levels of management and staff, and all program areas • Typical Team: • 1) Health Director; 2) Accreditation Coordinator; 3) Senior Management; and 4) Program Staff • Considerations: • Size of LHD, organizational structure, manner in which responsibilities are assigned to staff, workload, time it will take to collect evidence and adequately complete the self-assessment, subject matter expertise

10. Developing a Work Plan • Once key players identified, make a work plan • Considerations: • (1) Delegating responsibilities • (2) Training the team • (3) Developing a timeline • During the initial planning phase of the self-study process, the Accreditation Coordinator should consider developing a team charter which is a written document that clarifies the team mission and how to achieve it. • Duffy, G. L., Moran, J.W. (2010). Team Chartering. Access: www.phf.org/resourcestools/Documents/Team_Chartering.pdf

11. Delegating Responsibilities: Model 1 (for Large LHDs) • Team: Accreditation Coordinator, senior management and program staff • Senior management, including division directors, assign specific domains or Standards and Measures to staff in their respective divisions or programs based on area of expertise • These staff members gather documentation for their assignments and score each measure based on their findings • Senior management will then analyze these results and make recommendations

12. Delegating Responsibilities: Model 2 (Small to mid-size LHDs) • Accreditation team is comprised of the Accreditation Coordinator and senior management • Together they divide all the standards and measures amongst themselves and complete the entire process, including gathering documentation, scoring standards, analyzing results, and making recommendations • This model is more typical in mid-sized LHDs

13. Delegating Responsibilities: Model 3 (Small to very small LHDs) • Accreditation Team is comprised of the Accreditation Coordinator and the Health Director • The Health Director may also choose to serve as the Accreditation Coordinator and complete the entire process • Typically in very small LHDs, the entire self-study process could be successfully implemented with only these one or two individuals

14. Training Team Members • Accreditation Coordinator provides training to members to ensure consistency • Training: • Purpose of the self-assessment, how the results will be used, detailed description of the process, discussion of relevant, and assignments for the Standards and Measures • Each team member thoroughly reviews the relevant documents prior to the beginning of the self-study process

15. Developing a Timeline • Time will vary greatly from one LHD to another depending on the size of the agency, available staff and resources to devote to the process. • Very important for the Health Director to allow staff to allot time for this process • Leadership support necessary • Target Date Template • Timeline Example • Specific Timeline Example

16. Select & Organize Documentation • Gathering Documentation: • Gather documentation to show conformity to PHAB Standards and Measures • Use this information to score each measure • PHAB Standards and Measures Version 1.0: Focuses on what the HD provides, not how they provide it.

17. Select & Organize Documentation • National Public Health Department Accreditation Documentation Guidance • General guidance for HDs to consider when selecting the specific documentation that will be submitted to PHAB for each documentation requirement

18. PHAB Documentation • Each measure includes: Purpose Statement, Significance Statement, Required Documentation , Guidance • Additional Tips: • No draft documents • Must be in effect and in use at the time that they are submitted to PHAB • Electronically submitted (PDF preferred) • Most demonstrated only once • Two examples unless otherwise noted • Health departments are encouraged to provide narrative that describes how the submitted document relates to and meets the requirement

19. Documentation Resources • NACCHO’s Example Documentation for Accreditation: http://www.naccho.org/topics/infrastructure/accreditation/exampledocumentation.cfm • Organize the process: • LHDs will be required to upload the required documentation into e-PHAB. • Internal system to organize the documentation and streamline the process. • http://www.naccho.org/topics/infrastructure/accreditation/documentation.cfm • Blank Document Tracker • Questions to List-Serve • MaiKia and Erin collecting documentation form CLHO, state, FAQs, etc.

20. Identify and Analyze Strengths and Weaknesses • Accreditation Coordinator and preparation team to study, analyze, and process the results • identify the major strengths and weaknesses of the agency • First aggregate the results within each domain and each standard and display it in a way that will allow the team to easily identify strengths and weaknesses • Collectively examine information and make note ofdomains with a large number of standards and measures that have not been met. • This process will assist in gaining insight and developing a plan of action.

21. Self Assessment Tools • NACCHO Local Health Department Self Assessment Tool • APEX Public Health • http://www.naccho.org/topics/infrastructure/APEXPH/index.cfm • Performance Management Self- Assessment Tool from the Turning  Point Performance Management National Excellence Collaborative • http://www.phf.org/resourcestools/Documents/PM_Self_Assess_Tool.pdf • Baldrige Performance Excellence Program • http://www.nist.gov/baldrige/enter/self.cfm • Others?

22. Analyzing Strengths • Drawing upon strengths from one area and applying them to develop and support new strategies in other areas will support an agency’s efforts in CQI. • For instance, similar strengths across multiple Standards and Measures could identify emerging themes • This step highlights positive aspects of the self-assessment and provides an opportunity to celebrate the successes of the agency. • Share these findings with stakeholders including the entire staff, or the community.

23. Analyzing Areas for Improvement • Analyzing areas for improvement uncovered by the self-study is an important step to developing a quality improvement process that will result in solutions.

