Site Visitor Training

Transcription

1 CASE STUDY 3 E-PHAB DOCUMENTATION ASSESSMENT DISCUSSION GUIDE Site Visitor Training NOTE: The documents used during Site Visitor Training are for training purposes only and do not represent actual documentation, nor is it indicative that similar documentation should be accepted or rejected by site visitors. This guide is to be used for discussion about the training documents and does not cover all aspects of document quality, nor how they would or would not meet PHAB requirements. PUBLIC HEALTH ACCREDITATION BOARD Education Services Revised April 2013 PHAB EDUCATION SERVICES - Discussion Guide Page 1 of 49

2 DOCUMENTATION EXERCISE GUIDE Site Visitor Training Documentation Exercise using e-phab Here are the measures that are in the SVT Training Health Departments. The documentation is also located on the flash drive distributed at the training T/L T/L A A A A A A A T/L A A A A A A A A Acronyms ACHC Acme County Health Center EH Environmental Health OFI Opportunity for Improvement NOTE: Many of the Measures are either largely or slightly demonstrated for training purposes. They are not designed to show that health departments would submit many measures that would be assessed as such most measures will likely be fully demonstrated. PHAB EDUCATION SERVICES - Discussion Guide Page 2 of 49

3 Measure T/L Domain 1: Conduct and disseminate assessments focused on population health status and public health issues facing the community Standard 1.1: Participate in or Conduct a Collaborative Process Resulting in a Comprehensive Community Health Assessment T/L: Complete a Tribal/local community health assessment Required Documentation 1: A Tribal or local community health assessment dated within the last five years that includes: Documentation that data and information from various sources contributed to the community health assessment and how the data were obtained A description of the demographics of the population A general description of health issues and specific descriptions of population groups with particular health issues Example 1 Example 2 A description of contributing causes of community health issues A description of existing community or Tribal assets or resources to address health issues Title ACHC Community Health Assessment Part 1 File Acme 2010 CHA Volume One File Description This is the primary report of the ACHC CHA from Title ACHC Community Health Assessment Part 2 File Acme 2010 CHA Volume Two File Description Part 2 of the ACHC CHA from 2010 contains Environmental Health data. PHAB EDUCATION SERVICES - Discussion Guide Page 3 of 49

4 Required Documentation 2: Documentation that the Tribal or local community at large has had an opportunity to review and contribute to the assessment Example 1 Example 2 Title Website Comment for CHA File Measure Website Comment File Description This document details the CHA posting on the ACHC website inviting comment and questions. Title Press Release for CHA File Measure CHA Press Release File Description This press release was sent on announcing the CHA reports and asking for comment. Measure Narrative The documentation in this measure related to the CHA process that the ACHC undertook in We use the CHA protocols established by Healthy Carolinians at the State Division of Public Health (See L). For this CHA, we collaborated with the NC Institute for Public Health, which facilitated the process. The report was issued in two parts. The first dealt with health care needs, demographics and health data. The second dealt with environmental health issues and data. The examples of distribution and seeking of input are but two of many - others are available upon request. The Board of Health also sought input at BOH meetings. The press release and website posting were two primary means of publicizing the reports and seeking input. Referenced in Narrative (1.1.1L) Required Documentation 3: Description of the process used to identify health issues and assets Title CHA Guide Book File Measure CHA Guide Book File Description This is the guide book for the CHA process established by the Healthy Carolinians Branch at the NC Division of Public Health. PHAB EDUCATION SERVICES - Discussion Guide Page 4 of 49

5 Assessment 1. While all the required components are most likely in the reports, none of the bullet points have been flagged or highlighted. (The first four bullets are in the documents. The fifth bullet is touched on throughout but is not fully developed.) Unless the Site Visitor wants review some 330+ pages in the reports, the health department should be asked to provide narrative on where the required elements can be found in the document. 2. These two examples are fine. A documentation OFI to make the documentation stronger would be to have a screen shot from the web site showing the info that was posted and to include a fax cover or showing distribution of the press release. Pre-Site Visit Assessment: Pending, until the required elements in the CHA are located. The material does fully demonstrate with an Opportunity for Improvement to better delineate the available community resources. PHAB EDUCATION SERVICES - Discussion Guide Page 5 of 49

