phab-local_public_health_department_standards_feedback_form

Public Health Accreditation Board Local Public Health Department Standards Feedback Form Thank you for participating in the vetting process for the Public Health Accreditation Board (PHAB) standards Your feedback will help PHAB revise and refine the standards that will be proposed for use in the voluntary national accreditation program for local public health departments If possible, we encourage you to provide your feedback online rather than through this form to improve the consistency of comments collected and to allow you to provide more detail in your comments Please visit www.phaboard.org for the online form However, if you are unable to so, please complete this paper-based form and return it to PHAB by April 30 (See below for instructions on returning it.) This form is for the standards for local public health departments Please note that for some standards and measures, there are different versions for state public health departments and local public health departments If you would like to complete the state version, please visit www.phaboard.org or contact PHAB at 703-778-4549 About This Process This vetting process is being conducted on behalf of PHAB by the National Opinion Research Center (NORC) NORC is a not-for-profit social science research organization affiliated with the University of Chicago Your open and honest feedback on this form is appreciated NORC will take necessary steps to safeguard your privacy Information that you provide during this process about the organization you represent will be separated from your responses Quantitative data will be reported in aggregate form and will not be linked to the identity of a particular respondent or organization You may choose to make comments about the proposed standards These comments may be shared with the individuals revising the standards If possible, please refrain from writing comments that include identifying information (for example, organization name or state) when providing comments about the standards By completing this form, you acknowledge that you understand that your participation is voluntary You understand that you may choose not to answer any questions and/or end your participation at any time There are no foreseeable risks to your participation nor are there any immediate benefits to your participation The information you provide, however, will be helpful to PHAB as it continues to refine the proposed standards Understanding the Accreditation Framework The PHAB accreditation framework consists of 11 domains—Part A contains one domain and Part B contains 10 domains Each domain is made up of standards (i.e., specific public health functions that are actionable, attainable, and measurable) Each standard is made up of one or more measures (i.e., statements of quantification/qualification/action to determine compliance with a standard) This feedback form is primarily focused on the draft standards If you wish to provide feedback on the individual measures, please visit www.phaboard.org and complete the online form Return This Form by April 30, 2009 When you have completed the form, please either return it to a member of the PHAB staff or workgroup, e-mail it to prakash-shivaani@norc.org, or mail it to this address: Shivaani Prakash NORC 4350 East-West Highway, Suite 800 Bethesda, MD 20814 (Because this survey is several pages long, it will require more postage than a typical letter.) Questions If you have any questions about PHAB, please visit www.phaboard.org or contact Robin Wilcox at rwilcox@phaboard.org or 703-778-4549 If you have questions about this form, please contact Shivaani Prakash at NORC (prakash-shivaani@norc.org or 301-634-9351) If you have questions about your rights as a participant in this process, contact the NORC Project Director, Michael Meit (301-6349324 or meit-michael@norc.org) or the NORC Institutional Review Board Administrator, Kathleen Parks (1-866-309-0542) Local Public Health Department Standards Page What type of organization you represent? Please check the box to the left of your response Local public health department Territorial health department Public Health Institute Board of health Other (please specify): State public health department Tribal health program Academic institution Nonprofit organization If you work for a public health department, please write the name of that department: Directions: This table lists the proposed standards Under each standard, the accompanying measures are listed For each question, please check the box that indicates the extent to which you agree or disagree with the statements (If you not work at a health department, think about health departments in general.) Part A: Administrative Capacity and Governance Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard A1: Provide Infrastructure for Public Health Services (Develop and maintain an operational infrastructure to support the performance of public health functions.) Measure A1.1: Implement policies and procedures regarding agency operations, review policies regularly and assure these are accessible to staff Measure A1.2: Demonstrate written policies regarding confidentiality, including HIPAA requirements Measure A1.3: Implement a Human Resources system Measure A1.4: Maintain information systems that support the agency’s mission and workforce by providing infrastructure for data collection, program management, and communication Measure A1.5: Establish strategies for future information services technologies Measure A1.6: Maintain facilities that are clean, safe, accessible, and secure Meeting Standard A1 is important for improving the performance of my public health department The important components of Standard A1 are captured in the measures for the standard Standard A2: Provide Financial Management Systems (Establish effective financial management systems.) Measure A2.1: Comply with requirements for externally funded programs Measure A2.2: Maintain written contracts with entities providing processes, programs and interventions delegated or purchased by the public health agency Measure A2.3: Operate under a budget approved by the appropriate authority Measure