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AmyBelflowerThomasHealthDirectors’LegalConference
April4,2018
ComplianceUpdate
PresentationOverview
1. Programupdates1. ReaccreditationwithHonors2. ConditionalAccreditationProtocol3. Onlineevidencesubmissionpilot
2. ReviewofStandardrevisionprocess1. Annualchanges2. ChangesrequiringRulesCommission
3. Humanservicesconsolidation4. Questionsandcomments*
*
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ProgramUpdates
ReaccreditationwithHonors
• LHDsthatmissoneorfewerActivitieswithineachoffiveStandards
• Congratstoinauguralclass:– AnsonCountyHealthDepartment– CatawbaCountyPublicHealth– Granville‐VanceDistrictHealthDepartment– MaconCountyHealthDepartment
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OperationalGuidelinesAdoption
• 20+policies/proceduresreorganizedtothreesetsofOperationalGuidelines:– AccreditationProcess– Board– SiteVisitTeam
RequestforReviewoftheSiteVisitReport
• Processclarifiedfor:– WrittenResponse: ifadepartmentdisagreeswithafinding.– ErrorofFact: ifthedepartmentfindsanerrorthatisquantifiable,objectiveandnotsubjecttointerpretationinitsmeaning.
• LHDmaysubmitaReviewAppealtoBoardifdisagreewithBoard’sactionforWrittenResponseorAccreditationAdministrator’sfindingsofErrorofFact.
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ConditionalReaccreditationRecommendationProtocol
Purpose: togiveanLHDanadditionalopportunitytosubmitevidencecompiledduringtheiraccreditationcycleinordertomeetaccreditationrequirements.
Thewrittenevidencecannotbenewlycreatedorreviseddocumentation.Itmaybeanydocumentationthatwasinplaceasofthebeginningofthesitevisit.
1. CarefullyreviewyourSiteVisitReportandseewhichStandardsyoumissed.2. ConsultpagenineoftheNCLHDAAccreditationProcessOperational
Guidelines.3. IfyouhaveevidencetosubmitforanActivitywithinamissedStandard,
followProtocolandrequestevidencebereviewed.4. SiteVisitTeamwillreviewmaterialoff‐siteandreassess.
1. IfevidencenowallowsenoughActivitieswithinStandardtobemet,recommendationischangedtoReaccreditation.
2. Ifrecommendationisnotchanged(eithermaterialnotresubmittedorstilldoesnotmeet),agencywilllikelybecomeConditionallyReaccreditedatBoardmeetingandhastwoyearstoreapplyforReaccreditation.
WhatifourRecommendationisforConditionalReaccreditation?
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OnlineEvidencePortalPilot
• Adaptingasystemfornotonlyreal‐timeevidencesubmissionandreview,butaccountability
• 2018pilots:– AlbemarleRegionalHealthServices– HydeCountyHealthDepartment– GreeneCountyHealthDepartment– Martin‐Tyrrell‐WashingtonHealthDistrict– WayneCountyHealthDepartment
StandardRevisionProcess
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NCLaw
• SenateBill804‐ GS130A‐34.1– EstablishedNCLHDABoardwithinNCIPH(17membersappointedbyNCDHHSSecretary)
– DirectsCommissiontoadoptrulesestablishingStandardsforLHDs– MandatesallLHDstoobtain(byDecember1,2014)andmaintainaccreditation
• 10ANCAC48B– Definesscoringrequirementsbycorefunction– DescribesBenchmarksandActivities
NCLaw
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NCLaw
• Boardcanassignthefollowingstatus:• Accredited• ConditionallyAccredited:periodofuptotwoyearswithagencyreapplyingwhenready
• Unaccredited:uponexpirationofconditionalaccreditation
• Beingaccreditedistiedtofunding:
OverallGoalofChanges
Improve LHD’s
Ability to Succeed
Provide training
Remove un-
necessary structural barriers
Provide clear and consistent guidance
Support sharing of
best practice
Make requirements
easier to meet
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• AnychangestomaterialsmadeonanannualbasiseffectiveJanuary1– Agenciesheldtowhatiseffectiveasoftheir90‐daynotification
• Allmaterialsonwebsite• Annualcolorschemeforchanges— 2018• ChangesalsodetailedinSummaryofChangesdocument
SummaryofChanges
• Providedwheneverchangesaremadetoassessmentdocuments(HDSAI,Interpretation)
• Listsanddetailschangesmadesincelastupdate
• Correspondstochangesmarkedinorangeinupdateddocuments
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HumanServices
Consolidation
Changesin2015
• 10ANCAC48BamendedApril1,2015duetoHB438
• ChangesweremadetoHDSAI/Interpretationeffective6.1.15:– Benchmark34shuffled,includingdeletingoneActivity– WhereAdvisoryCommitteeallowed,specificallyidentified(38.2,38.3,39.1,39.4,40.1,40.2,41.1,41.2,41.3)
– WhereConsolidatedHumanServicesDirectorapplicable,specificallyidentified(37.1,37.3,37.4,37.5,37.6)
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AretheNCLHDAStandards
achievableforaCHSA?
