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Public Health Accreditation: A Model Process for a Model Practice

State: NY Type: Promising Practice Year: 2019

Located on Long Island, Nassau County (NC) is home to 1,339,532 residents. NC is bordered by New York City (NYC) to the west and Suffolk County to the east.  NC has seen a significant increase in its Hispanic population, from 10% in 2000 to 14.6% in 2010. Compared to New York State (NYS), NC has a higher percentage of whites (65.7% of NYS residents), a lower percentage of blacks (15.9% of NYS residents) and a slightly higher percentage of Asian/Pacific Islanders (7.4% of NYS residents).  NC is home to many immigrants, in part due to its proximity to NY's largest international airport. Approximately 20% of NC's population is foreign born (2010 US Census).

Public health accreditation of local and state health departments is a relatively new process initially launched by the Public Health Accreditation Board (PHAB) in 2009 to promote quality and performance within health departments (www.phaboard.org/accreditation-overview/what-is-accreditation/).  In the fall of 2011, the Commissioner of Nassau County Department of Health (NCDOH) decided to pursue accreditation.  The challenge to this goal or the problem that the department faced was establishing the health department's readiness for accreditation with satisfactory training and documentation in an environment where the priority was maintaining core and mandated public health functions.  The health department was faced with instituting and compile the necessary policies, processes and evidence with limited resources and strict mandated functions.  This problem is not unique to Nassau County, yet the approach that was used was creative and effective and therefore should be considered a model practice.

To achieve accreditation, the health department utilized the collective impact model.  According to the seminal work by Kania and Kramer, this model to effectuate social change relies on five elements including common agenda, shared measurement system, mutually reinforced activities, on-going communication, and an independent backbone organization (Kania J and Kramer M.  Collective impact, https://ssir.org/articles/entry/collective_impact).  The approach has been successfully used by consultants and organizations working with multi-agency collaborations to solve complex social problems (FSG: Reimagining Social Change, www.fsg.org/our-people, https://clearimpact.com; Collaboration for Impact, www.collaborationforimpact.com/collective-impact; Council of Non-Profits, www.councilofnonprofits.org/tools-resources/collective-impact; Aspen Community Solutions, https://aspencommunitysolutions.org/resources/).  NCDOH employed the collective impact model as a viable solution to the challenging and complex problem of accreditation readiness.  In the long run, this model would prove to be effective and sustainable.

The goal was to achieve accreditation using the principles of the collective impact model framework.  These principles were utilized to execute the three primary objectives for this project: 1) To educate, engage and collaborate within the department creating a common agenda; 2) To develop, collect and evaluate evidence of required domains; 3) To improve processes to fulfill measures and increase performance.

The first objective was met by establishing a department-wide common agenda, achieving public health accreditation.  This required education, engagement and collaboration among department staff.  The second objective, developing, collecting and evaluating evidence of required domains, was successfully met when NCDOH submitted documentation to PHAB in January of 2017.  This was achieved by creating data collection tools and measuring results consistently across all NCDOH staff to ensure a shared measurement. The final objective, to improve processes to fulfill measures and increase performance, was met throughout the accreditation practice.  The department accomplished this by creating a plan of action outlining and coordinating mutually reinforced activities. 

The collective impact model was evaluated by NCDOH and considered to be effective.  The evaluation was on-going throughout the process, included both primary and secondary data sources, and quantitative results on process and outcome measures. Ultimately, satisfactory documentation increased over time leading to 100% collection and submission.  Meetings and trainings were evaluated by frequency and attendance, respectively, and were on target, as most staff participated.  Collective impact became a creditable framework in which the health department could operate internally.  It also sustained its efforts as relationships were created, fortified and were mutually beneficial among staff and divisions. Furthermore, collaboration of this kind required attention to including individuals with different perspectives, the strength of relationships among the individuals, sharing credit, identification of adaptive and multiple solutions, as described by Kania et al.,( Kania J, Hanleybrown F, Splansky Juster, J. Essential mindset shifts for collective impact, https://ssir.org/articles/entry/essential_mindset_shifts_for_collective_impact)

The public health impact of this practice is that the collective impact model can be used within an agency, not only across agencies.  The collective impact model, as modified by NCDOH, was successfully used to achieve accreditation.  Accreditation will allow the health department to improve services to its residents.


www.nassaucountyny.gov/1652/Health-Department


Public health accreditation of local and state health departments is a relatively new process initially launched by the Public Health Accreditation Board (PHAB) in 2009 to promote quality and performance within health departments (www.phaboard.org/accreditation-overview/what-is-accreditation/). In the fall of 2011, the Commissioner of NCDOH decided to strive for accreditation.  The challenge to this goal or the problem that the department faced was establishing the health department's readiness for accreditation with satisfactory training and documentation in an environment where the priority was maintaining core and mandated public health functions.  With limited resources and strict mandated functions, how could the health department institute and compile the necessary policies, processes and evidence?  This problem is not unique to Nassau County, yet the approach that was used was creative and effective and therefore should be considered a model practice.