A2.4: Demonstrate that effective financial management systems are in place Measure A2.5: Demonstrate that resources are sought to support agency infrastructure, processes, programs and interventions Meeting Standard A2 is important for improving the performance of my public health department The important components of Standard A2 are captured in the measures for the standard Standard A3: Identify Public Health Authority (Assure that specific authorities for public health roles and responsibilities are current and operationally defined.) Measure A3.1: Assure that the agency provides mandated public health functions Measure A3.2: Assure that the governing entity complies with regulations regarding governing entities Measure A3.3: Demonstrate evaluation of the agency director Meeting Standard A3 is important for improving the performance of my public health department The important components of Standard A3 are captured in the measures for the standard Standard A4: Provide Ongoing Education for the Governing Entity (Provide ongoing education for members of the governing entity regarding their responsibilities and those of the public health agency.) Measure A4.1: Provide continuing education to the governing entity regarding the responsibilities of the public health agency Measure A4.2: Provide continuing education to the governing entity regarding their responsibilities Meeting Standard A4 is important for improving the performance of my public health department The important components of Standard A4 are captured Local Public Health Department Standards Page in the measures for the standard Local Public Health Department Standards Page Domain 1: Conduct assessment activities focused on population health status and health issues facing the community Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 1.1: Collect and Maintain Population Health Data (Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on the health status of the population.) Measure 1.1.1: Assure a surveillance system is in place for receiving reports 24/7 and for identifying health problems, threats, and hazards Measure 1.1.2: Communicate with surveillance sites on at least an annual basis Measure 1.1.3: Collect primary data and secondary data from multiple sources Measure 1.1.4: Provide reports of primary and secondary data to SHA Meeting Standard 1.1 is important for improving the performance of my public health department The important components of Standard 1.1 are captured in the measures for the standard Standard 1.2: Analyze Public Health Data (Analyze data to identify trends, health problems, environmental public health hazards, and social and economic risks that adversely affect the public’s health.) Measure 1.2.1: Analyze and draw conclusions from data to identify trends over time, clusters, health problems, environmental health hazards, and social and economic conditions that adversely affect the public’s health Measure 1.2.2: At least annually, provide health data to the community in the form of reports on a variety of public health issues Measure 1.2.3: Maintain ability to develop routine and special statistical reports Meeting Standard 1.2 is important for improving the performance of my public health department The important components of Standard 1.2 are captured in the measures for the standard Standard 1.3: Use Data for Public Health Action (Provide the results of health data analysis to report health status and use to develop recommendations regarding health policy and program development.) Measure 1.3.1: Use surveillance systems to initiate investigations Measure 1.3.2: Develop and distribute community health data profiles to support health improvement planning processes at the state and local level Meeting Standard 1.3 is important for improving the performance of my public health department The important components of Standard 1.3 are captured in the measures for the standard Local Public Health Department Standards Page Domain 2: Investigate health problems and environmental public health hazards to protect the community Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 2.1: Investigate and Respond to Health Problems and Environmental Public Health Hazards (Conduct timely investigations and response to health problems and environmental public health hazards in coordination with other governmental agencies and key stakeholders.) Measure 2.1.1: Maintain protocols for investigation process Measure 2.1.2: Demonstrate expertise and capacity to conduct an investigation Measure 2.1.3: Establish partnerships and work collaboratively with governmental and community partners on reportable/disease outbreak or environmental public health investigations Measure 2.1.4: Assure timely reporting of notifiable diseases, lab test results, and investigation results Measure 2.1.5: Complete an After Action Report (AAR) following significant events Measure 2.1.6: Assure SHAs and LHDs work together to build capacity and share resources to address state and local efforts to identify, analyze, and respond to public health problems and threats Meeting Standard 2.1 is important for improving the performance of my public health department The important components of Standard 2.1 are captured in the measures for the standard Standard 2.2: Contain Health Problems and Environmental Public Health Hazards Prevent, minimize, and contain adverse health events and health risks using evidence-based practices Measure 2.2.1: Implement protocols for mitigation, including disease-specific procedures for mitigating an outbreak and conducting follow-up documentation and reporting Measure 2.2.2: Assure that investigation protocols include decision criteria for determining when an outbreak or environmental public health event triggers the All Hazards/ERP Measure 2.2.3: Develop strategies to protect the public from preventable conditions and environmental public health hazards Meeting Standard 2.2 is important for improving the performance of my public health department The important components of Standard 2.2 are captured in the measures for the standard Standard 2.3: Maintain Epidemiological, Laboratory, and Support Response Capacity (Maintain access to laboratory and