Public Health Accreditation Board

Judy Monroe, MD

Tennessee Public Health Association

September 3, 2009

Presentation Overview• Introduction to PHAB• Program development and timeline• Practitioner involvement• Benefits and incentives• Questions from you

A Rising Tide…

CDC’s Future Initiatives

“Future of the Public’s Health”in the 21st Century (IOM)

Statewide Accreditation Programs

Exploring Accreditation

Accreditation “Fits” in 2008Accreditation, as envisioned by the Public

Health Accreditation Board, is in tune with heightened national movement

• The Healthiest Nation• Trust for America’s Health – Blueprint for a Healthier

America

Credentialing and Accreditation

• Credentialing is a concept that applies to individuals who seek public health certification.

• Accreditation is a concept of validating performance improvement that applies to state, local, tribal, and territorial health departments.

Commitment of the PHAB Board of Directors and Staff

• Create demand and successfully deliver PHAB accreditation– Develop and establish PHAB accreditation– Market and manage the PHAB brand– Promote strategic partnerships ***– Establish sufficient funding– Strengthen PHAB organizational

effectiveness

Robert Wood Johnson Foundation Goal

60% of the population will be covered 60% of the population will be covered by accredited health departments by by accredited health departments by 2015.2015.

The goal of a voluntary national accreditation program is to improve and protect the health of the public by advancing the quality and performance of state, local, territorial and tribal public health departments.

Voluntary Accreditation Goal

Public Health Accreditation Board• Established May 2007 in Alexandria, VA• Governed by state, tribal and local public

health officials and board of health members

• Health department involvement:– Board of Directors representation– Workgroups oversee development– Volunteer opportunities

Executive Committee

• Chair: Paul K. Halverson• Vice Chair: unfilled• Secretary/Treasurer: Ed Harrison• Immediate Past President: Marie Fallon

• Kaye Bender, President and CEO

• Rex Archer (MO)• Shepard Cohen (MA)• Leah Devlin (NC)• Marie Fallon (OH)• Fernando A. Guerra TX)• Paul K. Halverson (AR)• Edward Harrison (IL)

PHAB Board of Directors

•Kenneth Kerik (OH)•Carol Moehrle (ID)•Judy Monroe (IN)•Bud Nicola (WA)•Alonzo Plough (CA)•William Riley (MN)•F. Douglas Scutchfield (KY)•H. Sally Smith (AK)

Funding Partners

Eligible Applicants

All variations of state, local, tribal and territorial health departments can apply for national accreditation

Developmental Work

• Standards Workgroup

• Assessment Process Workgroup

• Beta test

• Equivalency Recognition Workgroup

• Research and Evaluation Committee

• Fees & Incentives Workgroup

• Marketing and Communication

PHAB Timeline2007 2008 2009 2010 2011

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Internal Operations

Standards and Measures

Assessment Process

18 Month Beta Test

Applications

Standards Development Workgroup

• Workgroup comprises state and local health department leaders and BOH members

• Collaborative, consensus, iterative process

• Facilitated by consultant with standards development expertise– MCPP Healthcare Consulting, Inc

Standards Development Workgroup• Leah Devlin (NC): Co-Chair• Carol Moehrle (ID): Co-Chair• Terry Allan (OH)• Rex Archer (MO)• Tim Callahan (CT)• Rick Danko (TX)• Robert Fulton (MN)• John Gwinn (OH)• Mary Kushion (MI)• Richard Morrissey( KS)• Rita Parris (NE)

• Sylvia Pirani (NY)• Joy Reed (NC)• Stephen Ronck (OK)• Jane Smilie (MT)• Torney Smith (WA)• Bonita Sorenson (CA)• Jeffrey Stoll (CO)• Susan Turner (FL)• Harvey Wallace (MI)• Christina Welter (IL)• Kathy Vincent (AL)• Barbara Worgess (AZ)

Standards and Measures Development

• Develop standards for all health departments

• Measures specific to local and state health departments

• Guidance for documentation and demonstration of department performance on meeting standards and measures

• Scoring and weighting methodology

Standards and Measures: Principles• Advance the collective practice

• Be simple, reduce redundancy

• Minimize burden

• Reinforce local and state health departments’ roles, demonstrate shared accountability

• Apply to all sizes and all forms of governance structure

• Based on American National Standards Institute principles

Principles continuedBased on a body of existing work

Essential PH ServicesNACCHO Operational DefinitionNational Public Health Performance Standards ProgramState ExperiencesASTHO Survey Data

Essentially all of the concepts in the Operational Definition and NPHPSP have been addressed

