Accreditation Process

Step 1: Pre-Application

Before applying for accreditation, a quick review of Standards Workbook will provide the agency management with a general sense of whether agency performance will meet standards and measures.

It is important for a health department considering accreditation to have key staff members, agency governing body, and strategic community partners sharing the vision.  The process requires time and energy, and needs to be supported and endorsed by the health department’s governing body and administration.  A kickoff event is one way to initiate the process and create enthusiasm among staff about accreditation.

A work plan and road map to success developed at the pre-application phase should set a time goal to submit the application and complete the document submission.  The initial plan should identify and document obvious variances between performance measures and the current situation, assign staff to begin working on shortfalls, and set regular meetings to coordinate efforts.  Download a checklist and accreditation planner.

Other local public health agencies found it helpful to designate an accreditation coordinator.  The coordinator might be the administrator, office manager, other staff person or even an outside person hired to oversee this project.  This person will work with the staff, communicate with the assigned MICH liaison, and assemble the documentation for uploading into Dropbox.

From the MICH website (www.michweb.org) accreditation materials can be downloaded.  They include: The Application, Fees and Contact Information, Standards Workbook, Glossary of Terms, Acronyms, Flow Chart of Accreditation Process, Interim Plan of Action Form Template, Annual Report Template, Tools and Resources.

 

 

 

Step 2: Application, Fees, and Prerequisites

LPHAs wishing to start the accreditation process must apply for accreditation.  The application can be downloaded from  https://michweb.org/accreditation-standards/or here and after completion sent to michoffice@michweb.org.  Upon receipt of the application, MICH will send an invoice for the application fee.  Once the fee is received, MICH will assign a liaison to the LPHA.  This liaison will partner with the LPHA by sending the information on document submission and coordinate with the LPHA in all matters pertaining to accreditation.

In our constant commitment to make the Missouri Voluntary Accreditation Program as user friendly as possible, all LPHAs who wish to apply or reapply for accreditation will use Dropbox for their application, prerequisites, and supporting documents. Drop-box will also be used by reviewers and staff to review files and prepare for the review. LPHAs may view Dropbox as an opportunity to create a running history of the accreditation process and a baseline for reaccreditation.

In addition, it is at this time that LPHAs will submit their four prerequisites of their Community Health Assessment (CHA), Community Health Improvement Plan (CHIP), agency Strategic Plan, and agency Quality Improvement Plan (QIP). If the LPHA does not have these four prerequisites completed, the LPHA will need to dedicate its time and resources toward their development before they apply for accreditation. Also, before applying for accreditation, the health department should have completed or substantially completed an emergency operations plan, a communications plan and a workforce development plan. A performance management policy/system should also be in place.  These documents and systems require significant time to complete. If they are not in place or near completion the health department will need to take the time to develop them before applying for accreditation.   MICH will send LPHAs an email to state the prerequisites have been accepted or if additional information is required.

 

Step 3: Documentation Submission

When applying for accreditation, LPHAs have many steps to work through; choosing the documents they will provide, writing descriptions of how the documents meet each measure, highlighting appropriate passages, and ensuring the scanning and uploading of the documents meet MICH’s requirements. Take this opportunity to focus on quality improvement initiatives and ensure all staff members are part of the effort.

The method of identifying documentation for each measure is one of the most critical parts of the accreditation process.  It will be important to describe why you chose this particular document and highlight the section of the document that will demonstrate conformity to the measure.  The descriptors you write will be in the Excel document called the Standards Workbook.  The descriptors are vital for reviewers to understand the context of how your LPHA uses the document and allows you to tell your story on how your LPHA meets the standard and measure or to document work needed to meet the measure. Accredited health departments 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. They have found it helpful to schedule regular meetings to discuss assignments, coordinate activities, resolve performance or capacity issues and assess progress.  It is during these meetings where developing consistent descriptors and how you tell your story will become important.  If questions arise at any stage of the accreditation process, contact your MICH liaison to assist you. To assist you in your documentation submission, MICH has created a Word document of the Accreditation Standards and Measures.  These Accreditation Worksheets also lists resources that may assist you as you work on meeting the accreditation measures. Please click here for a copy of the Accreditation Worksheets.