epidemiological expertise and capacity to help monitor health status, diagnose and investigate public health problems and environmental hazards.) Measure 2.3.1: Maintain 24/7 access to epidemiological capacity capable of providing for rapid detection, investigation and containment of health problems and environmental public health hazards, including surge capacity Measure 2.3.2: Maintain 24/7 access to laboratory capacity capable of providing for rapid detection, investigation and containment of health problems and environmental public health hazards, including surge capacity Measure 2.3.3: Maintain support personnel and infrastructure capable of providing additional surge capacity Meeting Standard 2.3 is important for improving the performance of my public health department The important components of Standard 2.3 are captured in the measures for the standard Standard 2.4: Maintain Urgent Communication Policies and Processes (Maintain policies and processes required for urgent communications and electronic data exchange.) Measure 2.4.1: Maintain written protocols for urgent 24/7 communications Measure 2.4.2: Implement a system to receive and provide health alerts and appropriate public health response for health care providers, emergency responders, and communities on a 24/7 basis Measure 2.4.4: Provide timely communication to local media during public health emergencies Measure 2.4.5: Provide timely communication to the general public during public health emergencies Meeting Standard 2.4 is important for improving the performance of my public health department The important components of Standard 2.4 are captured in the measures for the standard Local Public Health Department Standards Page Domain 3: Inform and educate about public health issues and functions Strongly Agree Disagree Strongly Don’t Agree Disagree Know Standard 3.1: Communicate Information on Public Health Issues and Functions (Provide information within and outside the agency on public health issues and functions.) Measure 3.1.1: Assure communications procedures to provide information within and outside the agency Measure 3.1.2: Make information available through a variety of methods including the existence of a website for the agency Measure 3.1.3: Provide information on community health risk, health status, and health needs; and public health mission, roles, programs and interventions to improve the community’s health Measure 3.1.4: Ensure that accurate and current information is available in formats that are culturally and linguistically relevant for the community Measure 3.1.5: Implement socially, culturally, and linguistically relevant approaches in agency processes, programs, and interventions Meeting Standard 3.1 is important for improving the performance of my public health department The important components of Standard 3.1 are captured in the measures for the standard Standard 3.2: Provide Health Education and Promotion Activities (Provide health education and promotion activities to address identified health problems.) Measure 3.2.1: Implement health education and promotion strategies, including evidence-based interventions Measure 3.2.2: Conduct ongoing evaluation of health education and promotion strategies Measure 3.2.3: Revise strategies and measurable objectives based upon evaluation results Meeting Standard 3.2 is important for improving the performance of my public health department The important components of Standard 3.2 are captured in the measures for the standard Domain 4: Engage with the community to identify and solve health problems Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 4.1: Engage the Public Health System and the Community in Comprehensive Planning (Engage the public health system and the community in comprehensive planning through an ongoing, collaborative process.) Measure 4.1.1: Recruit governing entity members, stakeholders, community partners and the public to participate in a community planning process to improve health Measure 4.1.2: Provide technical assistance to community stakeholders regarding models for developing partnerships, recruiting and engaging with the community in planning processes Measure 4.1.3: Establish and support collaborative partnerships to solve priority public health issues Meeting Standard 4.1 is important for improving the performance of my public health department The important components of Standard 4.1 are captured in the measures for the standard Standard 4.2: Engage the Community to Promote Policies to Improve the Public’s Health (Promote understanding of and support for policies and activities that will improve the public’s health.) Measure 4.2.1: Disseminate the results of community health assessments to the community Measure 4.2.2: Educate and seek support from the community on policies and activities that will improve the public’s health Meeting Standard 4.2 is important for improving the performance of my public health department The important components of Standard 4.2 are captured in the measures for the standard Local Public Health Department Standards Page Domain 5: Develop public health policies and plans Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 5.1: Establish, Promote, and Maintain Public Health Policies (Serve as a primary resource to governing entities and elected officials to establish and maintain public health policies, practices, and capacity based on current science and best practice.) Measure 5.1.1: Monitor public health issues under discussion by governing entities and elected officials Measure 5.1.2: Contribute to the development and/or modification of public health policy by facilitating community involvement and engaging in activities that inform the policy development process Measure 5.1.3: Alert governing entities, elected officials and the public of potential public health impacts (both intended and unintended) from current and/or proposed policies Meeting Standard 5.1 is important for improving the performance of my public health department The important components of Standard 5.1 are captured in the measures for the standard Standard 5.2: Engage in State or Local Health Department Strategic Planning (Engage in state or local health department