The scope of the problem is properly realized by the health department's recent history.  While the NCDOH was chartered in 1938, naturally, its infrastructure has changed substantially over the last 80 years. The county and the health department have undergone significant restructuring and reorganization over time.  At the time of accreditation submission, the NCDOH employed 231 full time employees.  NCDOH consists of nine divisions, aside from its administration:  Community and Maternal Child Health Services, Communicable Disease Control, Communications and Health Information, Environmental Health, Laboratory Services (for environmental health specimens only), Public Health Emergency Preparedness, Quality Improvement, Epidemiology and Research, Social Health Initiatives and Minority Health, and Tuberculosis Control.  Each division has its own agenda and mandated public health function and therefore did not prioritize the process of accreditation.  Many staff did not understand the value of accreditation.  Over the six years between deciding to apply for accreditation and the submission, the health department responded to Super Storm Sandy and experienced a move in office location.  In addition, staff responsible for executing the accreditation effort was limited to two individuals, considered Co-Accreditation Coordinators (ACs), who concurrently served as tuberculosis programmatic director and epidemiologist, and were also responsible for the Community Health Assessment (CHA), Community Health Improvement Plan (CHIP) and Strategic Plan (SP).

Therefore, the target population consisted of two audiences: 1) the health department staff, itself which needed to actively contribute the accreditation process, and 2) the residents of the county who would benefit from an accredited health department.  The health department was comprised of 231 full time employees, of whom 68% were white, 12% Hispanic, 14% black and 6% Asian.  The county population is similar in distribution: 76% white, 17% Hispanic, 13% black and 10% Asian.  This innovative practice of using collective impact to achieve accreditation resulted in 100% of the health department staff accredited and 100% of the community served by an accredited department of health. 

While the health department has collaborated department-wide for large activities, these situations were considered short-term and emergent.  NCDOH has rightly received praise for its emergency response activities, including Super Storm Sandy, where all divisions were mobilized for many months in order to ensure the safety of its residents.  Internal organization and collaboration with partners was necessary in order to address urgent issues.  The incident command system (ICS) was implemented in order to respond appropriately.  Accreditation provided another opportunity for departmental collaboration both internally and externally.  In this case, the partnership could evolve more slowly, be nurtured and with less time constraints, resulting in a sustainable and strong organization.  An ICS approach that is based on hierarchy, control and command would not be fitting for this situation, rather a collaborative approach that emphasized cooperation, teamwork and self-actualization was developed. 

To achieve accreditation, the health department utilized the collective impact model.   According to the seminal work by Kania and Kramer, collective impact initiatives are long term commitments by a group of actors from different sectors to a common agenda for solving a specific social problem,” (Kania J and Kramer M.  Collective impact, https://ssir.org/articles/entry/collective_impact).   This model to effectuate social change relies on five elements including common agenda, shared measurement system, mutually reinforced activities, on-going communication, and an independent backbone organization.  Furthermore, collaboration of this kind requires attention to including individuals with different perspectives, the strength of relationships among the individuals, sharing credit, identification of adaptive and multiple solutions, (Kania J, Hanleybrown F, Splansky Juster, J. Essential mindset shifts for collective impact, https://ssir.org/articles/entry/essential_mindset_shifts_for_collective_impact). While the approach has been used by consultants and organizations working with multi-agency collaborations to solve complex social problems, NCDOH employed it to solve the challenging and complex problem of accreditation readiness (FSG:Reimagining Social Change, https://www.fsg.org/our-people, https://clearimpact.com; Collaboration for Impact, http://www.collaborationforimpact.com/collective-impact; Council of Non-Profits, https://www.councilofnonprofits.org/tools-resources/collective-impact; Aspen Community Solutions, https://aspencommunitysolutions.org/resources/).  In the long run, this model would prove to be effective and sustainable.

Thus, collective impact approach was creatively used in the context of the health department's quest to achieve accreditation.  The five elements described by Kania and Kramer were adapted to a different scenario.  In this case, the common agenda was accreditation.  While the decision to strive for accreditation was made by the Commissioner, staff still needed to gain buy-in to a common agenda and perceive the value of accreditation.  Staff involved in the process were not from different agencies as the collective impact describes; but rather, acted as such, as they were from different divisions and bureaus within the health department, with different priorities and specific core functions.  The shared measurement system for accreditation was the evidence of required activities for the required domains.  Domains detailed twelve areas of public health that together reflect processes and performance to continuously improve health department work to improve the health of the county (PHAB, www.phaboard.org/ ).  Mutually reinforced activities in the accreditation use of the collective impact model included coordination of the strategic plan subcommittees, the efforts of the accreditation team meeting members who identified gaps in process and evidence, and the leadership team who provided verification and testimony at the site visit.  Communication was on-going throughout the five years manifested in electronic dashboards, regular meetings, emails and one-on-one conferences.  Communication included not only in reading comprehension and analysis, but a shared vocabulary which emphasized key concepts such as quality improvement and workforce development. Finally, the backbone of the accreditation operation consisted of the ACs who provided technical and operational functions and also maintained coordinating control over the process.  This means that all documentation was funneled through the hands of the ACs; they conferred on its applicability; and they often consulted when creating descriptions and narratives.  The two ACs worked in concert, and regulated what was submitted.  The adapted collective impact approach reflected in the key five elements, provided the mechanism necessary to achieve accreditation.