Standards Development Timeline• Draft standards and measures

developed by workgroups

• Alpha test/desk review

• Public vetting

• Revised based on feedback

• PHAB Board approval

• Beta testing

Feb 08-Feb 09

Oct 08-Nov 08

Feb 09-April 09

May 09-June 09

July 09

Late summer 09-Nov 10

Now, To The Standards

11 Domains

31 Standards

>100 Measures

Documentation

Draft Standards Framework

Eleven DomainsPart AAdministrative Capacity and GovernancePart B1. Conduct assessment activities focused on population

health status and health issues facing the community 2. Investigate health problems and environmental public

health hazards to protect the community 3. Inform and educate about public health issues and

functions 4. Engage with the community to identify and solve health

problems

5. Develop public health policies and plans6. Enforce public health laws and regulations7. Promote strategies to improve access to

healthcare services8. Maintain a competent public health workforce9. Evaluate and continuously improve processes,

programs, and interventions10. Contribute to and apply the evidence base of

public health

Eleven Domains (cont.)

Monitor Health

Indiana monitors influenza activity at sentinel sites throughout the state. Testing determines influenza activity and which strains are circulating. Our first confirmed case of the novel H1N1 influenza was detected through one of our sentinel sites.

Diagnose and Investigate• When new cases of confirmed novel

H1N1 influenza were diagnosed, public health did case investigations to determine the epidemiology of this new emerging influenza virus.

Inform, Educate, Empower• Public health quickly informed the public

about the threat of the novel H1N1 influenza virus and developed educational tools.

Mobilize Community Partnerships

• The novel H1N1 influenza virus called upon public health to mobilize community partners to prevent the spread of the virus.

Develop Policies

• The novel H1N1 influenza virus required policy development for school closure, vaccine target groups, etc.

Enforce Laws

• Quarantine/isolation• Worker’s compensation

Link to/provide care

• Uninsured and indigent • Emergency departments• Vaccine administration

Assure Competent Workforce• Vaccinators• Call centers• Medical and public health

Evaluate

• School policies• Collecting and reporting cases• Communications• Unintended consequences

Research

• Viral mutation• Risk factors

Indiana Public Health System Quality Improvement Project

Statewide initiative led by the state healthcommissioner in partnership with PurdueUniversityObjectives

1. Promote quality improvement processes2. Engage public health system partners3. Prepare Indiana for national accreditation

Phase I Phase I –– AssessmentAssessmentCDCCDC’’s National Public Health Performance Standards Programs National Public Health Performance Standards Program

• Early user of Version 2.0 Local and State Instruments.

• Collaboration with partners is critical to developing clear, measurable standards for local and state public health systems.

• Final report provides a means of evaluating system-wide performance

• Results provide a foundation for public health system quality improvement processes.

Phase II Phase II -- TrainingTrainingFour Day Training Course: Team Building, Leadership and Four Day Training Course: Team Building, Leadership and

Problem SolvingProblem Solving

• Participants learn team building and leadership skills.

• Teams learn how to apply problem solving methodologies and toolsto identify primary causal factors limiting program success in public health.

• Teams create a foundation for implementation plans to mitigate/remove primary causal factors and improve program performance related to the 10 Essential Services and Healthy People 2010 objectives.

Root Cause AnalysisThe general principles of root cause analysis are:

•Targeting corrective measures at root causes is more effective than treating the symptoms of a problem•To be effective, RCA must be performed systematically, and conclusions must be backed up by evidence•There is usually more than one root cause for any given problem

Phase IIIPhase IIIPerformance Improvement ProgramsPerformance Improvement Programs

• Identify written performance objectives based on root cause analysis

• Identify key public health partners to collaborate

• Create strategies to meet objectives

• Design and implement plan

Project Charter StepsStep #1 – Define the Problem• Problem Statement• Goal Statement• Project Scope• Output MetricsStep #2 – Analyze the Problem• Current Process Map• Future State Process Map• Cause and Effect Diagram (5 Whys)• Process Observation Worksheet• Spaghetti Diagram• Interviews & Records Reviewed

Project Charter Steps

Step #3 – Evaluate Possible Solutions• Impact & Effort Matrix• Solution ListStep #4 – Test & Implement Solutions• Implementation Plan• Milestones & Completion DatesStep #5 – Standardize and Sustain Solutions• Action Item List

Delaware County, IndianaChildhood Obesity

Effects of being overweight for children

“caused by”

