Accreditation and Emergency Preparedness:
The Value, The Overlap, and How To Do It
NACCHO’s Accreditation Preparation & Quality Improvement (QI) Webinar Series
Thursday, May 24, 2012 2:00PM ET
In May 2012, NACCHO hosted a webinar entitled “Accreditation and Emergency Preparedness: The
Value, The Overlap, and How To Do It.” This webinar featured Resham Patel, Program Analyst with
NACCHO’s Project Public Health Ready (PPHR) project, David Brummel, Public Health Improvement
Coordinator with Hennepin County Human Services and Public Health (MN), and Noreen NickolaWilliams, Quality Improvement and Accreditation Coordinator with St. Johns County Health Department
(FL). These presenters discussed the overlap in their PPHR and PHAB preparation activities.
The questions below were posed during the webinar.
Preparedness Questions
Do all or most health departments use the National Incident Management System Capability
Assessment Support Tool (NIMSCAST) to roll up their compliance measures?
PPHR criteria call for the application to contain evidence that the health department has completed a
baseline assessment of NIMS implementation. For this criteria element, PPHR requires the use of
NIMSCAST, or another assessment tool approved by NACCHO. Most applicants NACCHO sees use
NIMSCAST, but PPHR staff is happy to review and discuss another tool that you might use. Contact
[email protected] with questions.
Does a crosswalk exist that links PHAB Standards and Measures and PPHR individual criteria (not just
goals)? If so, where can it be found?
NACCHO’s accreditation team is working on a document that highlights documentation prepared for
PPHR that may be suitable for specific PHAB standards and measures. This information will be released
this summer. In addition, NACCHO’s PPHR team will be releasing a document that compares PPHR
criteria to other preparedness performance measures, including PHAB standards and the CDC’s PHEP
capabilities.
Can you clarify the differences between the PHEP capabilities and PPHR? Is it worthwhile to complete
both before/during the accreditation process?
The CDC's Division of State and Local Readiness recently released 15 preparedness capabilities that state
and local jurisdictions can use to better organize their work, plan their priorities, and decide which
capabilities they have the resources to build or sustain. Public Health Emergency Preparedness (PHEP)
awardees (states, territories, and directly funded cities) are expected to achieve each of the 15
capabilities as part of a 5 year cooperative agreement. As PHEP awardees, states are required to
develop plans, in coordination with their local jurisdictions, on how to prioritize and achieve the
capabilities. This allows the CDC to help ensure that federal preparedness funds are directed to priority
areas within individual jurisdictions. As part of receiving PHEP funds from the state, local jurisdictions
may also be required to meet certain or all capabilities.
Accreditation and Emergency Preparedness:
The Value, The Overlap, and How To Do It
NACCHO’s Accreditation Preparation & Quality Improvement (QI) Webinar Series
Thursday, May 24, 2012 2:00PM ET
Project Public Health Ready (PPHR), a collaborative project with NACCHO and the CDC, is a voluntary
national recognition that assesses preparedness and assists local health departments to respond to
emergencies. Each of the three PPHR project goals—all-hazards preparedness planning, workforce
capacity development, and demonstration of readiness through exercises or real events—has a
comprehensive list of standards that must be met in order to achieve PPHR recognition. Some states
have included PPHR recognition for LHDs as part of their PHEP cooperative agreements, while others
have kept participation in the program voluntary.
NACCHO has not determined whether it is beneficial to complete PPHR before accreditation or vice
versa. Remember that agencies can only pursue PPHR recognition if their state is a PPHR state.
However, as the LHD speakers on this webinar noted, their work and preparation for one program
significantly contributed towards their work on the other.
Accreditation Coordinators and Staff
Who do you believe would be the best choice for an Accreditation Coordinator in a medium sized
health department?
Accreditation Coordinators need to be able to work with many staff members in order to collect and
organize documentation. Therefore, this person should have experience working in the health
department and should have sufficient credibility to reach out to managers with requests. This person
also needs to know about how the health department functions overall so that he/she can contact
appropriate staff or partners for necessary documentation. An Accreditation Coordinator should have
some level of project management experience in order to meet timelines, manage workloads, and
organize information/documents. NACCHO has developed a sample job description for Accreditation
Coordinators and PHAB has developed an Accreditation Coordinator Handbook that includes required
duties for PHAB. Additionally, PHAB has developed a tip sheet for selecting an accreditation coordinator.
What is your estimate of FTEs and dollars (other than the actual accreditation fee) that you have
invested in the accreditation process?
There is no official estimate of staff time and resources needed to prepare for and go through
accreditation as each local health will experience different staffing and resource needs. There was some
research done on this issue from the PHAB Beta Test sites. NACCHO is also using information from
recent demonstration sites to come up with some additional summary information on this topic. Some
experts have indicated that 0.5-1 FTE for one year or more is sufficient for the Accreditation
Coordinator’s time.
Does an agency have to add staff to pursue accreditation?
Both of the presenters were at their agencies for many years in other roles before they were appointed
as Accreditation Coordinators. Their duties in the past focused on performance management and the
transitions were smooth.