Collective impact is an evidenced-based practice as referenced in the conceptual work conducted by Kania and colleagues (Kania, J and Kramer M.  Collective impact, https://ssir.org/articles/entry/collective_impact).  Its use has been demonstrated in identifying interventions for large and complex problems.  For example, CDC cites the use of collective impact in a multi-state effort to promote safe environments for nurturing children and also as a strategic tool to improve oral health (www.cdc.gov/violenceprevention/childmaltreatment/essentials.html, www.cdc.gov/oralhealth/state_programs/infrastructure/index.htm). Meinen et al described the role of collective impact among government, public health and education sectors in Wisconsin in agreeing on a common agenda, maintaining communication and the importance of the backbone component to decrease childhood obesity (Meinen A, Hilgendorf A, Korth AL, Christens BD, Breuer C, Joyner H, Polzin M, Adams A, Wolfe D, Braun A, Hoiting J, Paulson J, Cullen B, Stader K. The Wisconsin early childhood obesity prevention initiative:  an example of collective impact,  www.ncbi.nlm.nih.gov/pubmed/29095590).  This collaborative has been effective in policy development and system change.  Similarly, Amed et al also addressed childhood obesity, from a community based, multi-sector perspective highlighting the five elements of collective impact (Amed S, Naylor PJ, Pinkney S, Shea S, Masse LC, Berg S, Collet JP, Wharf Higgins J. Creating a collective impact on childhood obesity:  lessons from the SCOPE initiative, www.ncbi.nlm.nih.gov/pubmed/26680435).  In this case, the sectors represented were government, schools, media and community services. Flood et al, in an environment with limited resources, collaborated across sectors to improve health messages and food access (Flood J, Minkler M, Hennessey Lavery S, Estrada J, Falbe J. The collective impact model and its potential for health promotion:  overview and case study of a health retail initiative in San Francisco, www.ncbi.nlm.nih.gov/pubmed/25810470).  In addition to the collective impact approach, these researchers added a model of consensus building among diverse community areas, establishing that collective impact can be modified to different situations.  Interestingly, collective impact as a strategy has been employed in relation to accreditation.  Carman discussed the partnership of the University of Kentucky and local health departments and its use of the collective impact model to achieve accreditation (Carman, AL. Collective impact through public health accreditation and academic partnerships:  a Kentucky public health accreditation readiness example, www.ncbi.nlm.nih.gov/pubmed/25806362).  Similar to all these published studies, the collaborating sectors come from multiple separate agencies:  the university which provided the backbone to the process and the community sectors engaged in the community health assessment and planning.  The university provided the strong partnership needed to increase the capacity of each health department's workforce.  While the outcome was accreditation readiness, the collective impact effort was implemented as originally prescribed:  a result of multiple organizations' collaborations and subsequent activities.  In the circumstance surrounding NCDOH's goal of accreditation, the collective impact model was modified and used differently.  NCDOH did not rely on separate outside agencies to achieve collaboration, but rather defined internal divisions and bureaus as sectors with their own missions, functions and expertise.  The five elements of the collective impact were adapted to an internal process, one that ultimately was sustainable and stronger, as a result.

NCDOH sought to achieve public health accreditation through PHAB.  The goal was to achieve accreditation using the principles of the collective impact model framework: a common agenda, shared measurements, mutually reinforced activities, continuous communication and backbone support.  These principles were utilized to execute the three primary objectives for this project: 1) To educate, engage and collaborate within the department creating a common agenda; 2) To develop, collect and evaluate evidence of required domains; 3) To improve processes to fulfill measures and increase performance.

The first objective was met by establishing a department-wide common agenda, achieving public health accreditation.  This required education, engagement and collaboration among department staff across all divisions representing different sectors.  Prerequisites for accreditation included a CHA, CHIP and a strategic plan.  The CHA and CHIP, were not new to the department, as both were historically mandated by New York State Department of Health (NYSDOH).  Therefore, the CHA and the CHIP efforts were already in place.  The department, however, required a first time ever strategic plan.  The strategic plan was facilitated by an outside consultant who served to educate and engage staff.  Through its development, three strategic issues were identified, 1.) workforce development: maintaining a competent engaged and informed workforce, 2.) accreditation, quality improvement and data management: improving the availability and maximizing the functionality and effective use of data and information technology, 3.) community engagement: serving as a vital resource for and partnering with our community. Within the department, engagement and education began regarding accreditation, its gears and prerequisites, as they became components of the strategic priorities.  Subcommittees were formed based on these strategic priorities and supported the accreditation effort.  These subcommittees were charged with activities that were aligned with the accreditation process to enhance the work of the department and provide documentation.

The strategic planning process also offered insight into the potential gaps in achieving accreditation.  In response, the ACs led a more formal educational campaign to engage staff regarding accreditation, specifically performance management and quality improvement. These workshops introduced concepts and allowed for discussion, sharing of ideas and fostering a culture of Quality Improvement (QI), thus supporting the common agenda.  In addition, the ACs recognized the need for consistent outreach to maintain staff engagement and collaboration to advance the common agenda.  To begin with, the ACs oriented division directors and program heads to accreditation domains including education on documentation date limitations, presentation requirements and authentication rules established by PHAB.  Then and there, initial collaboration and brainstorming occurred on what documentation would appropriately satisfy PHAB measures and standards. Subsequently, multiple individualized follow-up meetings occurred between the ACs and staff at all levels engaging and reinforcing PHAB requirements for standards and measures.  Informal requests and collaboration efforts for documentation occurred with all levels of staff as well.  Furthermore, leadership staff meetings provided opportunities for the Commissioner to set deadlines for collection dates and reinforce the department's priority to achieve accreditation status.  This agenda became more frequent and widespread throughout meetings as the health department progressed through the accreditation process. 