Causes

1. Misbehavior in school Limited parental involvement in family meals or physical activities

2. Lower test scores Inability to concentrate due to sleep disorders

3. Poor general health (increased risk for high blood pressure, asthma, high cholesterol, & type 2 diabetes)

Overweight due to sedentary lifestyle

4. Low self-esteem and isolation from peers

Ridicule about weight from peers

5. Visits to school psychologist or nurse

Poor nutrition and healthy food-insufficiency

1 2 3 4 5 A continuum of causes for childhood obesity

Cause and EffectCause and Effect

Adult and Childhood

Obesity

Poor Nutrition

Caused By

Sedentary Lifestyle

•Less expensive junk food•Easy access to fast food

•Fewer family meals•Lack of nutrition education

•Poor grocery shopping habits

•Marketing high fat foods•Super-sized options•Calorie dense foods

•Skipping meals•Sweetened beverages

Caused By

Caused By

•More time watching television

•Less recess•Limited access to facilities

•Less need for manual activities

•Attractive sedentary options (i.e., video games &

ipods)•Limited PE requirements

•Fewer family outdoor events

•Lack of motivation•Increased time on computer

•Inconvenient to exercise

Causal Tree

Too much television & computer time at home

Lack of meal times together

Using food as a reward

Childhood and Adult Obesity

FamiliesSchools

EnvironmentCommunity

Making unhealthy food purchases

Reliance on processed meals

Using activity as punishment

Healthy food is expensive Lower SES community

Fast food is more convenient

Limited access to exercise facilities

Societal reliance on quick fixes

High fat/calorie menuProhibiting recess as

punishment

Lack of side walks

Cost & convenience of videos & gaming options

Outdoor recreational safety concernsLack of motivation to

change

Minimal time for recess

Lack of nutrition education

School parties & events with unhealthy foods

Food pantry items not healthy

Lack of awareness about resources

Parents not role modeling healthy behaviors

No time set aside in day for exercise

Little advocacy for value of nutrition and physical education

Fish Bone DiagramFish Bone Diagram

Logic ModelInputs

Healthy Living Take Charge!

Delaware County Schools

Delaware County Health

Department

Community Agencies &

Organizations

YMCA

Purdue Extension

Activities

Communicate Healthy Living Take Charge! updates at civic, school, and

community events

Identify educational resources for schools

Assign HLTC team members to website

development & continue to update it

Document current participation of Kidz Marathon of schools

Develop pilot project timeline to propose to 2-3 interested schools

Submit budget to ISDH

Promote new physical activity & nutrition

programs

Facilitate growth of existing community

programs

Outputs

Healthy Living Take Charge

team members shares activities with constituents

Expand on the developments and

news items that are significant

Team member creates a website to track progress

Assess gaps at schools to develop resources that fit

their needs

Start preliminary work for

implementing new fall project w/

parent involvement

Outcomes-Impact

Short Term Medium Term Long Term

Residents of county can see that Healthy Living Take Charge! exists and wants to

make a difference in health outcomes

Create or improve awareness of

resources for the schools and families

Teacher liasion, students & parents actively involved in

project

Collaborate with community agencies

and schools in programs that lead to more physical activity and includes nutrition

component

Students and parents participate in physical activity and nutrition education program

More schools and organizations apply for mini-grants to

implement programs

Delaware County schools and residents are better aware of

community resources for nutrition

education and physical activity.

Increased participation of kids in available physical activity

and nutrition programs.

Schools utilizing nutrition and

physical activity resources in the

classroom

Improved awareness by community members of

resources and capabilities

Evaluation methods developed

to track health outcomes noting better lifestyle

habits to reduce prevalence of

obesity in county.GOAL:Preventing obesity in Delaware County by increasing awareness of healthy food

choices and physical activity benefits.

Influential FactorsSchool time off, YMCA

coordination to implement and sustain

programs, Healthy Living Take Charge!

members’ participation, student and parent support, support by

schools, Delaware Co. Health Department &

ISDH budget.

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Legend

Domain 1: Conduct assessment activities focused on population health status and health issues facing the community

Standard 1.1 B: Collect and Maintain Population Health Data

Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on the health status of the population.

Measure Documentation and Scoring Guidance Type of Measure

Type of Review

1.1.1 B: Assure a surveillance system is in place for receiving reports 24/7 and for identifying health problems, threats, and hazards

Documentation should address:• Processes and protocols to maintain the

comprehensive collection, review, and analysis of data from multiple sources,

• Processes and protocols to assure data are maintained in a secure and confidential manner

• Current 24/7contact information, in the form of a designated telephone line or a designated contact person (which may be provided in rural areas via regional or state agreements)

• Reports of testing 24/7 contact systems, such as, internet, fax, page phone line, etc.

Capacity HealthDepartmentLevel

1.1.2 B: Communicate with surveillance sites on at least an annual basis.

Documentation should address:• List of providers and public health partners who

may be surveillance sites

Process HealthDepartmentLevel

Standards VettingWhy?Improve standards and measures

What?Standards, measures and documentation guidance

How? Through a variety of online and in-person opportunities

When?February-April 2009

We need to hear from YOU!