6 Measure T/L Domain 2: Investigate health problems and environmental public health hazards to protect the community Standard 2.1 Conduct Timely Investigations of Health Problems and Environmental Public Health Hazards T/L: Demonstrate capacity to conduct an investigation of an infectious or communicable disease Required Documentation1: Audits, programmatic evaluations, case reviews or peer reviews of investigation reports against protocols (2 examples) Example 1 Example 2 Title Evaluation of HepA Response File Measure ACHC Evaluation of HepA Response File Description Title Acme OSWW Program Review 2008 File Measure Acme OSWW Program Review 2008 File Description Here is a complete program review of the On-Site Wastewater (OSWW) program in Environmental Health at ACHC. This was conducted by the State OSWW Division and was conducted in February, The report was dated May 16, 2008 and details the evaluation of the program against protocols. Title OSWW Plan of Action File Measure Plan of Action File Description Here is the Plan of Action developed by the ACHC in August of This follows up and is in response to the Program Review of Note highlighted text. Required Documentation 2: Completed After Action Report (AAR) PHAB EDUCATION SERVICES - Discussion Guide Page 6 of 49

7 Title Acme Shigella Outbreak Report File Measure Acme Shigella Outbreak report-final File Description Here is the final report of the November 2009 Shigella Outbreak in the county and the response of ACHC. The report was finalized on and forwarded to the State Division of Epidemiology. Measure Narrative ACHC has provided two examples of programmatic reviews. One was done by the state for our On-Site Waste Water program. Another review was an internal review of our response to a Hepatitis A outbreak. The AAR is from an investigation of a Shigella outbreak that the ACHC responded to, mitigated and contacted those affected in the outbreak. Assessment 1. There are two examples provided. The guidance specifies that the examples should be related to the capacity to respond to outbreaks of infectious or communicable disease. Also note that the guidance and the measure state that the documentation should be reviews of investigation reports against protocols. Acme has provided two examples. The evaluation is for a Hepatitis A outbreak. There is a need to have the protocol that was used as a part of the evaluation and this should be asked for. The OSWW example is a program review that is nonspecific to a particular outbreak or disease situation. It could be possibly argued that the review does contain information of work against protocol, and that improper disposal of sewage or a system failure can cause an outbreak of disease, but this is a stretch and does not meet the intent of the measure. This example would not be acceptable. There could be a question with a reopen to ask for another example that has a focus of an infectious or communicable disease. 2. The department does provide an AAR of a communicable disease outbreak and how the HD conducted the response. This is acceptable evidence for this requirement. (Note that this outbreak provides a means for developing documentation for the other requirement in this measure. The AAR could be reviewed against the department s communicable disease response protocols to determine if the response was handled in the best way possible. However do not ask for this specific type of evidence. However, you could mention this in your comments regarding Opportunities for Improvement. Pre-Site Visit Assessment: Largely Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 7 of 49

8 Measure A Domain 2: Investigate health problems and environmental public health hazards to protect the community Standard 2.3: Ensure access to laboratory and epidemiological/environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards A: Maintain 24/7 access to laboratory resources capable of providing rapid detection, investigation and containment of health problems and environmental public health hazards Required Documentation 1: 1. Laboratory certification Document 1 Document 2 Title ACHC Laboratory CLIA Certificate File Measure ACHC CLIA Certificate File Description This is the CLIA certificate showing that the department is authorized to conduct the listed laboratory testing. Title NC State Lab CLIA Certification File Measure NC State Lab CLIA Certification File Description This is the CLIA certificate for the NC State Lab of Public Health, which serves as a main reference lab for the health department. Required Documentation 2: 2. Policies and procedures ensuring 24/7 Coverage Title ACHC Emergency Operations Procedures File Measure ACHC duties EOP File Description See highlighted text showing our responsibility to have full time coverage of all major services and for response to public health emergencies. PHAB EDUCATION SERVICES - Discussion Guide Page 8 of 49

9 Required Documentation 3: 3. Protocols for handling and submitting specimens Document 1 Document 2 Document 3 Title Clinical Laboratory & Clinical Lab Specimens File Measure Clinical Laboratory & Clinical Lab Specimens File Description none Title Laboratory Specimen Handling Policy File Measure Laboratory Specimen Handling Policy File Description none Title Laboratory Specimens Protocol File Measure Laboratory Specimens Protocol File Description none Measure Narrative Through our own laboratory services and the reference labs we use, we maintain the necessary capacity for both daily services and emergency or outbreak response. We maintain a moderate level CLIA certified lab (offsite) and provide basic support at the health department. All laboratory policies follow both the department protocol and CLIA protocols for review and revision. Assessment 1. There are two CLIA certificates provided one for ACHC and one for the State Lab. The State Lab Certificate has expired, so a new one will need to be requested. Also, the team should ask if there are any other reference labs used by the HD. This could be done as a question thru e-phab, or could be noted by the team as a question during the interview. In either case, if there are other labs, the team would decide if those certificate copies will be asked for. PHAB EDUCATION SERVICES - Discussion Guide Page 9 of 49

