Collect and Organize Documentation

Each LHD must demonstrate compliance with PHAB standards and measures by collecting and submitting documentation. This phase of the accreditation preparation process includes the following two steps: 

  1. Formation of an accreditation preparation team and 
  2. Collection and electronic organization of documentation. These two activities should begin well in advance of submitting the PHAB application. The following resources exist to assist LHDs with organizing for accreditation.

PHAB's Standards and Measures Version 1.5 contains an ethics requirement. A new measure (11.1.2 A) requires that health departments document that they identify ethical issues and make ethical decisions. Visit NACCHO's Public Health Ethics webpage to access training and resources that will equip you with the insights and skills needed to address ethical issues that arise in the practice of public health. Take the CDC Good Decision Making in Real Time online course, with the option of obtaining continuing education units (CEUs), or peruse a variety of materials covering different aspects of public health ethics. The website serves as a portal through which you can learn more about CDC/NACCHO ethics projects, PHAB ethics requirements, and ethical considerations associated with specific sub-disciplines of public health.

NACCHO and the CDC's Community Guide Branch would like to announce the launch of The Community Guide – Public Health Accreditation Board Crosswalk. The Community Guide – PHAB Crosswalk is a tool to assist health departments in identifying evidence-based interventions from The Community Guide whose implementation could help document conformity with PHAB domains, standards, and measures.

As a companion tool, the NACCHO Model Practices-Community Guide Crosswalk: A Resource for Implementing Effective Public Health Strategies, can inform LHDs as they consider ways to address public health concerns with effective strategies. The crosswalk identifies NACCHO Model Practices implemented by LHDs alongside related recommendations from The Community Guide to help LHDs enhance their practice-based initiatives with evidence, while simultaneously providing examples of ways LHDs can translate evidence into practice in their jurisdictions.

If you’re interested in learning more about how these principles have been implemented in LHDs across the nation, check out our stories from the field from West-Allis Health Department and our Lessons from Locals story.

This document serves as the official standards, measures, and required documentation for PHAB national public health accreditation. It provides guidance on the meaning and purpose of a measure and the types and forms of documentation that are appropriate to demonstrate conformity with each measure. The standards are based on the ten essential public health services and focus on “what” the health department provides in services and activities, regardless of “how” they are provided or through what organizational structure.

This document provides general guidance for health departments to consider when selecting the specific documentation that will be submitted to PHAB for each documentation requirement contained in the PHAB Standards and Measures, Version 1.5.

PHAB has created this Excel spreadsheet template to assist health departments with organizing their documentation.

This guide walks through the principle steps in undertaking the process for collecting PHAB documentation including forming the accreditation preparation team, orienting staff to accreditation, gathering documentation, and identifying areas of strength and weakness.

NACCHO's Documentation Selection Tools are designed to facilitate the process of accreditation preparation in local health departments. There are several tools available that highlight connections between measures that appear across different PHAB domains, simplify the preparation of major documents required by PHAB, and drive efficiencies in assigning and organizing the documentation collection process.

These tools cover several topic areas and are recommended for use in conjunction with PHAB's tools and resources.


  • Selecting Programmatic Documentation (UPDATED for V1.5) - This tool was developed to help Accreditation Teams understand the documentation requirements from their different program areas.This tool includes a chart that lists measures and accompanying guidance that require documentation from health department program areas. This can be used to guide discussions with program staff regarding documentation assignments.
  • Programmatic Documentation Matrix (UPDATED for V1.5) - PHAB requires that programmatic documentation reflects the breadth and depth of the services available at a local health department. This tool includes a chart that lists the program-related measures and health department program areas.This is intended to track the amount of documentation coming from different program areas and thus help ensure that a wide range of programs are represented. NOTE: This tool is made available in .DOC form so that health departments can edit the chart to include the names of all their programmatic services.
  • PHAB Prerequisites (UPDATED FOR V1.5) - This tool includes charts that list the measures, required documentation, and notes on related measures for each of the PHAB pre-requisites (Community Health Assessment (CHA), Community Health Improvement Plan (CHIP), and Strategic Plan). This tool also contains checklists for the requirements related to CHAs and CHIPs.
  • Workforce Requirements (UPDATED FOR V1.5) - This tool is a checklist of PHAB measures that specifically reference the public health workforce, including general human resource requirements, functions/responsibilities that must specifically be designated to a staff member, staff development and training requirements, and staff participation in a performance management system and quality improvement plan.*Requirements regarding staff and emergency preparedness are not included in this tool, and instead can be found in the Project Public Health Ready Overlap tool.
  • Project Public Health Ready Overlap (UPDATED FOR V1.5) - This tool is a chart that describes how documentation required by NACCHO's Project Public Health Ready (PPHR) may be used to help demonstrate conformity with related PHAB measures.
  • Miscellaneous Documentation (UPDATED for V1.5) - This tool is a list of miscellaneous topics with several references throughout the standards and measures, including diverse populations, governing entities, and public health laws.