The second objective, developing, collecting and evaluating evidence of required domains, was successfully met when NCDOH submitted documentation to PHAB in January of 2017.  This was achieved by creating data collection tools and measuring results consistently across all NCDOH staff from every division representing different sectors to ensure a shared measurement.  To facilitate this process, the ACs attended two trainings, the Public Health Improvement Training: Advancing Performance in Agencies, Systems and Communities (PHIT) hosted by the National Network of Public Health Institutes and a mandatory coordinator training held by PHAB. Initially, NCDOH used readiness checklists provided by PHAB.  The ACs used these checklists to guide activities. In addition, the ACs conducted a comprehensive review of each domain with its respective standards and measures, analyzing what program would potentially best provide documentation.  This information was summarized and diagrammed on a spreadsheet and presented to leadership staff, including the Commissioner of Health. This tool also provided a tracking mechanism of who among the health department staff would perform activities and provide evidence to support these actions to meet PHAB requirements within the needed timeframe.  As documents were received and reviewed by the ACs, snapshots of the spreadsheet, in the form of summary tables, were provided to the document contributor with relevant feedback, whether it met the measure, and if not, the reason.  These snapshot tables were also periodically sent to staff as a reminder of what remained outstanding. This allowed for a consistent method of tracking and communication.  ACs also provided staff with standardized templates to document activities, such as meeting sign in sheets, agendas and minutes, facilitating conformity to PHAB requirements.  Also utilized were guides for creating plans and policies published by already accredited health departments.  In the later stages of the accreditation process, NCDOH gained access to PHABs electronic dashboard, e-PHAB, which replaced the spreadsheet for tracking progress, as it provided real-time information and could be accessed by any designated staff.  Jointly, these tools were used for collecting data and measuring results consistently across all staff ensuring a shared measurement for alignment and accountability. 

The final objective, to improve processes to fulfill measures and increase performance, was met throughout the accreditation practice.  The department accomplished this by creating a plan of action outlining and coordinating mutually reinforced activities among all divisions as distinct sectors.  As part of the action plan, the strategic plan subcommittees were created according to the strategic priories set by the department and were aligned towards achieving a common agenda, accreditation.  These committees included: Workforce Development, Community Engagement, Performance Management and Quality Improvement, Emergency Preparedness, and Data Management.  The committees, differed in activities, but worked in unison to further the agenda.  Through them departmental plans were created, implemented and evidence documented.  Such plans included: Quality Improvement, Workforce Development, Branding Strategy, Communications and Guidelines for Health Promotion and the Outreach.  Furthermore, the Accreditation Team was formed, consisting of representatives from the department's distinct divisions and programs.  These individuals were charged with devising how to fill the outstanding gaps in documentation.  Staff came with knowledge from their various programs and collaborated to satisfy outstanding measures.  Finally, the leadership team was formed. The team was comprised of key departmental staff in leadership positions. Each facilitated accreditation activities within their programs, served as liaisons with the ACs and provided document verification at the PHAB site visit.  The leadership team also participated in a pre-site visit run through to better coordinate and collaborate with other leadership members regarding each domain. Each committee and team had specific and distinct set of activities, leveraging each other's efforts towards a common goal, to become nationally accredited. 

These three objectives and in turn the goal to become accredited was accomplished not only by the aforementioned collective impact framework of a common agenda, shared measurements and mutually reinforced activities, but also through its principles of continuous communication and a backbone structure.  Throughout the process continuous communication was key.  Through the collaborative work of the strategic plan subcommittees Quality Improvement and Workforce Development, the department launched an intranet platform where information was communicated to staff, including accreditation news, departmental policies, plans, tools and templates.  Also utilized were directories within NCDOH's network where working documents could be shared.  These directories included information such as subcommittee meeting agendas, minutes and reports allowing staff real-time access to materials.  These directories also housed some accreditation documentation for staff to review to submit. Communication also occurred via more traditional methods such as emails and meetings.  The ACs routinely emailed and met with staff regarding specific standards and measures.  Strategic plan subcommittee meetings, leadership staff meetings, accreditation team meetings and annual department meetings were all venues where communication occurred.  This platform of communication also facilitated a common language. Staff became comfortable with accreditation terminology and its use was prevalent.  The ACs provided the backbone support for the accreditation effort, from getting the department ready to apply, to becoming accredited.  The ACs were charged with preparing the CHA, CHIP and strategic plan.  Also, they were responsible for reviewing, approving and uploading all documentation.  They educated, engaged, collaborated and communicated with staff and stakeholders regarding accreditation.  They served as liaisons between PHAB and the department.  The ACs guided NCDOH to achieve accreditation.