10 2. There is only one weak piece of evidence here. It is a HD duties section from the Co. EOP that states that the HD will maintain 24/7 coverage for the lab. However there is no policy or protocol included. This does not meet the documentation requirement. The team could ask for the policy on how the HD maintains the coverage of the lab. 3. There are three polices/protocols attached and all are named for laboratory specimens. While between the three this element is demonstrated, there is a definite opportunity for improvement. All three protocols have components of specimen handling and three different policy formats. How does staff know which one to refer to? Or would all three have to be referenced, if needed, when handling specimens? These three should be consolidated into one protocol. Also, there are no protocols for handling environmental health specimens. This could be a question now or during an interview. The team would determine if it would reopen to request environmental health specimen handling protocols. Pre-Site Visit Assessment: Slightly Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 10 of 49

11 Measure A Domain 3: Inform and educate about public health issues and functions Standard 3.2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences A: Establish and maintain communication procedures to provide information outside the health department Required Documentation 1: Written procedures for communications, updated biennially, that include: a. Disseminating accurate, timely, and appropriate information for different audiences b. Informing and/or coordinating with community partners for the communication of targeted and unified public health messages c. Maintaining a current contact list of media and key stakeholders d. Designating a staff position as the public information officer e. Describing responsibilities and expectations for positions interacting with the news media and the public, including, as appropriate, any governing entity members and any department staff member Document 1 Document 2 Document 3 Title Acme Media Policy File Measure Acme Media Policy File Description Health Department media policy Title ACHC Crisis Communication Policy File Measure ACHC Crisis Communication Policy File Description This document demonstrates the appointment and role of the PIO Title Acme County Emergency Pub Info Plan File Measure Acme Co Emer Pub Info Plan File Description Contains communication procedures. See highlighted list of media contacts on page 24 PHAB EDUCATION SERVICES - Discussion Guide Page 11 of 49

12 Required Documentation 2: Dissemination of public health messages outside the health department Example 1 Example 2 Document 1 Document 2 Document 1 Measure Narrative Title Diabetes Press Release File Measure Diabetes Press Release File Description 1 st example of disseminated message Part 1 Title Diabetes Advocacy Day Press Release File Measure Diabetes Advocacy Day Press Release File Description 1 st example of disseminated message Part 2 Title Heat Related Illness Press Release File Measure Heat Related Illness Press Release File Description 2 nd example of disseminated message We submit our Crisis Communications Plan, our Media Policy and our Acme County Emergency Public Information Plan, as referenced above, as examples of the department s ability to establish and maintain communications procedures to distribute timely information in an appropriate fashion outside the agency. We also have provided examples related to two programs diabetes care from adult health/chronic disease and heat related illness from community health promotion to demonstrate the implementation and following of our plans. Assessment 1. The three documents include two department policies and a county plan. The documentation listed is only part of what is needed. The attached policies do not PHAB EDUCATION SERVICES - Discussion Guide Page 12 of 49

13 have the required elements. We do know that they have a PIO, so requirement d is well covered. Some of requirement e is covered also. While there is a list of media contacts, there is no list of key stakeholders included for requirement c. Requirements a and b have some documentation in the county plan, but they are not pointed out or highlighted, so the site visitor would have to read thru and pick out what they think applies. 2. Here two examples are presented and one is a chronic disease - diabetes. The other is within health promotion (injury prevention?). This section is met. An OFI would be to include the or fax cover showing that the releases went out. Pre-Site Visit Assessment: Largely Demonstrated The main deficiency is within required documentation 1. PHAB EDUCATION SERVICES - Discussion Guide Page 13 of 49

14 Measure A (NOTE: This documentation is the same as in 7.2.1) Domain 4: Engage with the community to identify and address health problems Standard 4.1 Engage with the Public Health System and the Community in Identifying and Addressing Health Problems Through Collaborative Processes A: Establish and/or actively participate in partnerships and/or coalitions to address specific public health issues or populations Required Documentation: 1. Documentation of current collaborations that address specific public health issues or populations Example 1 Document 1 Document 2 Title Access to Care Annual Report File Measure Coalition Report File Description This is an annual report on the Access to Care project of the ABO Health Care Coalition. Title Agreement for Nurse Practitioner Services File Measure Agreement for NP Services File Description This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner to serve at the ACHC clinic sites. Example 2 Document 1 Title Access to Care Action Plan 2010 File Measure Access to Care Action Plan File Description This is the action plan regarding access to care from the 2010 Community Health Assessment. Partners are highlighted (for required documentation 2). PHAB EDUCATION SERVICES - Discussion Guide Page 14 of 49

