Set 1. Case Study. Discussion Guide. Site Visitor Training

Transcription

1 Set 1 Case Study Discussion Guide Site Visitor Training NOTE: All documents used during Site Visitor Training are for training purposes only. The scenarios in the case studies are not representative of actual situations that have or will occur. This guide is to be used for discussion about the case studies and does not cover all possible aspects of the scenarios provided. PUBLIC HEALTH ACCREDITATION BOARD Education Services April, 2013

2 Case Study 1 It is the first day of the Site Visit and the team is in the midst of conducting Domain interviews. You are the only Site Visit Team member who is in the interview for Domain 8. There are two health department representatives present. You noticed one carried a folder of documents as she came into the room. The interview is going well. After about 10 minutes of conversation, the interview topic becomes implementation of the Workforce Development Plan. One of the employees quickly states, We have been doing so much work in this area since our documentation was submitted. We have already made revisions to our plan and put lots of our objectives into place. I have a revised copy of the plan I would like for you to look at, along with some documents showing how the plan is being implemented. As she finishes up speaking, she opens up the folder, grabs a stack of documents and holds them out for you to take. She concludes, Would you please look at these to see how we are working to implement workforce development? How do you proceed? Here are some possible responses: Take the material and look at it Take the material, look at it and ask for it to be uploaded into e-phab Do not look at the material, but ask for it to be uploaded into e-phab Take the material, just to be polite, and say you ll look at it later Apologize that you will not be able to review the material and go back to the list of questions you brought. State that you do not need the material, as any documentation considered must have been completed prior to the submission date Start a conversation around the new material Remember that the Health Department is not to offer documentation to site visitors and you are not to consider paper documentation. Since the material was developed after the documentation submission date, you should not ask for it to be uploaded into e-phab. The interview is a time to round out your perceptions about the health department and its efforts in the Domain. Thus it is OK to discuss the material. The best response is to say, I do have a few more questions. We ll talk about the contents. Let s talk about the contents. Tell me how the department has revised its plan and how it has been successful in implementation. Although this discussion cannot be used in determining conformity with the measure since the revised plan and steps towards implementation occurred after the documentation submission date, it can be used to help shape the overall idea of how the health department is functioning.

3 Case Study 2 Below are interactions between a Site Visitor and a health department representative during an interview. Which are appropriate and which are not? a. Supervisor introducing another employee in the interview, This is Michele. She directs our worksite wellness program in our Health Promotion Division. She s expecting twins in March. Site Visitor responds, That s great. I have twins as well! I remember when I was pregnant. Gosh, was I ever sick. And by the time I delivered I looked like I was ready to bust wide open. Appropriate Not Appropriate You are to be cordial, but keep your role as assessors, not colleagues. It is OK to engage in friendly conversation, but limit the interaction. In this example, the response would be to congratulate Michele and then move on. You would not add your own personal story to any conversation. b. Site Visitor asks, I know that your health department had developed a performance management system just prior to submitting documentation, so there is not yet a record of implementation. Would you tell me how the department has continued to develop the system, and how do you plan to evaluate whether it s accomplishing what you want it to? Appropriate Not Appropriate It is important for interviews to include all Domains, so the Team can have a full picture of the work of the Health Department. If there are no questions from the pre-site visit review of the documentation, or the documentation is very recent, there can still be questions about process, documentation development or implementation.

4 c. Health Department Employee, We are really proud of the way staff have committed to fulfilling our Strategic Plan. It took a long time to develop the templates to implement, and follow-up, on our objectives. The system that we have developed works great for us. Site Visitor responds, This is impressive and I can see that you have gotten results. I would love to try this at my own health department. Would it be possible for me to get a copy of your template set before we finish up the Site Visit? Appropriate Not Appropriate This request is always inappropriate during the site visit. You never ask for materials or copies of documentation for personal use or for the health department where you work. PHAB recognizes the importance of learning from others and sharing among public health professionals. It is fine to note the example or document that you want to follow-up with later and then contact the health department AFTER the process is complete and accreditation status has been determined. d. Health Department Employee, and that s how I m involved in our Emergency Operations Planning, as well as how the whole thing is implemented in our department and in our community. Site Visitor responds, Thanks. Well, that s all the questions I have, but we still have a few minutes left. Could you tell me why you like working here at the Acme County Health Center? Appropriate Not Appropriate The interview is a time for questions regarding the documentation and health department conformity to the Measures of the Domain, not personal questions to staff. Site Visitors should first have questions or notes prepared about the pre-site visit review, along with possible follow-up questions. You should plan on having more questions than you may have time to ask. If all your questions have been answered and a few minutes remain, it is fine to conclude the interview early.