PHAB states that the goal of the voluntary national accreditation program is to improve and protect the health of the public by advancing the quality and performance of Tribal, state, local, and territorial public health departments.  Therefore, as a local health department, NCDOH fulfills PHABs criteria for seeking public health accreditation.  Furthermore, as part of the department's criteria in seeking public health accreditation, a large contributor was the benefit accreditation would bring to all its residents.  Improving NCDOH's programs and delivery in the community supports the health of the community.  Within the health department itself, the collective impact model allowed for the entire department to be actively involved and receive the practice.  

Initial consideration by NCDOH leadership of accreditation took place in October 2011.  In May 2012, its prerequisites were reviewed.  The department began CHA and CHIP activities in Oct 2012 and continued until its submission to NYSDOH in November 2013. The strategic plan development began February 2013 and was completed in June 2013. Its subcommittees were established in October 2013.  The ACs attended the PHIT training in April 2013.  Preliminary collection of documentation began in 2014 and continued into 2015.  During this time, policies, procedures and plans needed for accreditation were considered and continuous education and engagement of staff by the ACs occurred.  In September 2015, the department submitted a Statement of Intent to apply for accreditation to PHAB. In November 2015, the application was submitted, which included the three prerequisites.  Payment to PHAB ensued in December 2015.  The ACs attended a mandatory coordinator training in Virginia in February 2016.  Following the training, the department gained access to PHAB's electronic dashboard, e-PHAB. At that juncture, a one-year deadline to submit all documentation commenced.  All remaining documentation was collected, reviewed and submitted to PHAB on Jan 3, 2017.  PHAB reviewed the documentation for completeness in February 2017 and asked for clarification or further evidence in May 2017.  The site visit transpired in June 2017 and the department achieved accreditation in September 2017.     

NCDOH has long standing pre-existing relationships with partners from all sectors of the public health system, including its governing entity, other governmental agencies, hospitals, community based organizations (CBOs) and academia.  These partners remained stakeholders in NCDOH's pursuit for national public health accreditation.  Consistent engagement and collaboration occurred with the department's governing entity.  The Board of Health (BOH) serves as the governing entity of NCDOH. From its inception, the accreditation process was supported by the Board of Health. Throughout its course, the Board was educated, engaged and informed as to the department's progress, primarily through BOH reports and monthly meetings. In addition, the BOH contributed to several measures and was instrumental in the PHAB site visit.  NYSDOH was invested in NCDOH becoming accredited, as it oversees NCDOH. Bringing up the standards of services benefits the state health department.  Having already achieved public health accreditation through PHAB, NYSDOH became a valuable resource.  NYSDOH provided trainings to support accreditation, funded interns through the Public Health Training Center and gave the county access to examples of documentation. The health department's already well-established relationships with hospitals and community based organizations (CBOs) facilitated the accreditation process.  NCDOH routinely works with the twelve hospitals within the county and numerous CBOs on initiatives and programs, such as the CHA and CHIP, the Perinatal Network, Ending the Epidemic and Cribs for Kids.  Many of these programs were used as evidence of domains in the accreditation submission.  These partners played a key role in the PHAB site visit.  PHAB requested a community partner meeting where they participants about their collaborations with the health department.  Some in attendance were representatives from Northwell Health, NYU Winthrop Hospital, United Way, Hispanic Counseling Center, Long Island Association for AIDS Care and Long Island Health Collaborative.  NCDOH has strong relationships with many academic institutions and is host to numerous students annually.  Throughout the accreditation process, NCDOH benefited from carefully selected and trained interns by the ACs.  These interns aided in educating department staff, analyzing data for the CHA, facilitating collaborative CHIP meetings, compiling, preparing and reviewing documentation, as well as tracking progress.  Over the course of the six-year timeframe, NCDOH hosted eight accreditation interns.

Accreditation funding consisted of a fee to PHAB and in-kind NCDOH staff time. The department submitted its application in 2015 and adhered to the PHAB Accreditation Jan 1, 2014-June 30, 2016 Applicant Fee Schedule. This fee is based on population size, Nassau County's 1.3 million residents resulted as a PHAB designated Category 5 health department, with a population between 1 million to 3 million. NCDOH opted for a one-time payment of $ 47,700 rather than a three or five-year payment plan. This fee included the following: An assigned accreditation specialist to guide the department through the application process; In-person training for the health department's accreditation coordinator; Access to PHAB's online accreditation dashboard (e-PHAB); The site visit and PHAB guidance and support for 5 years.  NCDOH provided in-kind staff time at 50% of the ACs overall time and additional staff time as needed.  Interns were at no cost to NCDOH.  Two were funded by the New York City, Long Island, Lower Tri County Public Health Training Center.  The others were volunteers.



Nassau County Department of Health confirmed that it could achieve accreditation by PHAB's criteria. The department demonstrated its capacity to fulfill the twelve domains of public health accreditation: to assess population health, investigate public health problems and hazards, inform and educate the community through policies, programs and processes, engage community to address problems, keep current policies and plans including strategic, emergency preparedness and health improvement plans, enforce public health laws, promote access to health care, maintain competent workforce through development, institute a quality improvement culture using performance management, apply evidence based activities, develop administration and management capacity and engage with Board of Health.

