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Accreditation Preparation Is Underway


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Local health departments (LHDs) that have key prerequisite documents in place (community health assessments, community health improvement plans, and agency strategic plans) and are ready to take the next step can find resources to learn about how others have prepared and developed a strategy to move forward and/or engage in quality improvement (QI) efforts. These resources can be used by LHDs at any level of accreditation preparation, but are designed for those currently preparing.

Organizational Self-Assessment Guide & Prioritization Methods
As a part of the PHAB accreditation process, completing an organizational self-assessment uncovers the strengths and areas for improvement within a health department. This guidance document walks through the principle steps to completing a self-assessment along with some tips and tools on how to act on self-assessment results to bring forth continuous improvement. Although this guide is intended to help LHDs organize and prepare for accreditation, it serves as a useful tool for those undertaking a self-assessment outside of the PHAB accreditation process.

Once an LHD has completed an organizational capacity assessment, the possible areas for improvement may seem overwhelming. Where do you start doing QI? How do you choose a project? This document 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.

Informing Local Governing Entities
As LHDs move towards preparing for national accreditation, it is important to remember that local governing entities (LGEs) are critical players in this process. Whether the authority of the LGE is defined as governing, policy making, or advisory, LHDs are held accountable to them and therefore must gain support before proceeding with the accreditation process. Often, LGEs have limited knowledge of accreditation making it essential for LHDs to proactively provide the necessary information. The training materials below are intended for local health officials to inform their respective LGEs on the basics of public health and the importance of accreditation.

Examples of Accreditation Preparation Processes
The Accreditation Preparation and QI Demonstration Sites Project was designed to support accreditation preparation efforts among 66 LHDs across the nation. This project consisted of an accreditation preparation process whereby 41 LHDs worked individually to complete an agencywide self-assessment, identify a priority area for improvement, and implement a QI process targeted toward increasing capacity in the specified area. The remaining 25 LHDs worked within five regional collaboratives executing a similar process to complete self-assessments, identify collective areas for improvement, and create a mechanism for collaborating in the future. The demonstration site project page showcases the exemplary progress these LHDs have made towards meeting accreditation standards and measures. The beta test QI project page includes the final reports from PHAB's local beta test sites, who conducted QI initiatives with technical assistance from NACCHO as an add-on to the beta test.
Organizing Your Accreditation Documentation: Free Accreditation File for "Mind Manager" Software
The Spokane Regional Health District (SRHD) developed a file that pre-populated version 1.0 of PHAB’s standards and measures (local version) for use with Mind Manager software. Mind Manager is a tool that can be used for organizing documentation intended for submission for PHAB accreditation. Mind Manager is an information mapping software compatible with most operating systems. When the file is added to the Mind Manager software, users can upload documentation for each accreditation measure, and include notes on how the documentation contributes to meeting the measure. SRHD has provided copies of the file on CDs, for use by local health departments that are using Mind Manager software in their agencies. These CDs are available FREE to any local health department that has Mind Manager software and seeks to use it for organization accreditation documentation. Please note that the file is for use ONLY WITH MIND MANAGER SOFTWARE. If you do not have the Mind Manager software, the file will not open and cannot be used. For more information about Mind Manager, visit www.mindjet.com. To request a CD ROM of the file from NACCHO, e-mail accreditprep@naccho.org and include “Mind Manager PHAB Template” in the subject line. For information about SRHD’s use of the software or development of the template, contact Gwendolyn Dutt at gdutt@spokanecounty.org.
Regionalization is an effective strategy for small LHDs that may lack the capacity to meet all national accreditation standards on their own to formalize relationships and work in concert to ensure delivery of the essential public health services to those jurisdictions. This process involves taking strengths of individual LHDs in a region and combining efforts to enhance efficiency and effectiveness throughout the region.

NACCHO explored regional models with Kansas and Massachusetts and provides resources and lessons learned from these initiatives:

More information on regionalization is available on NACCHO''s Regionalization website.