MICH requires LPHAs to abide by the following points in 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.  You can also 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 web screen shots, 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:

  1. Application and application fee submitted and accepted by MICH;
  2. The Prerequisites (CHA, CHIP, Strategic Plan and Quality Improvement Plan) uploaded to Dropbox and approved by MICH;
  3. Accreditation fee submitted and accepted by MICH;
  4. A completed Standards Workbook uploaded to Dropbox;
  5. All supporting documents uploaded using the Dropbox format sent to the LPHA via the liaison;
  6. An email sent to MICH detailing steps 1-5 have been completed.

 

 

Step 4: Review by Missouri Local Public Health Professionals

Each on-site reviewer is a qualified public health practitioner. Two reviewers and your assigned MICH liaison make up the on-site review team.  The LPHA will be notified of the names and qualifications of the review team prior to the visit.

Before coming on site, reviewers will examine the applicant’s Standards workbook and the supporting documentation found on Dropbox.  Measures that can be substantiated from these documents, the local public health department’s web site, or reports posted on the MDHSS web site 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 documents that have not been posted on Dropbox need to be ready for the reviewers.  Reviewers will interview staff members and representatives from the health department’s governing body to verify that the agency is meeting standards as recorded in the 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 on-site review, an exit interview will be conducted during which reviewers will discuss areas where the agency excels, and identify areas with opportunities for improvement.  The administrator may invite staff and governing body members to participate in the exit interview. Click here for a sample Site Visit Agenda.

After exiting, the reviewers will write a detailed Feedback Report of their findings and will present the report along with their recommendation at the next scheduled meeting of the Accreditation Council.

 

 

Step 5: Determination of Accreditation Status

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
  • Conditionally Accredited (Interim Plan of Action Required)
  • Not Accredited.

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.

 

 

Step 6: Quality Improvement with Annual Reports

The time after accreditation approval is an important time for self-reflection, understanding, and growth.  Connecting the cycles of accreditation with a continuous quality improvement (CQI) approach will improve the public health system in Missouri leading to greater assurance that public health activities are working.

During the on-site visits, reviewers identify strengths and areas for improvement and with this information create information for the Accreditation Score Sheet (a tab in your Excel Accreditation Standards Workbook).  Accreditation is designed to encourage the local public health agency to continually improve processes, public health practice, and program outcomes.  All accredited health departments will validate a commitment to quality improvement by demonstrating progress in identified areas for improvement based on the feedback received from the Reviewers and written in the Excel Standards Workbook with their Annual Reports, Years 1, 2, 3, and 4 (the last tabs in the Excel Standards Workbook).  The Excel Standards Workbook that details your Annual Report will be sent to MICH at michoffice@michweb.org.  Annual Reports will be due on the anniversary of their accreditation date.  For planning purposes a Word template of the Annual Report can be downloaded here, as well as https://michweb.org/accreditation-standards/.  In addition, it will be important to LPHAs to indicate they continue to be in compliance with all Standards and Measures in the Excel Standards Workbook.  The Annual Reports will be reviewed by the MICH Board for approval or if additional information is required.  Notification will be sent to the LPHA.

If requested, your MICH liaison will provide technical assistance with the development of plans and feasible CQI methods to address any accreditation improvement areas.  Together, we will be able to make the Missouri public health system more effective in protecting and promoting health, resulting in a greater impact on the health status indicators and the quality of life of Missouri residents and visitors.

 

 

Step 7: Reaccreditation

In year 4 of the accreditation cycle, the LPHA will start to prepare for reaccreditation.  A new application, submission of documents and site visit will be required.  As MICH continues to evaluate the accreditation program, changes in process and updated standards may occur.  Please contact MICH for details on these changes and the process you must go through to be reaccredited.