In addition, by receiving accreditation, NCDOH proved that it could leverage its limited resources, improve its services, mobilize staff and reinforce its partnerships.  The collective impact model was the best strategy to accomplish the following objectives:  1) To educate, engage and collaborate within the department creating a common agenda; 2) To develop, collect and evaluate evidence of required domains; 3) To improve processes to fulfill measures and increase performance.  These objectives were met with 100% completion. The outcome goal of accreditation was also met with 100% completion.  The collective impact model effectuates change by relying on five elements including common agenda, shared measurement system, mutually reinforced activities, on-going communication, and an independent backbone organization.  Furthermore, collaboration of this kind requires attention to including individuals with different perspectives, the strength of relationships among the individuals, sharing credit, identification of adaptive and multiple solutions.  Therefore, this practice was innovative in its application to accreditation. 

The collective impact model was evaluated by NCDOH and considered to be effective.  The evaluation was on-going throughout the process, included both primary and secondary data sources, and quantitative results on process and outcome measures. Collective impact became a creditable framework in which a health department could operate, internally.  It also can sustain its efforts as relationships were created, fortified and were mutually beneficial among staff and divisions.

Sources were composed of both primary and secondary data.  Primary data sources were collected by the ACs from division and program staff, representing different sectors of the health department over the course of the process.  The primary sources considered for this project were documentation and thus evidence that the health department satisfied a measure within PHAB's criteria.  Documentation, in this analysis, is considered the data unit.   Documents were collected electronically, as available, reviewed for accuracy and annotation, and uploaded into the e-PHAB system.  The ACs analyzed each document with its respective standards and measures. This information was summarized and diagrammed on a spreadsheet. This tool provided a tracking mechanism.  As documents were received and reviewed by the ACs, snapshots of the spreadsheet, in the form of summary tables, were provided to the document contributor with relevant feedback, whether it met the measure, and if not, the reason.  These snapshot tables were also periodically sent to staff as a reminder of what remained outstanding. This allowed for a consistent method of tracking and communication.  ACs also provided staff with standardized templates to document activities, such as meeting sign in sheets, agendas and minutes, facilitating conformity to PHAB requirements.  Also utilized were guides for creating plans and policies published by already accredited health departments.  Secondary data sources included documents provided by other partner agencies.  Some evidence was publicly available, some were already previously adopted by NCDOH and others required requests. Requests were made by NCDOH staff who had relationships with collaborative partners.   

Both process and outcome measures were evaluated.  Process measures incorporated both personal interactions, as well as, accounting metrics.  These measures were assessed as both short and long-term indicators.  Personal interaction measures included meeting frequency and training attendance.  Meetings included strategic plan subcommittee, accreditation team, leadership team, one-on-one and annual department meeting. Trainings were in person and on-line, quality improvement, performance management, cultural competency and site visit preparation.   Accounting metrics included tracking documentation submission by completion and timeliness.  The quality of the documentation was also assessed.  New and improved documentation was also considered.  The outcome measure was the successful submission of documentation to PHAB and the award of accreditation.

These process and outcome measures are linked to the three objectives which are inherent in the collective impact model.  Personal interactions and training were essential to educate, engage and collaborate within the department creating a common agenda. Completion and timeliness was the result of the development, collection and evaluation of the shared measurement of documentation.  The quality of the documentation, along with enhanced protocols, reflected improved processes to fulfill measures and increase performance as a consequence of mutually reinforced activities.  In addition, the timeliness and completeness of the documentation collected demonstrated the effectiveness of communication, necessary for all objectives.  The backbone of the operation, its ability to coordinate and consistently assess and maintain operational functions was evidenced in the outcome measure of successfully submitting the documentation to PHAB.   The ACs, as the backbone, were able to manage the data collection independently, while the other sectors (the program division staff) could still devote the necessary time and effort to their respective missions and core functions, in addition to understanding the shared agenda.

The results were analyzed quantitatively. Personal interaction took many forms.  Meetings were tracked by frequency.  The strategic plan subcommittees met quarterly with the exception of data management who met three times; the accreditation team met formally once and participated in regular email correspondence; the leadership team met twice per month; one-on-one meetings occurred monthly; the annual department meeting was held twice during the process.  Trainings were measured by attendance.  In person PHAB training was attended by the ACs (100%); on-line PHAB training was completed as required by the ACs and the Commissioner (100%). The trainings regarding quality improvement and performance management were completed by 95% of staff and cultural competency training was required by all staff (100%).  Site visit preparation training was completed by all the leadership team (100%).  Document tracking occurred over the course of three years during the collection phase.  PHAB domains consist of a total of 100 measures.  In 2014, the ACs received documentation for 30% of the measures; of which, 20% was deemed acceptable.  In 2015, the ACs received a documentation for an additional 30% of the measures; of which 20% was deemed acceptable.  In 2016, the ACs received the remaining 60% of the documents which were eventually deemed acceptable.  Of the total measures, 5% contained documents provided by outside agencies with whom we partnered, considered secondary data. During the process of accreditation, additional plans to improve processes were developed.  Ten plans and/or policies were created.  They included:  QI Plan, Workforce Development Plan, Cultural Competency Policy, Strategic Plan, Confidentiality Policy, Communications Plan, Research Policy, Branding Strategy, Guidelines for Health Promotion and the Outreach Plan.  The final outcome measure was the award of accreditation.