5 e. Site Visitor states, Your health department is involved in a large number of enforcement activities, and some are not the direct responsibility of the health department. What is the health department s process for keeping track of, and assuring, all of this enforcement activity? Health Department Employee, Oh, we have a very detailed log where we track all enforcement activities in which we work with outside agencies, including a reporting and tracking form for individual cases. Site Visitor responds, That sounds interesting. Could you upload an example of the completed log and tracking form into e-phab? Appropriate Not Appropriate It is fine for a Site Visitor to request documentation from the health department as long as it is related to a specific measure. It must be uploaded into e-phab prior to the Site Visit Team's last Executive Session and it must have been in place prior to the documentation submission date. For the example requested, it must have evidence (date) of being in use or completed prior to the date documentation was submitted to PHAB.

6 Case Study 3 The documentation provided by the Acme County Health Center (a local health department) for Measure A was excellent. It thoroughly addressed the Measure s requirements and showed an involvement at the local and the state level. The Measure was assessed as Fully Demonstrated. What is the best conformity statement from the examples below? Refer to Measure A in the PHAB Standards & Measures, Version 1.0 as needed. a. The health department provided 4 documents demonstrating how it met this measure. One was an agenda of a task force on smoking in county facilities that includes commissioners as members. The second was a white paper produced by the task force. The third was a hearing schedule at the state legislature with the Health Director scheduled to testify on a bill to require helmets on all four-wheeler (ATV) vehicles. The fourth was the statements that the Health Director delivered at the hearing. Yes No This is a listing of the documentation submitted by the health department. Other than telling what was reviewed, it gives no information to the Accreditation Committee on how the documents conform to the Measure. b. The health department provided detailed information on its involvement with commissioners and state legislators to influence and shape public policy around such issues as smoking in public facilities. Efforts range from local task forces to testimony at the state legislature. Other efforts include building community involvement as advocates for public health policy. Yes No This is the best of the examples given. It tells HOW the documents demonstrate conformity, gives an example of a policy issue and also tells who is involved by the health department.

7 c. The health department provided documentation that was within the last 24 months showing contributions to deliberations concerning public health policy and practice. The health department engaged those who set policies and also encouraged community involvement in the development of public health policy. Documentation did address two of the three required items. Yes No This is a restatement of the guidance in the Standards and Measures. It is just general information that helps the Accreditation Committee no more than example d. d. All required elements of the Measure were met in the documentation provided. Yes No This is a simple statement of conformity that would be appropriate for some Measures and of no use in others. This statement could be used in Measures where the documentation was fully met, was straightforward and where the required documentation and guidance details the extent of the contents. e. All required elements of the Measure were met in the documentation provided. The fact that the department is active at the state level and leadership has testified in multiple hearings at the state legislature is commendable and should be adopted by other health departments in the state. Yes No A basic statement of conformity is provided and then the comments move into area of excellence. Again, the conformity statement is the same as example d. The following sentence doesn t belong in the conformity box. This should be separated and placed in the correct comment boxes for the report.

8 Case Study 4 Domain 11 addresses Administrative and Management Capacity. Measure A is Maintain written agreements with entities providing processes, programs and/or interventions delegated or purchased by the public health department. Attached are two documents that the Acme County Health Department has submitted as documentation for the measure. They completed their submission of documentation on January 18, Review the documentation against the requirements in the Standards and Measures. How would you assess (rate) the documentation? Based upon the documentation presented, write the Conformity Statement and note Areas of Excellence and Opportunities for Improvement. Refer to Measure A in the PHAB Standards & Measures, Version 1.0 as needed. Assessment: Fully Largely Slightly Not Demonstrated The two contracts are good, have financial content and correctly executed. One is with the state and one with another governmental entity (local school system). However, the contract with the state is not one where the health department has purchased services but one where the health department is provided services to the state. The pathway required by the measure is reversed and the contract does not meet the intent, or the requirement, of the measure. The contract with the school system is acceptable, but the most recent budget agreement must be requested to determine if the contract is still in effect. After the pre-site visit review, the measure would be slightly demonstrated. This would be discussed by the full team to determine the types of questions you may wish to submit questions to the health department Site Visitors, after team discussion, can ask for another example from the health department to replace the contract with the state that is not acceptable. When requesting another document, do not mention that one is not acceptable, or define the one that has been rejected. Remember that reopening a measure is not the opportunity for a do-over. However, here the health department submitted a contract that meets the requirements except for the pathway. This may have been an oversight by the health department.

9 Conformity Statement (How does this deserve the assessment, or score, you determined?) Based upon the evidence here, there are questions to be asked after the pre-site visit review. Without this information, it is not possible to write a true conformity statement. Assuming that the contracts submitted is the documentation being rated for the measure, here is a sample: The two contracts submitted were appropriately dated and fully executed. One contract was for nursing services provided through the local school system. However, one was a contract to provide Environmental Health Services to the state and is not acceptable. Areas of Excellence (What strengths did you find in the way that the health department is demonstrating this measure?)?? (This discussion varies based on the experience and judgment of the Site Visit Team. Opportunities for Improvement (How could the health department improve the way it is demonstrating, or not demonstrating, the measure?)?? (This discussion varies based on the experience and judgment of the Site Visit Team. At this point, it is difficult to determine any areas of excellence or opportunities for improvement. You have noted in the conformity statement that one of the contracts was not acceptable, and there is no need to make any kind of statement about that here.