Accreditation Process
Advancing public health quality and performance
1
Pre-Application
Before applying for accreditation, LPHAs should review the Standards Workbook for a general sense of whether agency performance will meet MICH standards and measures. LPHAs should engage key staff members, the LPHAs' governing body, and strategic community partners to share the vision and journey to accreditation. The process requires time and energy and will require leadership support and staff buy-in. A kickoff event is one way to initiate the process and create enthusiasm among staff. LPHAs are encouraged to develop a work plan and road map to success including a time goal to submit the application and complete document submission. Plans should identify gaps between the current status and performance measures. LPHAs should assign staff, including an accreditation coordinator, to begin working on closing gaps. The accreditation coordinator can communicate with the MICH liaison and assemble documents for submission.
Tools
2
Application
To start the accreditation process, LPHAs should submit an application via email to support@michweb.org. MICH will issue an invoice for the application fee. When the application fee is paid, MICH will assign a liaison to coordinate with the LPHA on document submission and the accreditation process. LPHAs will submit the four prerequisite documents: Community Health Assessment (CHA), Community Health Improvement Plan (CHIP), agency Strategic Plan, and agency Quality Improvement Plan (QIP). LPHAs will need to have the prerequisites completed before applying for accreditation. LPHAs should also have already developed, or be in process developing an emergency operations plan, communications plan, workforce development plan, and a performance management policy/system before applying for accreditation.
Tools
3
Document Submission
Applying for accreditation requires several steps. LPHAs should focus on quality improvement during this process and ensure all staff members engaged. Identifying the appropriate documentation for each measure is one of the most critical parts of the accreditation process. LPHAs should describe why they chose a particular document and highlight sections of the document that demonstrate conformity to the measure. Descriptive narrative should be included in the Standards Workbook. These descriptors are vital for reviewers to understand the context of how LPHAs use the document and allows LPHAs to tell a story about how they meet the standards and measures. Accredited LPHAs feel this is the most important part of the accreditation process. It is an opportunity for staff to determine how well they are providing public health services and what they need to improve. LPHAs have benefitted from scheduling regular staff meetings to discuss assignments, coordinate activities, resolve performance or capacity issues and assess progress. These meetings facilitate the development of consistent descriptors and storytelling. LPHAs with questions may contact their MICH liaison for assistance. The Standards Workbook and accompanying pages on this website offer Accreditation Worksheets, templates, and other resources that may be helpful. MICH requires LPHAs to follow specific guidance with document submission: Highlight appropriate text in the document to indicate where the required elements are that show conformity to the measure. Reviewers will not read a 75-page document to find the one paragraph that meets the measure. Indicate in the descriptor what page in the scanned document reviewers should focus their attention on. Every document must be dated and must have a logo or some other identifying characteristics to show the reviewers the document is in use by the LPHA. When using Internet screenshots, be sure to date and identify the source/link. Unless otherwise stated, two examples will be required for each measure, preferably from different programs, to show the reviewers the measure is being demonstrated throughout the LPHA. LPHAs cannot upload 15 documents for one measure hoping the reviewers will find one that fits the measure. This is why descriptors are essential so reviewers can understand the context of the documents submitted. Draft documents or blank surveys will not be accepted. Any document that has a signature line, such as a contract, must be signed and dated. PDF documents are the preferred format. Scanned documents must be right-side up. Sideways or upside-down documents will not be accepted. The following steps must be completed before a site visit can be scheduled: Application forms and application fees submitted and accepted by MICH; The Prerequisites (CHA, CHIP, Strategic Plan and Quality Improvement Plan) uploaded to Dropbox and approved by MICH; Accreditation fee submitted and accepted by MICH; A completed Standards Workbook uploaded to Dropbox; All supporting documents uploaded using the Dropbox format sent to the LPHA via the liaison; An email sent to MICH detailing steps 1-5 have been completed.