As the process of accreditation continued, the collective impact model aspect of communication became increasingly more important.  In February of 2016, after the in person PHAB training by the ACs, documentation had to be uploaded within the year.  This hard deadline was communicated and served as motivation to staff as they were already invested in the common agenda.  Further education became paramount to increasing the quality of the documents received.  The dashboard provided a transparent update to staff as to the health department's progress.  Furthermore, the need for mutually reinforced activities increased over time.  At the outset, the strategic plan subcommittees and their overlapping agendas provided much of these activities.  As accreditation, moved forward, the Accreditation and the Leadership Team became necessary to identify gaps, make recommendations, verify documentation with justifications.  Therefore, over time, these committees demonstrated the principles of accreditation integrated throughout the department. 

The collective impact model and its creative and adapted implementation in NCDOH's effort to become accredited is sustainable because it strengthened the relationship within the department. While the department was awarded accreditation status, annual reporting is still on-going and re-accreditation will be in its future.  Therefore, the key lessons learned as described below, have led to a sustainable method going forward. 

The first key lesson was related to time necessary to complete accreditation.  Staffing dedicated to this project was limited.  Therefore, the CHA, CHIP, SP and QI and Performance Management System components plus the collection and annotation of documents took several years to amass.  The advantage to a long time-line was that it gave the staff time to consider and accept this process, and especially inculcate key concepts, such as quality improvement and branding. These efforts contributed strongly to investing in a common agenda and moving forward.  The disadvantage was that continuity of the process was not necessarily maintained with the same intensity over several years and documentation at times did expire.  Nevertheless, often over time, better examples of evidence were identified, and a better working knowledge and appreciation of division efforts was realized.

By far, the most successful method to data collection was an incremental approach whereby key staff became invested in the process and saw its rewards, personally. This resonates with importance of building strong relationships and sharing credit, important features to the collective impact approach.   In addition, after the initial application, once timelines were set by PHAB, the Commissioner's efforts to direct staff to provide necessary documentation was more fruitful.  Here, true leadership is clearly important.  If the leader is unequivocally supporting the process, then the staff will more likely prioritize, engage or at least adhere to the direction appropriately.  Leadership and committed staff should not disappear once accreditation is achieved, but should be perpetuated.   

Documentation was evaluated by the ACs and deemed either sufficient or insufficient.  The two ACs worked in concert and maintained control over what was eventually submitted.  Even so, errors did occur, which were not recognized until post submission.  The site visit provided an opportunity to make some small corrections.

Communication among staff was critical. Meetings of different combinations of staff and continuous updating of staff via emails and the e-PHAB dashboard were necessary to keep everyone current, and the data transparent.  The language and complexity of the domains required thoughtful and repeated critical analysis.  Ease with applications and e-PHAB was also required and improved coordination along the way.  There existed variation among staff with these skills and tools and therefore additional training was needed, provided by the ACs.  Again, training and communication tools that were learned during the process are still being used in other efforts.

Mutually reinforced activities, including the strategic plan subcommittee meetings, and leadership verification process proved successful.  The strategic plan subcommittees provided internal goals and objectives that were inter-divisional.  Membership was derived from many divisions and the goals were cross-cutting; Community Engagement and Workforce Development are good examples. Strategies to improve reaching the underserved population were explored, by understanding what was already in place and what approaches could be used.  Training across the department in cultural competency was also promoted.   These subcommittees continue to meet and seek improvements for the department to deliver public health to the community. 

In preparation for the site visit, the ACs provided opportunities for department staff to practice the interviews.  Mock interview conferences allowed staff to defend their documents and understand how the documents, together, met the measure—and were mutually reinforced.  It also reminded staff of the documents submitted, since in some cases, significant time had passed.  This type of preparation was invaluable and energized the staff in anticipation of the visit.  Such opportunities for cross-collaboration across the areas of accreditation will continue, especially as relationships have expanded.

In addition to the internal work that the department conducted to achieve the accreditation, stakeholders also played a role.  These relationships are long-standing and pre-dated the department's decision to seek accreditation. 

The PHAB site visitors specifically commented that our community partnerships were, numerous, long-standing…across diverse sectors… [and that] these partners recognize the NCDOH as the hub or force that brings the community together around priority health issues…NCDOH team is to be commended for leveraging existing resources for the benefit of the community's health.” These relationships have been nurtured by the leadership team over time.  They are built on mutual respect, attention to communication, and public health goals.  In advance of the meeting where the community partners would be interviewed in a group setting, department staff reached out to these colleagues with accreditation material with which to familiarize themselves. 

The NCDOH BOH was an important partner.  It was necessary to maintain communication and educational efforts between the board and the department to update them on new processes, committees and trainings.  These were often accomplished through monthly reporting as well as communication between the Commissioner and the board directly. 

NYSDOH also provided support to the accreditation process.  Since NYSDOH had already achieved accreditation itself, it provided trainings and tools that benefited the process at the county level.  One example included trainings on quality improvement approaches. 

In addition, partnerships with universities provided important collaboration, as an outside sector.  Intern staff were essential during the entire process, including developing the CHA and CHIP.  The ACs selected students based on their acumen and independence, as needed, during different phases.  Their skills consisted of critical thinking, analysis, creativity, organization and writing.  These volunteers assisted the backbone operations of the effort.  Continued efforts to host interns remain on-going.  The department actively seeks to establish these relationships with universities and unique, capable students.