15 Document 2 Title Access to Care Talking Points File Measure Access to Care Talking Points File Description This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders. 2. List of partner organizations or representation in each collaboration Title List of Coalition Partners File Measure List of Coalition Partners File Description Here is a list of partners for both coalitions, also highlighted in other documents in this measure. 3. Description of process used to mobilize the Tribal/state/local community Title Action Plan with process highlights File Measure Access to Care Action Plan - process highlights File Description The efforts to engage coalition members and the community is highlighted through our marketing plans for the project. Measure Narrative The examples included demonstrate the active participation of the ACHC in the coalitions submitted. The needs addressed by these efforts are supported through our CHA and CHIP. We work to engage both our partners and the community in these efforts to address public health needs. Assessment 1. Though there are two examples the (ABO coalition and HealthNet), it appears that the HealthNET project involves the ABO coalition and is one piece of their work. Can you argue that there is a coalition between BestHealth and ACHC? No, the NP contract is just that a contract and is a support to the HealthNet project. Nonetheless, they both are working on the same public health issue access to care, so another example of a coalition is needed. This can be a question with a reopen if desired. 2. Provided is a listing and both examples in required documentation 1 have the partners highlighted in the documents. PHAB EDUCATION SERVICES - Discussion Guide Page 15 of 49

16 3. This is the same document that was submitted for required documentation 1. That is fine and the health department has highlighted different information in the document. The work of the ABO coalition has some process listed in the Action Plan though weak and lacking in detail. The HealthNet report has no real info on process at all. This required documentation is not present. Pre-Site Visit Assessment: Slightly Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 16 of 49

17 Measure A Domain 5: Develop public health policies and plans Standard 5.1 Serve As a Primary and Expert Resource for Establishing and Maintaining Public Health Policies, Practices, and Capacity A: Inform governing entities, elected officials, and/or the public of potential public health impacts, both intended and unintended, from current and/or proposed policies Required Documentation 1: Documentation of the health department informing policy makers and/or the public about potential public health impacts of policies that are being considered or are in place Document 1 Document 2 Title County Commissioner Agenda Abstract File Measure BOCC Agenda Abstract July 12, 2010 File Description This document is the abstract of what the Health Director presented to the Board of County Commissioners at their meeting on July 12, Title County Commissioner Meeting Minutes File Measure BOCC Minutes File Description This document is a page from the meeting minutes of the Board of County Commissioners held on July 12, Highlighted is the Health Director s report on policy changes in the Environmental Health Water Sampling Program. Document 3 Document 4 Title Board of Health Agenda File Measure BOH Agenda Dated August 17, 2010 File Description This document is the agenda for the Board of Health meeting held on August 17, On the agenda is discussion of Environmental Health policies. Title Board of Health Meeting Minutes PHAB EDUCATION SERVICES - Discussion Guide Page 17 of 49

18 Document 5 File Measure BOH Meeting Minutes Dated August 17, 2010 File Description This document is the meeting minutes of the Board of Health for August 17, Highlighted are the two policy change discussions. Title Environmental Health Water Sampling Policy File Measure EH Water Sampling Policy File Description This is the Environmental Health water sampling policy discussed at the Board of Health and Board of County Commissioner meetings. Measure Narrative In the documentation requirement, policies is plural so two examples are needed. The documents for this measure contain two examples of policy change - state immunization policy and the ACHC Environmental Health water sampling policy. Presentations to policy makers and processes for public notification are included. Assessment 1. The documentation provided gets at what the measure is assessing but is disjointed. It appears that the department did inform both the governing entity and elected officials about the impact of a policy change. We are just unsure what the public health impact is. There are two issues here changes in immunizations and changes to an EH policy. The Board of Health agenda and minutes are uploaded, but the immunization fact sheet was not. That document is needed to help complete the requirement. For the EH policy, it is noted that the potential impact was discussed with the Board of Health, but no detail is recorded. The policy is included but again, we do not know what the changes are and how it could impact the community from a public health perspective. Also, the impact was discussed with the Commissioners, but the materials, comments presented or presentation itself needs to be added. Questions could be asked to define the impacts from the EH policy. The measure could be reopened to request the missing documentation. Pre-Site Visit Assessment: Slightly Demonstrated Missing documentation and no cohesive documentation about the EH policy impact PHAB EDUCATION SERVICES - Discussion Guide Page 18 of 49

19 Measure A Domain 6: Enforce public health laws Standard 6.2 Educate Individuals and Organizations On the Meaning, Purpose, and Benefit of Public Health Laws and How to Comply A: Provide information or education to regulated entities regarding their responsibilities and methods to achieve full compliance with public health related laws Required Documentation 1: Written record of the provision of information or education to regulated entities concerning their responsibilities for compliance with public health laws Example 1 Example 2 Example 3 Example 4 Title ACME Well Rules File Measure ACME Well Rules 2008 File Description Acme County Well Rules adopted in 2008 Title Effective Date of Well Rules File Measure Effective Date of Well Rules File Description Board of Health authorization on when the well rules will take effect. Title Open Forum Agenda File Measure Open Forum Agenda File Description Open forum for well-drillers regarding the well rules held March 15, Title Open Forum Minutes File Measure Open Forum Minutes File Description Minutes from the open forum held March 15, PHAB EDUCATION SERVICES - Discussion Guide Page 19 of 49