AretheNCLHDAStandardsclearfordifferentconsolidationscenarios?
IsitharderforaCHSAtobe
reaccredited?
WhatdoIdoifmyagencyis
consolidatinginthefuture? HowdoItalktomy
countyleadersaboutNCLHDA?
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Recentdata ToolswithinInterpretation
Guidance Thingstoconsiderfor
consolidatedagencies TrainingsandGuidance
documents
ReaccreditationDataAssessment
• 131Reaccreditations2011‐2018*– 17initialConditionalReaccreditationrecommendations(13%)
• HealthAgencyConsolidationallowedin2012– 24Reaccreditationsforconsolidatedagencies
• 13GovernedbyBoardsofCountyCommissioners• 11GovernedbyConsolidatedHumanServicesBoard
– 107ReaccreditationsforBoardofHealth‐governedagencies
107
1311
Governance Structure of Local Health Agency Reaccreditations, 2011-2018
Traditional Consolidated - BOCC Consolidated - CHS*Includesspringsitevisitreports,butnotfallfor2018
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ReaccreditationDataOverview
• 131ReaccreditationSiteVisits,2011‐2018
1 1
7 6 63
8 10
1313
15
13
20
15
0
5
10
15
20
25
30
2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
Nu
mb
er o
f A
gen
cies
Fiscal Year of Reaccreditation
Reaccreditation Site Visits (n=131) by Governance Structure, 2011-2018
Traditional (n=107)
Consolidated (n=24)
SummaryofActivitiesNotMet
• Ofthe131ReaccreditedLHDs:
– ActivitiesNotMetrangedfrom0to19Activities
– Mean=4.3Activities
– Median=3Activities
311 6 4
10
66
24
61
0
10
20
30
40
50
60
70
80
0 1-5 6-10 11-15 16-20
Nu
mb
er o
f A
gen
cies
Number of Not Met Activities
Traditional (n=107)
Consolidated (n=24)
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ActivitiesNotMet,2011‐2018
13%11%
23%
41%
13%11%
16%
29%
33%
12%
0
5
10
15
20
25
30
35
40
45
50
Assessment Policy Development Assurance Facilities &Administrative Services
Board ofHealth/Governance
% A
ctiv
itie
s M
isse
d
Activities Not Met, by Standard & Governance TypeFY2011-2018 LHD Reaccreditations (n=131)
Traditional (n=107)
Consolidated (n=24)
SummaryofActivitiesNotMetByConsolidationStatus
• Onaverage,consolidatedagenciesmissedanaverageofonlyonemoreActivitythantraditionalLHDs– 5.4vs4.1Activities
• Thisfindingisnotstatisticallysignificantduetolimitedsamplesize,butstillnotable
0
5
10
15
20
Traditional(n=107)
Consolidated (n=24) Overall(n=131)
Act
ivit
ies
No
t M
et
Box Plot of Activities Not Met, by Consolidation Status2011-2018 LHD Reaccreditations (n=131)
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SummaryofActivitiesNotMetByAgencyGovernance
• ConsolidatedagenciesgovernedbyaCHSboardaveraged2.5moreActivitiesmissedcomparedtotraditional– 6.7vs4.1Activities
• ConsolidatedagenciesgovernedbyaBOCCwerecomparabletotraditionalagencies– 4.2vs4.1Activities
• Smallsamplesizes,butstillmeaningfulresults 0
5
10
15
20
Traditional(n=107)
Consolidated -BOCC(n=13)
Consolidated - CHS(n=11)
Overall(n=131)
Act
ivit
ies
No
t M
et
