Seven Steps of Accreditation

seven steps

The Seven Steps of Public Health Department Accreditation

The PHAB accreditation process consists of seven steps:

1. Pre-application

Health department prepares and assesses readiness for application for accreditation, completes Online Orientation, and informs PHAB of its intent to apply.

Health departments should assess their readiness to pursue accreditation by reviewing the standards, measures, and required documentation to determine areas of strength and opportunities for improvement. Health departments should appoint a staff person to be their Accreditation Coordinator and establish a department accreditation team to help prepare for the accreditation process.

PHAB has developed Accreditation Readiness Checklists to help health departments determine if they are ready to begin the application process. The Checklists address eligibility, completion of prerequisites, internal processes, and initial preparation tasks.

Completion of the PHAB Online Orientation is required for the health department director and the health department’s Accreditation Coordinator before the health department submits a Statement of Intent (SOI). Health departments are encouraged to have several staff members participate in the Orientation, especially those in leadership positions, members of the governing entity, and members of the department’s accreditation team.

The health department must submit an SOI to inform PHAB of the department’s intention to apply for public health department accreditation. The SOI is non-binding and does not commit a health department to submit an application. To submit an SOI, the health department must register on e-PHAB.

2. Application

Health department submits application and fee, and completes applicant training

The application is formal notification to PHAB of a health department’s official commitment to initiate the public health department accreditation process. The application is an agreement that the applicant will abide by the current and future rules of PHAB’s accreditation process to achieve and maintain accreditation status for the five-year accreditation period.

Upon receipt of an application, PHAB will invoice the health department. The PHAB-determined application fee must be submitted to PHAB before the Accreditation Coordinator can attend training.

Accreditation Coordinators are required to participate in PHAB training before the health department can begin to submit documentation of conformity with the PHAB standards and measures. This in-person training, scheduled quarterly, will last two days and will be provided to groups of applicants.

3. Document Selection and Submission

Applicant selects documentation for each measure, uploads it to e-PHAB, and submits it to PHAB

The process of identifying and uploading documents that demonstrate the health department’s conformity with the standards and measures is one of the most important components of the accreditation process. The documentation submitted by the health department is what the site visit team will review and use to determine the health department’s conformity with the standards and measures.

The e-PHAB system, which accommodates multiple users, allows the health department to work on various parts of documentation submission over a period of time. Applicants must submit their documentation to PHAB within 12 months of the date that PHAB provides access to the module of the electronic system for submission of documentation.

4. Site Visit

Site visit of the health department is conducted by PHAB-trained site visitors and a site visit report is developed

Site visits will be conducted by a peer team of three to four PHAB-trained site visitors. The visit serves several purposes: verify the accuracy of documentation submitted by the health department, seek answers to questions regarding conformity with the standards and measures, and provide opportunity for discussion and further explanation. Site visits will typically last two to three days, depending upon the complexity of the application.

Following the site visit, the site visit team will develop a site visit report. The report will describe:

– how conformity with each measure was demonstrated, or detail what was missing;

– areas of excellence or unique promising practices, and

– opportunities for improvement.

5. Accreditation Decision

PHAB Accreditation Committee will review the site visit report and determine accreditation status of the health department

The Accreditation Committee, appointed by the PHAB Board of Directors, will review and determine the accreditation status of applicant health departments. There are two accreditation status decision categories: “Accredited” (5 years) or “Not Accredited.” The Accreditation Committee will make accreditation decisions based on the site visit report, including the site visit team’s scores and descriptive information. If the health department is not accredited, they will have an opportunity to submit an Action Plan. If the Action Plan is approved by the Accreditation Committee, is implemented by the health department, and site visitors positively assess the documentation of implementation, then the health department could be accredited at that time. Failure to submit an Action Plan or to implement the approved Action Plan will result in the health department being determined “Not Accredited.”

6. Reports

If accredited, the health department submits annual reports

The submission of annual reports is required of all accredited health departments. Annual reports describe how the health department has addressed areas identified by the Accreditation Committee as priority areas for improvement. Reports will also state that the health department continues to be in conformity with all the standards and measures of the version under which accreditation was received.

 

7. Reaccreditation

As accreditation status nears expiration, the health department applies for reaccreditation

Each accredited health department is required to submit a new application in the reaccreditation process and may be required to receive additional training. A health department applying for reaccreditation must participate in the entire accreditation process, including submission of an application and the site visit.

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