20 Example 5 Title Proposed time line for well rules File Measure Proposed time line for well rules File Description Timeline for the adoption of the well rules Measure Narrative These documents relate to the adoption of county well rules in 2008 and the sharing of the information with those who would be most impacted well drillers who work in the county. A copy of the rules are included as well as the information regarding a forum held to inform the well drillers. The rules and the timeline were distributed at the forum. Assessment 1. First, there is only one example here and two are needed. This is something that the AS will check for when doing the completeness check. They would notify the department that only one example has been provided (though there are multiple documents for that one example. Should something like this make it through the completeness review, the team would ask for another example since two are required by the health department. 2. There was some good evidence here but it applies to one example. Since the rules are signed and dated, there is no need for the effective date document, which isn t signed anyway. Just disregard this document it adds nothing. The minutes give the number of attendees. The guidance states an attendance list, so an OFI would be to include the list of participants or sign in list as a part of the minutes. The time line document doesn t really add anything here either and is just extra documentation. While it does show plans for the open forum, the minutes and agenda are stronger evidence. Pre-Site Visit Assessment: Pending Leave as pending since two examples are required PHAB EDUCATION SERVICES - Discussion Guide Page 20 of 49

21 Measure A Domain 6: Enforce public health laws Standard 6.3 Conduct and Monitor Public Health Enforcement Activities and Coordinate Notification of Violations among Appropriate Agencies A: Coordinate notification of violations to the public, when required, and coordinate the sharing of information among appropriate agencies about enforcement activities, follow-up activities, and trends or patterns Required Documentation 1: Communication protocol for interagency notifications Title ACHC Notification Policy File Measure ACHC Notification Policy interagency File Description This is the health center s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for interagency notifications. Required Documentation 2: Protocol for notification of the public when required Title ACHC Notification Policy File Measure ACHC Notification Policy public File Description This is the health center s notification policy for enforcement activities dealing with Environmental Health, Communicable Disease and Animal Control. See the high-lighted areas for public notifications. Required Documentation 3: Documentation of notification of enforcement actions, and sharing information concerning enforcement activities Title Environmental Health Notice of Violation File Measure EH Notice of Violation File Description Here is an example of a Notice of Violation that is a part of the Environmental Health rules. This sample was delivered in person by Environmental Health to the owner of the septic system that had failed. PHAB EDUCATION SERVICES - Discussion Guide Page 21 of 49

22 Title HIV Isolation Order File Measure HIV Isolation Order File Description This is a copy of an HIV Isolation Order that was given to an individual in July of This follows enforcement action as detailed by State Statute (listed in the letter). The individual information has been blacked out. Measure Narrative The communication protocols for both interagency and public notifications are included in the same policy. This policy is submitted for required documents 1 & 2, with sections highlighted to demonstrate how it contains that requirement. There are a number of communication protocols that are define by rule and statute. ACHC adopts those by reference as we are the agent of the state that enforces those regulations. ACHC has attached two examples of notification that we do as a part of our Environmental Health and Communicable Disease programs. Both follow the guidelines established by law and State Government. Assessment 1 & 2. The health department submitted the same document for both requirements. It is fine to have both required elements in the same document and they have highlighted the differences. Note that there are several references to statute. Guidance requires the submission of these laws. Thus the need to have the reference that includes lists of communication requirements in law or rule. This is a case of I said so, but the Site Visitors will not know the rules that the health department must operate by. While there are 4 other possible documents about protocols for interagency communications on the flash drive, none of the documents really deal with notification of violations. Measure ACHC Communication and Media Protocols Measure ACHC Crisis Communication Policy Measure Acme co Emer Pub Info Plan Measure Acme Media Policy These other protocols fit better in Measure The department did provide two examples of enforcement letters that was sent from the department. Both are fine examples of enforcement of laws, but notice that PHAB EDUCATION SERVICES - Discussion Guide Page 22 of 49

23 this correspondence goes to individuals and not the public or other agencies. So while the documents fulfill the requirement, they do not fulfill the measure. Remember to put the documentation requirement in the context of the measure. If these had been examples that 1) went to other residents in the mobile home park regarding the sewage leak, and; 2) the issuance of the isolation order had been communicated to the state public health department; then the requirement would have been demonstrated. This is an OFI for this measure and the note in the conformity box. Pre-Site Visit Assessment: Slightly Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 23 of 49