Once an LHD has completed the PHAB documentation collection process, the possible areas for improvement may seem overwhelming. Where do you start doing QI? How do you choose QI efforts? The document below outlines five prioritization methods LHDs can use to choose among the many and narrow them down to select the few best to start. It includes descriptions of each method as well as examples of how LHDs have used the methods.

NACCHO’s Quality Improvement (QI) and Accreditation Preparation Webinar Series provides periodic webinars as part of NACCHO's continued commitment to QI and preparing local health departments (LHDs) for national accreditation. This webinar series is funded by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.

NACCHO has compiled an FAQ document which answers questions that come up frequently during this webinar series.

If you would like to hear about webinars ahead of time, sign up to receive accreditNATION, NACCHO's periodic e-newsletter focusing on accreditation and quality improvement.

All webinars are free to view. All webinars recorded since 2013 are available online and some will be e-mailed if requested. Please contact Pooja Verma at pverma@naccho.org or 202-507-4206 with any questions.

6/24/2015

This webinar provided an overview of change management and concrete strategies for building an infrastructure for performance improvement and empowering staff so they are motivated and able to engage in accreditation and quality improvement.

This 90-minute webinar featured speakers from two small local health departments (LHDs) who described how they overcame common performance improvement barriers and specific challenges faced by small LHDS.

To download the program slides click here, and to watch the free archived recording click here. To see answers to questions from the webinar, click here.

Resources Mentioned

Using NACCHO's Resources for Performance Improvement

9/26/2013

This webinar provided an interactive demonstration of several resources from NACCHO staff. Additionally, staff of the New Orleans Health Department explained how they used several of the tools in their work. Participants not only learned how to find these helpful and FREE resources, but also heard how they have been practically used in the field. 

Click here to watch the free archived recording. Download the webinar slides here and the webinar resource list here. To see answers to questions from the webinar, click here.

Resources Mentioned

Performance Management in Public Health: From Conceptualization to Implementation

6/26/2013

Performance management is the use of data to continuously monitor and improve performance to ensure that agency processes and activities are achieving strategic goals. This webinar included an introduction to the concept and importance of performance management and featured the story of one health department's experience with developing a performance management system, using that system to evaluate the agency's activities, and connecting the system to quality improvement, strategic planning, and community health improvement.  

To watch the archived recording, click here. To download the slides, click here. To see answers to questions from the webinar, click here.

Resources Mentioned

Performing Better Together: Improving through Peer Networking

4/23/2013

This webinar focused on the value of peer-networking. Many opportunities to learn from peers are available to LHD staff as they conduct community health planning initiatives, prepare for accreditation, or work to develop a culture of quality improvement, including state groups, national communities, and regional networks.

To watch the archived recording, click here. To download the slides, click here. To see answers to the questions from the webinar, click here.

Resources Mentioned

3/30/2015

This program featured the stories of two local health departments (LHDs) and a new NACCHO-developed tool, 'The Community Health Improvement Matrix.' Participants that have community health improvement plans are encouraged to have a copy to reference during the webinar.  