Tools
4
Review & Site Visit
Reviewers are qualified public health practitioners. The LPHA will be notified of the names and qualifications of the review team prior to the site visit. Before the site visit, reviewers will examine the applicant’s Standards Workbook and supporting documentation. Measures that can be substantiated from these documents, the LPHA's website, or reports posted on the DHSS website will be examined. During the on-site review, the applicant’s policy manuals, personnel files, brochures, meeting minutes, community health assessment reports, and other documents and files will be examined. Only those that have not been previously submitted will need to be accessible to the review team. Reviewers will interview staff and members of the LPHA's governing body to verify that the LPHA is meeting standards as recorded in the Standards Workbook. Upon arrival, reviewers will meet with staff and governing body members to provide an overview of the site visit process. Reviewers will be onsite during normal business hours for no more than one day. At the conclusion of the site visit, the review team will conduct an exit interview to discuss areas where the agency excels, and identify areas where improvement is needed. The administrator may invite staff and governing body members to participate in the exit interview. After exiting, the review team will write a detailed Feedback Report and present ith with their recommendation at the next scheduled meeting of the Accreditation Council.
Tools
5
Determination
The Accreditation Council reviews the Standards Workbook scoring sheet and the Feedback Report completed by the reviewers, and considers the recommendation of the on-site review team in order to make a recommendation to the MICH Board of Directors. The MICH Board of Directors makes all accreditation decisions. MICH will notify the applicant of its decision within 45 days of completion of the on-site review. A LPHA can receive one of three accreditation designations: - Accredited: This designation indicates the health department has satisfactorily met all accreditation standards. The accreditation period begins on the date of notification and ends five years after that date. - Conditionally Accredited: This designation may be given for a term set by the MICH Board. It is awarded to LPHA that did not fully meet accreditation standards. LPHA’s given conditional accreditation are required to submit an Interim Plan of Action to MICH within 30 days after receiving notification of conditional status. Failure to submit the Interim Plan of Action forfeits the LPHA’s conditional accreditation, and the applicant is deemed not accredited at the end of the 30 days. The agency should use the Interim Plan of Action Form Template found on the MICH website. The form asks the LPHA to propose a plan of action for deficient areas, estimate the time needed to come into compliance for each deficient area, and designate staff responsible for plan implementation and oversight. After the Interim Plan is submitted, the Accreditation Council and the MICH Board will review the plan and, if accepted, a follow-up on-site review will be scheduled. The follow-up review will be scheduled at a time approved by all parties. The on-site reviewer(s) will submit a report to the Accreditation Council, and the Council will make a recommendation to the Board of Directors, which will make the final accreditation decision. Compliance with Standards Workbook results in the removal of the applicant’s conditional status and full accreditation is granted. The period of accreditation begins on the date of notification and ends five years after that date. If the LPHA does not meet Standards Workbook, conditional accreditation lapses and the applicant is deemed not accredited. If the Interim Plan is not approved by the MICH Board, the agency is deemed not accredited. - Not Accredited: LPHA’s that do not successfully meet all accreditation standards as determined by the Board of Directors, or upon re-review after being conditionally accredited, will receive the not accredited designation. The LPHA may re-apply for accreditation after 12 months. A health department that does not agree with the accreditation status decision may initiate the appeal process. MICH will make accreditation designations available to the public, if requested. Accredited health departments will be listed on the MICH web site.
Tools
Quality Improvement
Accreditation is designed to encourage the local public health agency to continually improve processes, public health practice, and program outcomes. Connecting the cycles of accreditation with a continuous quality improvement (CQI) approach strengthens the public health system. Accredited LPHAs will validate their commitment to quality improvement by demonstrating progress in areas identified by the MICH review team and documenting this progress in annual reports. These reports are due to MICH via email to support@michweb.org on the anniversary of the agency's accreditation. LPHAs should indicate continued compliance with all Standards and Measures in the Workbook. Annual reports will be reviewed by the MICH Board for approval and feedback to the LPHA. MICH liaisons are available to provide technical assistance with the development of plans and CQI methods to address any areas of improvement.
Tools
Reaccreditation
In year 4 of the accreditation cycle, the LPHA should prepare for reaccreditation. A new application, submission of documents and site visit will be required. As MICH continues to evaluate the accreditation program, updates to the process and standards may occur. Please contact MICH for details on any changes and the updated process for reaccreditation.