24 Measure A (NOTE: This documentation is the same as in 4.1.1) Domain 7: Promote strategies to improve access to health care services Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services A: Convene and/or participate in a collaborative process to establish strategies to improve access to health care services Required Documentation 1: Documentation that a coalition/network/council is working on collaborative processes to reduce barriers to health care access or gaps in access Document 1 Title Access to Care Action Plan 2010 File Measure Access to Care Action Plan File Description This is the action plan regarding access to care from the 2010 Community Health Assessment. This document supports both required elements of documentation. Document 2 Title Access to Care Talking Points File Measure Access to Care Talking Points File Description This document was developed for the members of the ABO Health Care Coalition. It is to help guide our discussions and to provide information and requests from funders and stakeholders. Required Documentation 2: Development of strategies through the collaborative process to improve access to health care services Document 1 Title Access to Care Annual Report File Measure Coalition Report File Description This is an annual report on the Access to Care project of the ABO Health Care Coalition. PHAB EDUCATION SERVICES - Discussion Guide Page 24 of 49

25 Document 2 Measure Narrative Title Agreement for Nurse Practitioner Services File Measure Agreement for NP Services File Description This is an agreement between BestHealth of the Piedmont and the ACHC for a Nurse Practitioner (NP) to serve at the ACHC clinic sites. Contraction for a NP is one of our strategies to address access to care issues. These documents demonstrate the efforts of the ACHC and community partners, including local medical providers and partners to increase and improve access to care. Through a regional coalition and the CHA, we are working to increase access by providing services and staffing, by contracting for NP services onsite at the ACHC, to meet identified needs. Assessment Is it OK to use the same material for different measures? Yes, but remember that the contents must conform to the requirements of the measure. If using documents more than once, there should be different elements in the documentation that meets the requirements for the separate measures. However, the documentation is a better match in this measure than in There is evidence of a collaborative process here in the action plan. The talking points would be better under Required Documentation 2, since it gets at strategies. 2. While there is documentation of strategies being used (and the HD submits that contracting for a NP is one), there is only sketchy evidence of how the strategies were developed by the coalition partners. This would be an OFI. The Annual Report has soon elements that could be highlighted for Required Documentation 1. While the documentation could be better arranged in the submission process, that s OK for assessing as what is needed is here. Pre-Site Visit Assessment: Fully Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 25 of 49

26 8.1.1T/L Domain 8: Maintain a competent public health workforce Standard 8.1: Encourage the Development of a Sufficient Number of Qualified Public Health Workers T/L: Establish relationships and/or collaborations that promote the development of future public health workers Required Documentation 1: Documentation of relationships or collaborations that promote public health as a career Document 1 Document 2 Title Internship Learning Agreement File Measure Learning Agreement File Description This document is a copy of an agreement to place an intern from Bowman University at the ACHC. Title Acme Comm College Contract File Measure Acme Comm College Contract signed File Description This is our agreement with the local community college regarding placing students in the Health Center for internships or practicums. Measure Narrative Included are two samples of agreements or contracts used by the ACHC to give students an opportunity to experience public health and gain exposure to a possible career choice. There are executed contracts on file at the department that can be reviewed on request. Assessment 1. There are two documents and only one example is needed. The Acme Community College contract has been signed and appears to be in place. Based upon the narrative, there are records at the Health Department demonstrating the use of the contract. The learning agreement is an executed document showing how a student is PHAB EDUCATION SERVICES - Discussion Guide Page 26 of 49

27 working in the health department for an internship. Again the narrative insinuates that there may be other contracts at the Health Department as well. While both are excellent in developing future public health workers, an OFI (based on guidance) would be for the Health Department to also document instances of making presentations to a university, college, high school or club about public health as a career. Pre-Site Visit Assessment: Fully Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 27 of 49

28 8.2.1 Domain 8: Maintain a competent public health workforce Standard 8.2: Assess Staff Competencies and Address Gaps by Enabling Organizational and Individual Training and Development A: Maintain, implement and assess the health department workforce development plan that addresses the training needs of the staff and the development of core competencies Required Documentation 1: Health department workforce development plan that includes: a. Nationally adopted core competencies b. Curricula and training schedules Document 1 Document 2 Title Workforce Development Policy File Measure Workforce Development Policy File Description This document is the ACHC Workforce Development Plan that was adopted in 2008 and revised in 2010 Title Training Calendar 2011 File Measure Training Calendar 2011 File Description This is the schedule of trainings for ACHC staff held in 2011 Required Documentation 2: Documentation of implementation of the health department workforce development plan Title Workforce Development Implementation Report File Measure Workforce Development Implementation Report File Description This is the 2010 report showing implementation of the Workforce Development Plan. PHAB EDUCATION SERVICES - Discussion Guide Page 28 of 49

