PHAB does not accept testimony, letters, phone calls, or other means of communication from the public about an individual health department while their accreditation process is in progress. Accreditation of a health department is based on demonstration of conformity with established standards and measures and is an indication of their capacity to carry out the ten essential public health services and selected core functions. National accreditation does not address local political or personnel issues.
PHAB Complaint Policy and Procedures
In an effort to maintain the overall credibility of the national public health accreditation process, the Public Health Accreditation Board (PHAB) uses information from various sources to monitor the sustained capacity and quality of the health departments that it accredits. Therefore, PHAB has established policies and procedures for receiving and addressing written complaints about an accredited health department. PHAB can only accept written complaints about an accredited health department that are specific to a possible lack of conformity with PHAB’s standards and measures under which the health department was accredited. PHAB cannot address complaints or disputes between individuals and health departments; complaints about health care services; social services; environmental health issues; professional licensing or practice; or any state, local or Tribal regulations. PHAB does not serve in the role of mediation between the health department and any party.
When a written complaint is filed with PHAB, the following procedures will apply. A written complaint against an accredited health department must be filed on the PHAB approved complaint form, must be specific as to the accreditation standard that is being violated, must identify the outcome sought, must include documentation that appropriate administrative processes have been exhausted and must be signed. Full disclosure of any other remedies that have been or are being sought must be included. Complaints against accredited health departments may be submitted to PHAB offices at any time and are maintained on file for the remainder of that health department’s accreditation cycle, or no longer than five years.
A filed complaint will be initially reviewed by PHAB staff. If the complaint is specific and includes documentation that administrative processes have been fully pursued, the following steps will be taken by PHAB:
1. PHAB staff will acknowledge receipt of the complaint within 10 business days and provide information about subsequent steps to be taken.
2. Copies of all materials received will be sent to the health department within 15 days of receipt of the complaint, along with a request for verification that administrative remedies have been exhausted.
3. If the accredited health department verifies that the complainant has exhausted the administrative remedies at the institution, PHAB will request that a written response to the complaint be submitted by the health department director within 30 days of receiving copies of the complaint materials from PHAB.
4. Three representatives of PHAB’s Executive Committee, appointed by the Chair of the Executive Committee, will convene a special teleconference meeting within 15 days of receiving the response of the health department for purposes of reviewing a complaint, will review the materials submitted by the complainant and the responses submitted by the health department and will determine whether there is sufficient evidence to believe the health department may be in violation of PHAB’s accreditation standards and measures. Their assessment will be forwarded to the President/CEO and to the Chair of the Executive Committee.
5. If the Executive Committee determines that the complaint lacks sufficient evidence to proceed with an investigation, the complainant and the health department will be notified in writing within 15 days of the Committee’s decision. No further action will be taken.
6. If the Executive Committee determines that the complaint contains sufficient evidence to proceed with an investigation, one of the following actions will be taken depending on the nature and timing of the complaint:
— If the health department has received accreditation in the last twelve months, the complaint may be forwarded to the site visitor team for review in light of the overall review of the health department.
— If the health department is scheduled for re-accreditation within the year, the complaint may be included in the review of relevant standards and measures during that review.
— The Chair of the Executive Committee may appoint a three-member investigative panel, which may be composed of board members and non-board members, based on the Chair’s discretion and the nature of the complaint. The investigation shall begin within 30 days of the establishment of the panel. It is expected that the panel’s deliberations will be handled by teleconference meetings. Both the complainant and the health department will be offered an opportunity to speak to the panel. The panel will have access to any and all information that is pertinent to the investigation.
— In rare cases, the Executive Committee or the investigative panel’s review of the complaint may lead to a site visit to the accredited health department.
7. Reports from site visitors or from the investigative panel will be provided to the Accreditation Committee at its next regularly scheduled meeting. The Accreditation Committee shall be the final decision-making body. Based on the Accreditation Committee’s deliberations, or in the event a health department fails to permit an investigation on a timely basis, PHAB’s decisions may include any of the following:
— Continue the accreditation status of the health department without change;
— Continue the accreditation status of the health department, but require reporting on the issues noted within the panel’s report in the next annual report (s);
— Place an accredited health department on probation for a period not to exceed twelve months during which time appropriate follow-up such as regular reporting or a repeat site visitor review (if done as part of the initial investigation) may be requested by the Accreditation Committee;
— Revoke the health department’s accreditation.
8. The accredited health department and the complainant will be advised of the Accreditation Committee’s decision and the reasons for the decision within 30 days. No other materials related to the complaint will be provided to the complainant.
9. Complaints, and their associated investigations, will be reported to the full Board of Directors quarterly.
10. Complaints, and their resolution, will be maintained on file in the PHAB office for the remainder of that health department’s accreditation cycle, or no longer than five years.
11. PHAB will not publically release the complaints received nor the results of the complaint assessments. PHAB reserves the right to incorporate the complaint details in the quality improvement data base in order to track trends in quality issues.
Approved by the PHAB Board of Directors, September 2013