strategic planning.) Measure 5.2.1: Conduct a strategic planning process Measure 5.2.2: Produce a strategic plan Measure 5.2.3: Implement the strategic plan Measure 5.2.4: Review and update the strategic plan Meeting Standard 5.2 is important for improving the performance of my public health department The important components of Standard 5.2 are captured in the measures for the standard Standard 5.3: Conduct a Health Improvement Planning Process (Conduct a collaborative planning process resulting in a community health improvement plan.) Measure 5.3.1: Conduct a health improvement process that includes broad participation from the community Measure 5.3.2: Produce a health improvement plan as a result of the community health improvement process Measure 5.3.3: Implement elements and strategies of the health improvement plan, in partnership with others Measure 5.3.4: Establish a monitoring system to track progress on strategies and health improvement in order to revise the CHIP, as needed Meeting Standard 5.3 is important for improving the performance of my public health department The important components of Standard 5.3 are captured in the measures for the standard Standard 5.4: Maintain All Hazards/Emergency Response Plan (Maintain All Hazards/Emergency Response Plan (ERP).) Measure 5.4.1: Develop an All Hazards/ERP Measure 5.4.2: Maintain or have access to resources to carry out the All Hazards/ERP effectively Measure 5.4.3: Collaborate in the testing of the All Hazards/ERP, through the use of drills and exercises Measure 5.4.4: Collaborate in revision of the All Hazards/ERP Meeting Standard 5.4 is important for improving the performance of my public health department The important components of Standard 5.4 are captured in the measures for the standard Local Public Health Department Standards Page Domain 6: Enforce public health laws and regulations Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 6.1: Maintain Up-to-Date Laws, Regulations, and Ordinances (Review existing laws, regulations and ordinances on a regular basis and work with governing entities and elected officials to update as needed.) Measure 6.1.1: Maintain access to legal and program expertise to assist in the review of laws, regulations, and ordinances Measure 6.1.2: Evaluate the need for changes in laws, regulations and ordinances with governing entity on routine basis Measure 6.1.3: Inform governing entity and elected officials of needed statutory and regulatory updates and make recommendations for action Meeting Standard 6.1 is important for improving the performance of my public health department The important components of Standard 6.1 are captured in the measures for the standard Standard 6.2: Educate About Laws, Regulations, and Ordinances (Educate individuals and organizations on the meaning, purpose, and benefit of public health laws, regulations and ordinances and how to comply.) Measure 6.2.1: Maintain agency workforce knowledge of public health laws, regulations and ordinances Measure 6.2.2: Make laws, regulations, ordinances, written policies and permit/license application requirements accessible to the public Measure 6.2.3: Provide education to regulated entities regarding their responsibilities and methods to achieve full compliance with applicable laws and regulations Meeting Standard 6.2 is important for improving the performance of my public health department The important components of Standard 6.2 are captured in the measures for the standard Standard 6.3: Conduct Enforcement Activities (Conduct enforcement activities for which the agency has the authority and coordinate notification of violations among all appropriate enforcement agencies.) Measure 6.3.1: Maintain current written procedures and protocols for conducting enforcement actions Measure 6.3.2: Conduct inspection activities of regulated entities according to mandated frequency and/or a risk analysis method that guides the frequency and scheduling of inspections of regulated entities Measure 6.3.3: Conduct enforcement activities and follow up on complaints according to procedures and protocols for both routine and emergency situations Measure 6.3.4: Coordinate notification of violations and assure that enforcement activities, analyses and results are shared among all appropriate enforcement agencies Meeting Standard 6.3 is important for improving the performance of my public health department The important components of Standard 6.3 are captured in the measures for the standard Standard 6.4: Monitor Compliance With Laws, Regulations, and Ordinances (Monitor and analyze over time the compliance of regulated entities and individuals.) Measure 6.4.1: Establish a system to track compliance over time for each regulated entity Measure 6.4.2: Monitor compliance of regulated entities according to mandated frequency Measure 6.4.3: Conduct analysis of complaints, violations and enforcement activities to determine patterns, trends, latent problems, compliance and effectiveness Meeting Standard 6.4 is important for improving the performance of my public health department The important components of Standard 6.4 are captured in the measures for the standard Local Public Health Department Standards Page Domain 7: Promote strategies to improve access to healthcare services Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 7.1: Assess Healthcare Capacity and Access to Healthcare Services (Assess healthcare capacity and access to healthcare services.) Measure 7.1.1: Convene and/or participate in a collaborative process to assess the availability of healthcare services Measure 7.1.2: Identify underserved and at-risk populations and those who may experience barriers to healthcare services Measure 7.1.3: Identify gaps in access to healthcare services Meeting Standard 7.1 is important for improving the performance of my public health department The important components of Standard 7.1 are captured in the measures for the standard Standard 7.2: Implement Strategies to Improve Access to Healthcare Services (Identify and implement strategies to improve access to healthcare services.) Measure 7.2.1: Convene and/or participate in a collaborative process to establish strategies to improve access