29 Measure Narrative The documentation included for this measure are the workforce development policy and plan for the ACHC. The plan was initially adopted in 2008 and has been guiding our workforce development since. It was revised in 2010 and has the support of the Board of Health. The implementation report and the training schedule are completed each year and are used in review and needed revisions of the plan. Assessment While the basics seem to be here, the documentation is weak. 1. There is a plan present. While the plan has a short paragraph on using the national core competencies, there is no real link to any of the implementation or training plans. Also, the plan just mentions using the competencies without any supporting detail about how they will be used for staff. There is a training calendar but it is very limited. There is no info on who is targeted, what the topic might cover and who is responsible. Also, some of the trainings are listed as updates and may just be info sharing versus an educational session. 2. There is an implementation report with a number of trainings listed. This will work but what is needed is the agenda, participant list and materials for two of the sessions to show who attended and the elements covered in the training and how those trainings relate back to the Workforce Development Plan. Pre-Site Visit Assessment: Slightly Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 29 of 49

30 Measure Domain 9: Evaluate and continuously improve health department processes, programs, and interventions Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions A: Establish a quality improvement program based on organizational policies and direction. The following documentation (2 files) and descriptions have been uploaded into this measure. Required Documentation 1: A written quality improvement plan Example 1 Document 1 Document 2 Document 3 Title ACHC Quality Improvement Plan (Example 1) File Measure Quality Improvement Policy and Plan File Description none Title ACHC Quality Improvement Plan (Example 2) File Measure Quality Improvement Policy and Plan with highlights File Description The QI Plan has highlights to note how the plan correlates to the guidance for the measure. Title Companion to ACHC QI Plan (Example 2a) File Measure Companion to QI Plan File Description This companion document is the key that supplements the highlights in the QI Plan. This document is color-coordinated to match with the QI Plan in highlighting the key elements. PHAB EDUCATION SERVICES - Discussion Guide Page 30 of 49

31 Example 2 Title ACHC Quality Initiatives File Measure ACHC QI Initiatives for FY File Description This is a work plan for the three initiatives from Measure Narrative The ACHC QI Plan has been adopted to provide the guidance in developing and implementing a strong QI plan at the health department. The Plan was initially adopted in 2008 and has been used in strategic planning and in programs review. It is reviewed annually by both the leadership of the ACHC and the Board of Health. A copy is on file in the County Manager s Office. Also included is the worktable of the QI initiatives undertaken at ACHC during the most recent Fiscal Year (July, 2011 to June 2012). Assessment NOTE: The examples are two representations of what could be submitted. The department would not submit both examples, but either 1 or 2. For example 1, the plan is OK, but would be frustrating and time consuming to review. The plan needs to have key elements highlighted or detailed so the site visitors can easily locate as they review the file. So it is fine to send a question to the health department asking them to point out the elements in the plan as listed in the guidance. For example 2 & 2a, the plan has highlighted the key elements as listed in the guidance. This plan is acceptable, though site visitors may fine some opportunities for improvement for some areas that need more detail, for example identifying and selecting projects. Also, there are the goals for the last year, but since a new year has started there should be a new work plan that can be included. It is fine to ask for this document (it must have been written prior to hitting the submit button) or offer it as an OFI. Note: the date uploaded date is not the submitted date. OFI add in elements of the process that is being studied for QI. Pre-Site Visit Assessment: Fully Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 31 of 49

32 Measure Domain 9: Evaluate and continuously improve health department processes, programs, and interventions Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions A: Implement quality improvement activities The following documentation (3 files) and descriptions have been uploaded into this measure. Required Documentation 1: Documentation of quality improvement activities based on the QI plan Document 1 Document 2 Title QI Team Notes for Media Relations Initiative File Measure Media Relations 2010 File Description This document is one of the working records of the QI Team. It demonstrates working through the QI process. Title Family Planning Storyboard File Measure Acme QI Storyboard File Description Storyboard of the ACHC project to decrease Family Planning waiting time results of the project are demonstrated. See highlighted areas in text to show project participants as well as actions taken and follow-up meeting QI plan guidelines. Required Documentation 2: Demonstrate staff participation in quality improvement activities based on the QI plan Document 3 Title QI Team Minutes for July 2011 File Measure QIT Minutes July 2011 File Description Minutes of the Quality Improvement Team showing actions of the group and the members of the team, thus demonstrating staff participation in QI see highlighted text. PHAB EDUCATION SERVICES - Discussion Guide Page 32 of 49