This 90-minute webinar featured representatives from local health departments in North Carolina, and New Orleans who will share their work on these initiatives and provide insight into how it has helped them improve health department performance and community health outcomes.

To watch the free archived recording, click here, and to download the program slides click here.

12/9/2014

This webinar featured the stories of three local health departments (LHDs) taking advantage of national resources and connections. While there are many resources available to LHDs, several national activities have received increased interest recently due to their value in accreditation preparation and community health improvement planning.

This 90-minute webinar featured representatives from local health departments in North Carolina, Florida and Massachusetts who shared their work on these initiatives and provide insight into how it has helped them improve health department performance and community health outcomes.

To watch the free archived recording, click here, and to download the program slides click here. To see answers to questions from the webinar, click here.

6/18/2014

This webinar featured an interactive presentation by Julia Joh Elligers, NACCHO's Senior Director of Performance Improvement and Workforce Development. The presentation included an overview of important principles, topics, and documents, and clearly laid out steps for HDs to follow on their journeys. There was also information from health departments across the country, and audience members were asked to share their stories and input.

To watch the free archived recording, click here, and to download the program slides click here. To see the overview from the webinar, click here.

5/29/2014

When building a culture of quality in LHDs, an evolution of change tends to occur, impacting both the people and processes within the organization. NACCHO's Roadmap to a Culture of Quality provides LHDs with guidance on progressing through six phases or levels of QI maturityuntil a culture of quality has been reached and can be sustained. 

NACCHO's Organizational Culture of Quality Self-Assessment Tool allows LHDs to conduct an in-depth assessment of critical aspects of a quality culture.

NACCHO's performance improvement webinar explained how to use each of these tools and shared the insights and perspectives of LHDs that leveraged these resources to grow a culture of quality. 

To watch the free archived recording, click here and download the webinar slides here.  To see answers to questions from the webinar, click here.

3/25/2014

This webinar featured three local health department speakers. Each speaker provided information on their process for developing their agency workforce development plans, including core competency assessment, plans for staff trainings, and more.

To watch the free archived recording, click here and download the slides, click here.

2/25/2014

This webinar featured two presenters: a performance management subject matter expert and a local health department representative. Participants learned strategies for developing and implementing performance management systems at their agencies, including different self-assessment tools and processes, methods for establishing effective performance measures, how performance relates to other agency and community plans, and more. Participants also heard about one agency's efforts to implement a performance management system, and their process for monitoring and reporting.

Click here to watch the free archived recording. Download the webinar slides here.

2/24/2014

This webinar featured the story of one accredited local health
department (LHD) and the insight of one PHAB site visitor. There were several options for setting up an accreditation team and for organizing the documentation selection process, and it's also important to consider when preparing for accreditation is what the PHAB site visitors expect before, during, and after the scheduled site visit. Download the slides here

Click here to watch the free archived recording. Download the webinar slides here. To see questions from the webinar, click here.

9/26/2013

This webinar provided an interactive demonstration of several
resources from NACCHO staff. Additionally, staff of the New Orleans Health Department explained how they used several of the tools in their work. Participants not only learned how to find these helpful and FREE resources, but also heard how they have been practically used in the field. 

Click here to watch the free archived recording. Download the webinar slides here and the webinar resource list here. To see answers to questions from the webinar, click here.

6/26/2013

Performance management is the use of data to continuously monitor and improve performance to ensure that agency processes and activities are achieving strategic goals. This webinar included an introduction to the concept and importance of performance management and featured the story of one health department's experience with developing a performance
management system, using that system to evaluate the agency's activities, and connecting the system to quality improvement, strategic planning, and community health improvement.  

To watch the archived recording, click here. To download the slides, click here. To see answers to questions from the webinar, click here.

DC DOH Accreditation Videos

4/23/2013

This webinar focused on the value of peer-networking. Many
opportunities to learn from peers are available to LHD staff as they conduct community health planning initiatives, prepare for
accreditation, or work to develop a culture of quality improvement, including state groups, national communities, and regional networks.

To watch the archived recording, click here. To download the slides, click here. To see answers to the questions from the webinar, click here.