The cost of accreditation was $47,700 for five years of accreditation status.  All staff effort was in-kind. The benefits of accreditation are short and long-term. Over the course of the accreditation process, specific standards were highlighted and required development and revision.  Simple modifications, such as documentation of meetings by minutes with sign-in sheet and dates became more routine.  Meaningful changes, such as the development of a branding strategy, its use and importance were created.  NCDOH emphasized the process of collaboration, not just the outcomes of collaboration.  The county provided necessary building ground improvements to align with necessary regulations and labeling needs of the department.  Finally, the effort to apply for accreditation provided a sense of departmental pride and community.

The department has already seen some long-term benefits from accreditation.  It became clear that the principle of standardization is important for documentation, protocols and policies.  Maintaining and revising rules and procedures benefit the department's function; revisions provide an opportunity to convene and discuss them on an on-going basis.  The culture of QI was seeded and centralized in the department, as consistent with the SP, and continues to be integrated within divisions and across them.  With proper leadership support, more successful projects will be generated.  Workforce Development increased its capacity to provide trainings, orientations and services to the department staff.  Cultural competency will continue to be reinforced throughout the department, as will attention to disabilities and special needs.

Such benefits that lead to improved process will translate to better serving the community.  These are difficult to quantify in terms of dollars, but rather are priceless if they lead efficiency, strength in staff and a healthier community.  According to PHAB, improved competitiveness for funding is a benefit of accreditation. Such a direct dollar benefit remains to be seen.  NCDOH looks forward to that outcome.  Decisions for re-accreditation and the cost that it incurs for the future would need to be based on the intangible benefits of accreditation, as well as, grant funding that results.

Stakeholder commitment to sustain the practice may be assessed from two perspectives.  The stake that the staff and division hold will only continue to ripple through the department.  New quality improvement efforts continue to energize others.  Strategic planning in which many staff participate also see goals realized.  Truly more and more staff continue to appreciate the value of accreditation; the Commissioner continues to support this effort as well.  Outside partners and the community also see the importance of accreditation.  NYSDOH and BOH consider this achievement invaluable and understands that it effectuates better processes which will in turn serve the population.  Accreditation demonstrates that NCDOH achieves, maintains, and commits to the highest standard of providing governmental public health services.

Plans to sustain this intradepartmental collaboration were realized and continue along a strong trajectory.  The first annual report reflected additional quality improvement projects, efforts towards developing enhanced departmental culture of QI, performance management monitoring, tracking and modifications for the community health assessment and improvement plans.  Engagement of staff in new and long-standing subcommittees continues.  The department organizational structure was modified, creating a new bureau charged with continued accreditation activities and support for strategic planning.  In addition, staff was hired to support this new bureau. 

NCDOH worked on eight QI projects, five of which were administrative, which impact all staff, 212 employees. Of the four QI projects which were fully implemented, nearly 145/212 staff participated. The three programmatic projects affect three of the five divisions of the health department related to disease prevention and health promotion. The QI projects were initially generated from 5 different members of the QI subcommittee but were supported by three strategic plan subcommittees which included approximately 25 individuals. Each QI project had a Project Owner. The number of QI projects did expand in general from prior to QI plan's initial date of approval and PHAB site visit and now equal eight.  Four of the eight have been implemented this year; two of the four projects have been conducted long enough for analysis of feedback.  The QI projects were :  1) Give a Superstar-administrative, derived from the QI and HR programs, implemented throughout the department, peer-to-peer recognition program to build morale, pilot program that has continued to expand in terms of participation; 2) Information and Referral Improved Scheduling-administrative, derived from clerical staff and HR, pending implementation, program to improve coverage issue related to phone calls from the public; 3) Improving Access to Care- programmatic, derived and implemented by Division of Maternal and Child Health, program designed to increase specific population's access to healthcare services, program has continued to expand in terms of the public participation over time; 4) Speakers' Bureau-administrative, derived from the Strategic Plan Community Engagement subcommittee, implemented throughout the department, program designed to streamline public requests for expert speakers from the health department; 5) Community Courtyard-administrative, derived from QI and HR programs, to be implemented throughout the department, program to create an outdoor space for employees to network and recharge during breaks, pending implementation; 6) Health Department Call-A-Colleague-administrative, derived from QI and Workforce Development subcommittees, to be implemented throughout the department but in early phase of development, program to identify key staff with technical skills (such as knowledge of Outlook or Excel) who can offer assistance to others who request it; 7) Standardized Surveillance Case Progress Notes-programmatic, derived from QI, implemented in TB Control, Immunization Program, Perinatal Hepatitis B Program and Communicable Disease Control, project to establish template on which to write progress notes with accompanying training for progress note procedures, currently program implemented in 4/5 disease control bureaus, may expand to STD/HIV if resources permit; and, 8) ResRem Online Database-programmatic, derived from Environmental Heath, will be implemented in the Office of Toxic and Hazardous Materials Storage once database design is complete, project will allow contractors and the public to schedule or confirm oil tank abandonment or removal online without having to call, fax or email NCDOH.

The commitment to accreditation beyond the award is evident by all staff's perceptions, efforts and continued support from administration.     


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