Vetting Details

• February 2, 2009: Draft standards, measures and documentation guidance

• Multiple ways to provide feedback

• Questions? E-mail vetting@phaboard.org

Equivalency Recognition Work Group Report

• Acknowledge states with existing programs that advised the national process

• Not a grandfathering process

• Recognizes programs that conform to the national program

• Not “PHAB accreditation,” but eligible for same benefits

Equivalency Workgroup Products

•Definition

•Guiding Principles

•Eligibility Criteria

•Recognition Criteria

• Application Process (and Fees)

• PHAB SER Review Process

• Scoring Methodology

• Glossary

More Recent Work on State-Based Accreditation

Think Tank to further the discussion

More work to come…..

Equivalency Recognition Workgroup

• Bud Nicola (WA): Chair• Rex Archer (MO)• Janet Canavese (MO)• Shepard Cohen (MA)• Kathleen MacVarish (MA)• Joan Brewster (WA)• Pamela Butler (OH)

• Martha Gelhaus (IA)• Joe Kyle (SC)• Edd Rhoades (OK)• Rachel Stevens (NC)• Debra Tews (MI)• Lee Thielen (CO)

Assessment Process Workgroup

• Determine how to evaluate whether a health department has achieved accreditation status

• Determine how health departments can appeal decisions

• Professional Accreditation Consultant– Michael Hamm and Associates

• Bud Nicola (WA): Chair• Christine Abarca (FL)• Joan Ascheim (NH)• Janet Canavese (MO)• Alan Kalos (KY)• Jerald King (IN)

Assessment Process Workgroup

•Laura Rasar King (DC)•Richard Matheny (CT)•Bruce Pomer (CA)•Rita Schmidt (WA)•David Stone (NC)•Jeffrey J. Zayach (CO)

Assessment Process

Process to include:– Readiness Review– Application Form– Self-assessment– Site Visit– Findings and

Recommendations Report– Final Determination – Appeals Process– Maintenance of

Performance– Re-accreditation

Assessment Process: Principles

–The assessment process should reduce anxiety and increase comfort for the applicant

–PHAB will offer training, technical assistance, and informational materials on the accreditation process

–All applicants will be required to participate in PHAB training on the application process

60

Research and Evaluation Committee

• Develop a plan for evaluating the assessment processes and identifying research that would improve the standards-setting and accreditation program.

• Review standards and measures for validity and reliability.

• Provide consultation on data collection and interface with accreditation tracking and application online system.

Research and Evaluation Committee

• William Riley (MN): Chair• Christine Bean (NH)• Mary Davis (NC)• Seth Foldy (WI)• Les Beitsch (FL)

• Paul Erwin (TN)• Kerry Gateley (VA)• Brenda Joly (ME)• Laura Landrum (IL)• Glen Mays (AR)

Financing

• Workgroup on fees and incentives

• Affordability of fees critical to success

• Accreditation process should be designed with cost controls in mind

Why participate?

Benefits of AccreditationAccountability & credibilityAccountability & credibility

Tool for improvement

Tool for improvement

Greater collaboration

Greater collaboration

Recognition & validationRecognition & validationBetter

understanding of public health

Better understanding

of public health

Team buildingTeam building

Highlights HD

strengths

Highlights HD

strengthsAccreditationAccreditation

IncentivesUniformly positiveParticipate in learning communityInformed by UNC researchPossible tangible incentives

Improved access to fundingGrants application requirementsGrants reporting requirements

Incentives Research

• What matters to State HDs?– Financial incentives

• Accredited agencies – 60%• Agencies applying for accreditation – 32%

– Infrastructure/quality improvement – 36%– Grants application and administration – 20%

Incentives Research

• What matters to Local HDs?– Financial incentives

• Agencies considering accreditation – 51%• Accredited agencies – 37%

– Infrastructure/quality improvement – 33%– Technical assistance and training – 27%

Incentives Underway

Areas for Further Exploration

• Incentives thresholds• Incentives from States to Locals• Providing incentives

– Menu– Sequencing

• Incentives for Tribal Health Departments

Your Next Steps…..• Review Exploring Accreditation Final Recommendations

• Visit www.phaboard.org often for updates

• Convene key “thought leaders” to discuss next steps in your agency

• Work with your association– ASTHO, NACCHO, NALBOH

• Employ the National Public Health Performance Standards

• Employ NACCHO’s Operational Definition for Local Health Departments

• Comment on the Standards!

www.phaboard.org

Contact Kaye Benderor any Board Member

703.778.4549