24. Areas for Improvement • An agency may choose to first define problems at one of the following four levels and identifying areas of analysis for that level: • Individual Measures: weaknesses on individual measures. • Individual Standards: weaknesses among individual standards • Domains: Includes weaknesses among multiple standards and measures within domains • Cross-Domain Clusters: Includes all weaknesses, across all domains that seem to cluster around a common theme

25. Prioritizing Problems • Multiple problem areas that need to be addressed and with limited resources, time, and staff, an agency cannot begin to address all of them at once. • Prioritization Technique: • Multi-voting Technique • Strategy Grids • Nominal Group Technique • The Hanlon Method • Prioritization Matrix • Guide to Prioritization Techniques

26. Prioritization Feasibility/ Ability to Impact Need

27. Implementing Quality Improvement • Likely that many, if not all, high-priority focus areas identified through step 4 can be addressed through QI processes • Form a QI Team • Include front line personnel and staff that are routinely involved with the chosen focus area as the QI cycle is implemented • Develop a team charter to provide the team with a clear and concise plan of action

28. Quality Improvement • The Plan-Do-Check-Act cycle (PDCA) • Resources: • Gorenflo, G., Moran, J. W. (2010). The ABCs of PDCA. • Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook Bialek, R., Duffy, G. L., Moran, J. W. (2009). • The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ Quality Press. • NACCHO Quality Improvement Website • NACCHO Quality Improvement Toolkit

29. Institutionalizing the Continuous Improvements • Reaccreditation process every five years, demonstrating improvement from the previous cycle • Accreditation is a cyclical process of continuous improvement • Goals of the QI project are met for the first selected priority area the agency moves forward with institutionalizing the change • As a next step, the agency can move on to address the next highest priorities using the PDCA cycle and eventually, undergo another agency self-study process • http://www.naccho.org/topics/infrastructure/accreditation/stories.cfm

30. The Prerequisites • http://www.naccho.org/topics/infrastructure/accreditation/prerequisites.cfm • Community Health Assessment • Community Health Improvement Plan • Strategic Plan • Important to remember that the prerequisites alone will help you fulfill many of the Standards and Measures, will fill gaps and be a good base for the rest of your work.

31. Partnerships & Collaboration • A lot of the accreditation preparation process will involve engaging different groups: • Health Department Leadership • Elected Officials • Staff • Stakeholders • Community Members • Hospitals • NACCHO Resources

32. Collaboration • Establish a clear purpose for the effort (elevator speech) • Establish clear written expectations for the overall effort and for partners • Establish clear written expectations for partners • Establish clear purpose and timelines for work groups • Effective Meetings are Essential

33. Plan for Engaging Leadership or Governing Entity • To be eligible for accreditation, an LHD’s local governing entity (LGE) must sign a letter of support. • Additionally, Domain 12 of the PHAB standards relates to engaging the LGE • Essential for LHDs to proactively provide the necessary informationto LGE • http://www.naccho.org/topics/infrastructure/accreditation/lge.cfm

34. Plan for Engaging Leadership or Governing Entity • State a clear purpose of the effort • Clearly state what you want from them • Invite elected officials to meetings and key events • Ask the Mayor, County Executive to serve as honorary chair • Send very short (one-page) updates  to  elected  officials  on  the  effort’s  progress • Look for opportunities to speak about the effort at Council meetings and public hearings • Look for connections to government actions (i.e., strategic plan, budget process, work sessions) • Be visible at government-related events not directly related to the effort or your specific specialty area • Get media attention for the effort

35. Engaging Local Public Health System Partners • Build commitment • Engage participants • Use participants’ time well • Result in a plan that can be implemented successfully

36. Local Public Health System

37. Considerations for Engaging Hospital Partners • They serve the population you serve • They are/ will be conducting CHNAs for IRS requirement • Valuable data and knowledge complementary to public health’s own • Potential coordination of priority setting, plans and actions, costs and effort

38. Engaging Hospital Partners

39. Partnership Resources • PARTNER Tool • http://www.partnertool.net/ • MAPP Website • http://www.naccho.org/mappunder “Organizing” • Community Health Centers • http://www.nachc.com/ • Association for Community Health Improvement • http://www.communityhlth.org/

40. Resources for Partner Engagement: • http://www.naccho.org/topics/infrastructure/CHAIP/partner-engagement.cfm • On this website you will find: • Training Presentations for engaging local partners • Webinar recordings: facilitating meetings with diverse groups of people • Circles of Involvement Exercise • Advisory Committee Invitation Template • Steering Committee Letter of Commitment • Advisory Committee Spreadsheet • Advisory Committee Meeting Presentation • Flyers, handouts to help you engage partners, etc. • Presentation for engaging academic partners

41. Other issues to consider • CCOs and Accreditations • Hospital IRS Benefit CHA requirement • Minimum Standards Revision • Commissioner Support • Grant opportunities • Health equity and health disparities

42. Case Study Example • Big Gap Health Department Example Case Study

43. Slide References • NACCHO: http://www.naccho.org/topics/infrastructure/accreditation/index.cfm • PHAB: http://www.phaboard.org/

44. Thank you! • Questions • Evaluation Survey • Next Webinar April 3rd • Contact: • Erin Mowlds • (541) 280-6400 • erin@oregonclho.org