Box Plot of Activities Not Met, by Governance Structure2011-2018 LHD Reaccreditations (n=131)
ToolswithinInterpretationGuidanceSections
AddedGuidanceforConsolidatedHumanServicesAgenciesforeveryActivity
• Helpswithspecificscenarios• RemindsaboutwhetherAdvisoryBoardcanaddress
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WhatGoestoLocalBoardofHealth
IfBOCChasassumedpowers/dutiesoftheBoardofHealth,wheneverBOHisreferredto,itequatestoBOCC(e.g.,Activity2.4— diseaseincidence/trendreport).
WhatCanGotoAdvisoryCommittee
GuidancewillbeclearaboutwhethertheAdvisoryCommitteecanfulfillrole(e.g.,Activity38.2— CHAreview).
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BOCCisActingonBehalfofTheirRoleasBOH
IfBOCChasassumedpowers/dutiesoftheBOH,evidencemustshowthatcertainActivitiesaredonefirmlyintheirroleasaBOH(e.g.,Activity14.4— draftingordinancesandrules).
WhoNeedstobeTrained
IfBOCChasassumedpowers/dutiesoftheBOH,theymustbetrainedonroles/responsibilitiesofBOH.YoucanchoosetotrainyourAdvisoryCommittee,butthatisnotrequired.
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WhoHiresaHealthDirectorandWhoSupervises
Assurethattheappropriateperson(BOHorconsolidateddirector)inthechainofoversightisidentified(e.g.,Activity37.1— qualifiedLHD).Thisappliestohiringaswellasthingslikesigningoffonperformanceevaluationsandjobdescriptions.
TrainingsandGuidanceDocuments
Slidesandfour‐pageguideonwebsite(updated1.1.18)
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ResourcesandTraining
Opportunities
Accreditation101:NewAACBi‐annualTraining
SavetheDate:September18from9to4
HiltonCharlotteUniversityPlaceFee:$60
RegistrationavailableinJune
NexttrainingwillbeSpring2019inEasternN.C.
Audience:NewAACs,Co‐AACsorBackupAACs
PleasenotethisisNOTforexperiencedAACs.
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Accreditation101:Team‐basedTraining
• Offeredbyrequestatyourlocalsite(Jan.‐MayandOct.‐Nov.only)
• Forgroupsof15‐20• STRONGLYencouragepartneringwithneighboringLHDs
• Request“NCLHDAtechnicalassistance”fromyourlocalAHEC
AnnualSkills‐buildingWorkshop
SavetheDate:BuildingYourAccreditationToolboxAugust14‐15,2018SheratonImperialinDurham
RegistrationwillopeninJulywithanexpectedfeeof$150andstaterateguaranteeattheSheraton.
Sessions focused on sharing best-practice models and
addressing common challenges.
While aimed at AACs of all levels of experience, local
accreditation team members are also invited.
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AllcountiesinNorthCarolinahavebeenaccredited,andbyMay2018,all85willhavebeenreaccreditedatleastonce.
! Questions&Discussion?
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Thankyou.
AmyBelflowerThomas,MHA,MSPH,[email protected]
(919)843‐3973
TheNorthCarolinaLocalHealthDepartmentAccreditationProgramispartoftheNorthCarolinaInstituteforPublicHealthattheGillings SchoolofGlobalPublicHealthattheUniversityofNorthCarolinaatChapelHill.
