working toward accreditation joan ellison, public health director mary margaret stallone, director...
TRANSCRIPT
Working Toward Accreditation
Joan Ellison, Public Health DirectorMary Margaret Stallone, Director Center for Preventive ServicesLivingston County Department of Health
Conference of Environmental Health Directors / NYSACHO Meeting
December 18, 2012
Be A Part Of
Achieving ExcellenceAccreditation
Seven Steps to Accreditation
1. Pre-application2. Application3. Documentation Selection and
Submission4. Site Visit5. Accreditation Decision6. Reports7. Reaccreditation
Steps Taken…
1. Pre-application• Online Orientation• Assess Readiness• Inform PHAB-
Statement of Intent to Apply
2. Application• Community Health
Assessment
• Community Health Improvement Plan
• Agency Strategic Plan
Livingston County Department of Health Accreditation Timeline
Through November 2011
Prerequisites
Pre-application
Self Assessment
By November 16, 2011 January 2012-May 2012
Submit Application to PHAB
Documentation Selection and Submission to PHAB
Between June 2012 and November 2012
Scheduled Site Visit- Could be 1-6 months after submission of all documentation
By February? 2013
Accreditation
Decision
Steps Taken…
• Assemble Accreditation Team
• Assign Domains to Domain Leader
• Assemble Domain Teams
Steps Taken…
3. Documentation Selection and Submission
• Domain Team Meetings
• Discussion
• Gathering of materials/ documents
Steps Taken…
• Discussion of materials at Accreditation Team meeting
Steps Taken…
Accreditation Coordinator attended Accreditation TrainingShared information with Accreditation
TeamDiscussed revision of process
Steps Taken…
Public Health Director and Accreditation Coordinator met with Domain LeadersDomain Leaders then met with their
teams to discuss and revise information as needed
Steps Taken…
Accreditation Team met again to discuss new information to determine if the standards were met
Tracking Our Achievement
Getting Ready to Push the Button
Pushing the Button!
Final Submission!
Responding To Questions
Two Sets of Questions
1. Related to dates and signatures on documents
2. More information requested from site team
Steps Taken
11/29/12 and 11/30/12
4. Site Visit
Next Steps
5.Accreditation Decision Review Accreditation Site Visit
Report- within 14 days of the site visit
LCDOH has 30 days to respond Report is sent to the PHAB Board
for their review LCDOH to be contacted in
approximately two months regarding Board decision If LCDOH does not get accredited,
LCDOH has 90 days to take corrective action
Next Steps
5. Accreditation Decision
Accreditation- good for five years
Site visit team recommends opportunities for improvement
Not Accredited Must submit accreditation
plan within 90 days Must implement and provide
proof of implementation of action plan with 12 months
Next Steps
6. Reports Department reports
progress annually
7. Reaccreditation Application for
reaccreditation after 5 years
Successes
Appointing an Accreditation Coordinator
Appointing Domain Leaders
Include Diverse Group of Staff
Ensure Adequate Time to Gather, Revise and Submit Information
Successes
Staff Awareness and Involvement from the beginning
Staff Input – meeting the criteria
Creation of Several Policy and Procedures
Met Deadlines for Submission
Strive to Improve Various Areas
Strategic Plan
Lessons Learned Regarding Required
DocumentsComprehensive
meeting minutes
Presentations to include date, time, place
Documentation of process
Proceed with Domain in Numerical Order
What Are We Doing Differently?
Performance Management
Quality Improvement Minutes
Documentation of process Tracking systems in
place Identify who, what and
where presentations are made
Accreditation is the beginning
ImproveAccreditation
Improve ImproveRe-Accreditation
Improve
Improving the public’s health through continuous quality improvement
NACCHONational Association of County & City Health Officials
Questions
