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

Livingston County Department of Health

2 Murray Hill DriveMt. Morris, NY 14510

585-243-7270Dept-of-health@co.livingston.ny.us