to healthcare services Measure 7.2.2: Implement strategies to increase access to healthcare services, including linking individuals with needed services and/or establish systems of care in partnership with the community Measure 7.2.3: Lead culturally competent initiatives to increase healthcare access for health disparities populations Meeting Standard 7.2 is important for improving the performance of my public health department The important components of Standard 7.2 are captured in the measures for the standard Domain 8: Maintain a competent public health workforce Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 8.1: Provide a Competent Public Health Workforce (Recruit, hire, and retain a competent and diverse public health workforce.) Measure 8.1.1: Apply recruitment and retention policies and assure availability to staff Measure 8.1.2: Assure that job standards and position descriptions are available to staff Measure 8.1.3: Verify that staff meet qualifications for their positions, job classifications and licensure Meeting Standard 8.1 is important for improving the performance of my public health department The important components of Standard 8.1 are captured in the measures for the standard Standard 8.2: Improve Public Health Workforce Competencies (Evaluate staff competencies and address deficiencies through continuing education, training, and leadership development activities.) Measure 8.2.1: Assure that performance evaluations are completed and improvement/training plans exist Measure 8.2.2: Implement an agency workforce development plan that addresses the training needs of the staff and assures development of core competencies Measure 8.2.3: Demonstrate leadership and management development activities Meeting Standard 8.2 is important for improving the performance of my public health department The important components of Standard 8.2 are captured in the measures for the standard Local Public Health Department Standards Page Domain 9: Evaluate and continuously improve processes, programs, and interventions Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 9.1: Evaluate the Effectiveness of Public Health Processes, Programs, and Interventions (Evaluate public health processes, programs, and interventions provided by the agency and its contractors.) Measure 9.1.1: Engage governing entity in establishing agency policy direction for evaluation of agency performance and implementation of quality improvement Measure 9.1.2: Establish agency policies to implement evaluation of agency performance and quality improvement in processes, programs, and interventions Measure 9.1.3: Establish goals, objectives and performance measures for processes, programs and interventions Measure 9.1.4: Monitor performance measures for processes, programs and interventions Measure 9.1.5: Evaluate the effectiveness of processes, programs, and interventions and identify needs for improvement Measure 9.1.6: Assure a systematic process for assessing customers’ satisfaction with agency services Measure 9.1.7: Assure evaluation expertise is available Meeting Standard 9.1 is important for improving the performance of my public health department The important components of Standard 9.1 are captured in the measures for the standard Standard 9.2: Implement Quality Improvement (Implement quality improvement of public health processes, programs, and interventions.) Measure 9.2.1: Establish a quality improvement plan based on organizational policies and direction Measure 9.2.2: Implement quality improvement efforts based on the evaluations of processes, programs, and interventions Measure 9.2.3: Demonstrate quality improvement training activities and technical assistance are available to staff Meeting Standard 9.2 is important for improving the performance of my public health department The important components of Standard 9.2 are captured in the measures for the standard Domain 10: Contribute to and apply the evidence base of public health Strongly Agree Agree Disagree Strongly Disagree Don’t Know Standard 10.1: Identify and Use Evidence-Based and Innovative Practices (Identify and use evidence-based and innovative practices.) Measure 10.1.1: Seek and evaluate applicable evidence-based practices when implementing new or improved processes, programs or interventions Measure 10.1.2: Foster innovative practices in processes, programs and interventions that address priority health issues Meeting Standard 10.1 is important for improving the performance of my public health department The important components of Standard 10.1 are captured in the measures for the standard Standard 10.2: Promote Understanding and Use of Research (Promote understanding and use of the current body of research results, evaluations, and best practices with appropriate audiences.) Measure 10.2.1: Assure that agency has access to expertise to evaluate current research and its public health implications for the community Measure 10.2.2: Communicate research findings, including public health implications, to the community Measure 10.2.3: Develop and implement policies that ensure state and federal requirements are followed when the agency is involved in research activities Meeting Standard 10.2 is important for improving the performance of my public health department The important components of Standard 10.2 are captured in the measures for the standard Local Public Health Department Standards Page 10 Are there any standards or measures you would modify or delete? If so, please indicate the number of the standard or measure, place a check in the appropriate column to indicate if you would modify or delete it, and provide an explanation of either how you would modify it or why you would delete it Standard/ Measure Number Modify Delete Explanation Please provide any other comments you have in general about these draft standards or measures If you would also like to comment on the documentation guidance (i.e., the examples of how a public health department would demonstrate compliance with a measure), you may download a version of the standards, measures, and documentation guidance from www.phaboard.org, and provide comments here Local Public Health Department Standards Page 11