Accreditation and Emergency Preparedness:
The Value, The Overlap, and How To Do It
NACCHO’s Accreditation Preparation & Quality Improvement (QI) Webinar Series
Thursday, May 24, 2012 2:00PM ET
Accreditation Process and Documentation
How much do documents need to be focused on public health? For example in Domain 11, many
policies are City policies not just for the Health Dept.
According to PHAB’s guidance, “some health departments may use policies and procedures that are not
specific to the health department, but are government-wide (i.e., state, city or county) or relate to a
larger super-health agency or umbrella agency. These policies and procedures could demonstrate
compliance with the measure if they apply to the health department as well as other government
agencies.”
Who provides the letter of support from the "Governing Entity" for a County Health Department?
The governing entity is the board or individual to whom the health department director is responsible.
This could be a board of health, an appointed commissioner, or an executive branch official such as a
mayor or governor.
What accreditation preparation recommendations do you have for small local health departments
covering less than 100,000 people?
The PHAB standards and measures are applicable to all health departments, regardless of size. Many
small health departments have already applied for PHAB accreditation. If you would like to contact the
Accreditation Coordinator at one of these agencies, you can contact [email protected] and we
can facilitate an introduction.
We are part of a Regional PPHR application. How does this impact our application to PHAB?
How you've applied for PPHR does not matter in terms of your PHAB application. You could apply to
PHAB as an individual health department or, if you meet PHAB’s definition, as part of a multijurisdictional application.
Will the PHAB Standards and Measures change from year to year as the PPHR Criteria do?
Questions about the PHAB accreditation standards should be directed to PHAB directly. Robin Wilcox,
Chief Program Office, can answer questions about updates to the standards and measures. She can be
reached at [email protected]
Accreditation and Emergency Preparedness:
The Value, The Overlap, and How To Do It
NACCHO’s Accreditation Preparation & Quality Improvement (QI) Webinar Series
Thursday, May 24, 2012 2:00PM ET
Engaging Around Accreditation
What if the other health coordinators in my state do not wish to participate in accreditation? Can my
county stand alone in this?
Both presenters encouraged any health department considering accreditation to pursue their goals
regardless of the other local agencies in their states. Many agencies across the country have begun their
accreditation journeys, and if you can’t find support in your state, you can look outside it to find
guidance and resources. NACCHO has a number of resources for local health departments at all stages
of accreditation preparation.
Do the Centers for Disease Control and Prevention (CDC) support accreditation?
Yes, CDC is a supporter of accreditation. CDC provides funding to PHAB and also supports several
national partner organizations in providing technical assistance to health departments to prepare. They
also provide some funding, directly, or through organizations such as NACCHO, to health departments
that are preparing or applying for accreditation.
If my agency is not seeking PPHR recognition, what are some suggestions to help get our
preparedness department involved in PHAB accreditation?
Engage them early. Since many preparedness staff members have coordinated document preparation
for PHEP purposes or other reporting needs, they will be able to easily identify which sections of the
PHAB standards are most relevant to their work, such as the all-hazards plan, risk communications plan,
or after action report. This will also give the preparedness team ample time to ensure that all
documentation is current and ready for accreditation.
For any Agency that may be considering standards of excellence offered through PPHR, PHEP, PHAB,
even National Malcolm Baldrige, the best thing an organization can do is conduct a self-assessment of
where your organization stands with respect to each standard. These standards & criteria are a guide
that can help your agency better align its resources; improve communication, productivity, and
effectiveness; and achieve related strategic goals.
Some suggestions that might help your organization include:
(1) Enlist your Preparedness staff as Subject Matter Experts for your Accreditation Team
(2) Even if your organization is not formally pursuing PPHR, PHEP, PHAB, even National Malcolm
Baldrige – the best thing you can do is Complete a self-assessment - You need to know where
you are before moving ahead
(3) Treat this as an Incident or Training Exercise and implement concepts from ICS as part of your
Accreditation Preparation Activities
(4) Document, document, document!
(5) Most important: Have Fun!
Accreditation and Emergency Preparedness:
The Value, The Overlap, and How To Do It
NACCHO’s Accreditation Preparation & Quality Improvement (QI) Webinar Series
Thursday, May 24, 2012 2:00PM ET
Other Questions
What is the population of Hennepin County MN and St. Johns County, FL?
Hennepin County, MN is home to 1.1 million residents; St. Johns County, FL has 190,000 residents.
Could the presenter share a copy of the protocol for developing After Action Reports?
Yes, St Johns County Health Department staff are happy to share their organizational protocol for
developing After-Action Reports. Please email [email protected] or call 904825-5055 x1091 to receive a version that can be edited and to discuss this resource.
Do you have examples of measurable objectives from either the Beta test after action plan or Baldrige
strategic plan?
St. Johns County Health Department is happy to share their SJCHD Strategic Plan & Business Plan and an
excerpt from a recent presentation referencing the results.
Will you describe some of the workshops/presentations that will be at the NACCHO conference
related to accreditation and emergency preparedness?
In coming weeks, NACCHO will release a flyer that describes all sessions at NACCHO Annual 2012 that
relate to accreditation. This will be released in our accreditNATION e-newsletter. There is also a preconference training on how to develop an agency strategic plan, which is an accreditation prerequisite.