33 Measure Narrative These three documents show how the QI Team at the ACHC are workings to implement the QI plan and bring meaningful change to the department through the involvement of both leadership and frontline staff. Assessment 1. There are two examples provided. The storyboard is a good example, but needs some narrative to meet the required elements stated in the guidance. Based on the storyboard alone, site visitors cannot discern what is asked for in the guidance - what the problem was, what the process was, etc. The media project certainly has some QI aspects, but seems to focus on workforce development around specific staff, versus an administrative process. If there is documentation on how this is a QI project such as what is the problem regarding media exposure, how can it be improved, what are the steps, etc. it may be more acceptable. Also as a team report, it s written in a manner that only the HD can understand and doesn t clearly answer the questions that the examples must demonstrate. Also, the HD is submitting this as an administrative QI project. It really needs to be tossed and select another project with a focus on the administrative processes of the health department. One question with a reopen could be to ask for such a project. 2. The HD has provided a set of minutes with the QI Team members present. Both projects also list participants. However for the projects, it is not clear who actually participated in the project. The storyboard list the QI Team, but no project personnel. Pre-Site Visit Assessment: Slightly Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 33 of 49

34 Measure A Domain 10: Contribute to and apply the evidence base of public health Standard 10.2 Promote Understanding and Use of Research Results, Evaluations, and Evidence-based Practices with Appropriate Audiences A: Maintain access to expertise to analyze current research and its public health implications Required Documentation 1: Documentation of availability of expertise (internal or external) for analysis of research Measure Narrative No entry Assessment Title CV of Vincent Dude File Measure Dude CV data expert File Description Mr. Dude serves as our expert for data and research analysis. He is employed by the state Division of Public Health. He resides in the local public health regional office and serves a number of counties including Acme. 1. There is a CV that looks like a person who can provide the expertise is available to Acme. However according to guidance, since he is outside the HD some type of MOU is needed and should be developed by the HD/State and uploaded here. The MOU or documentation containing a description of this person s expertise and training would make the evidence stronger. Also, we don t know if there is a set amount of time dedicated to Acme County or if it is on an as needed basis. The MOU could be asked for in a reopen. Pre-Site Visit Assessment: Slightly Demonstrated Since the CV is nothing more than that without the MOU PHAB EDUCATION SERVICES - Discussion Guide Page 34 of 49

35 Measure A Domain 11: Maintain administrative and management capacity Standard 11.1 Develop and Maintain an Operational Infrastructure to Support the Performance of Public Health Functions A: Maintain policies and procedures regarding health department operations, review policies and procedures regularly, and make them accessible to staff Required Documentation 1: Policy and Procedure Manual or individual policies Document 1 Document 2 Document 3 Title Admin Policy Manual Table of Contents File Measure Admin Policy Manual Table of Contents File Description This document list the policies in the ACHC administrative policy manual. The full manual is available online and is available upon request or onsite. Title ACHC Dress Code Policy File Measure Dress Code Policy File Description This policy is an example from the department s administrative policy manual. Title ACHC Orientation Policy File Measure Orientation Policy File Description This policy is an example from the department s administrative policy manual. PHAB EDUCATION SERVICES - Discussion Guide Page 35 of 49

36 Required Documentation 2: Health department organizational chart Title ACHC Organizational Chart File Measure ACHC O-chart File Description This is the most recent organizational chart for the ACHC. Required Documentation 3: Reports of review at least every five years or proof of regular updating process Document 1 Document 2 Title Policy on Policies (Revising Policies) File Measure Policy on Policies - review & revise File Description This is the ACHC policy on policies with sections highlighted that define how the department reviews and revises policies. Title Admin Policy Manual Signature Page File Measure ACHC Policy Manual Signature Page File Description This is the signature page for the Administrative Policy Manual showing annual review. Required Documentation 4: Description of methods for staff access to policies Title Policy on Policies (Employee Access) File Measure Policy on Policies - employee access File Description This is the ACHC policy on policies with sections highlighted that define employee access to departmental policies. PHAB EDUCATION SERVICES - Discussion Guide Page 36 of 49

37 Measure Narrative Provided is the table of contents for the administrative policy manual for the department. A couple of examples of policies from the manual have been included. All policies are initially approved and signed off, then the manual as a whole is reviewed and annually signed and dated by the health director. The department has a policy on policies that defines the process for developing, approving, revising and accessing policy. This has been included under required documentation 3 & 4 with the appropriate sections highlighted demonstrating both the revision process and employee access. Assessment Documentation is fine for this measure. The Administrative Policy Manual is available online and should be reviewed. This is a measure that uses visual observation to verify the submissions. Look for locations of policies during the facility review (if hard copies are used for employee access). Also interviews could be used to ask about accessing policies or the review process. Pre-Site Visit Assessment: Fully Demonstrated PHAB EDUCATION SERVICES - Discussion Guide Page 37 of 49