Accreditation Readiness Resource Kit

Step 1: Pre-Application

Prior to submitting an application, the health department is required to submit a Statement of Intent to PHAB indicating that they are in the process of preparing to apply. Prior to submission of the SOI, the health department director and the Accreditation Coordinator must complete the PHAB Online Orientation. The SOI is non-binding, remains valid for 1 year, and does not commit a health department to submit an application. During this pre-application period, health departments are encouraged to conduct an organizational self-assessment of their readiness to apply and to develop the internal structure for the accreditation team.

 This section includes:

  • Agency Structure and Overview of staff roles for Accreditation
  • The Role of the Accreditation Coordinator
  • Structuring the Accreditation Team and Domain Teams
  • Other Staff and Leadership Roles
  • Tips for conducting an Organizational Self-Assessment and Determining Readiness
  • Communication Strategies for Accreditation

Agency Structure and Overview of staff roles for Accreditation

The Accreditation process will require the knowledge, experience, skills, and perspectives of a number of health department staff and stakeholders working together. PHAB requires that each health department appoint an Accreditation Coordinator; this individual will lead the agency through the accreditation process, develop a realistic plan of activities and tasks, and manage all accreditation related activities. The Accreditation Coordinator cannot be the Health Department Director. While the establishment of an Accreditation Team within the health department is not required by PHAB, it is strongly recommended. The Accreditation Team helps and supports the Accreditation Coordinator by determining conformity with specific measures of the Standards and Measures manual, compiling documentation, developing policies and procedures, overseeing implementation of the measures, record keeping, and preparing plans of action or quality improvement initiatives.

The Role of the Accreditation Coordinator

Health departments pursuing PHAB accreditation rely heavily on one staff member who will lead the health department’s accreditation efforts throughout the process; this individual will be assigned the role of the health department’s Accreditation Coordinator. The Accreditation Coordinator develops a realistic plan of activities and staff assignments leading to the completion of the documentation collection and other related tasks. The Accreditation Coordinator also organizes agency resources and activities and serves as the agency’s primary contact with the Public Health Accreditation Board. The Accreditation Coordinator is responsible for ensuring the agency staff receives an orientation process. It cannot be overemphasized that all agency staff needs to be provided an orientation to the process.

The Accreditation Coordinator is typically responsible for the following:

  • Conducting assessments of the health department’s readiness to seek accreditation
  • Completing PHAB’s Online Orientation
  • Coordinating the development and implementation of the health department’s internal plan to engage staff in the accreditation process
  • Engaging partner organizations and community partners in the accreditation process
  • Completing the Statement of Intent (SOI) and application through PHAB’s electronic information system, e-PHAB
  • Facilitating the health department’s Accreditation Team
  • Maintaining a documents management approach for proposed and selected documentation
  • Managing the process for selecting documentation for the PHAB measures
  • Preparing for and managing the site visit
  • Coordinating the health department’s review of the Site Visit Report
  • Organizing the development of any required accreditation action plans in response to the Site Visit Report
  • Managing the development and submission of required annual reports and fees to PHAB

The Accreditation Coordinator prepares and supervises the implementation of a work plan for accomplishing tasks required to achieve and maintain accreditation. This plan identifies agency staff that will be responsible for performing specific tasks and the dates for completing those tasks.


Structuring the Accreditation Team and Domain Teams:

Accreditation Team

Achieving accreditation will require the knowledge, experience, skills, and perspectives of a number of health department staff and stakeholders working together. While PHAB does not require the health department to establish an Accreditation Team, it is strongly recommended.The Accreditation Coordinator may assemble an Accreditation Team composed of staff members who will be responsible for determining conformity with specific measures of the Standards and Measures manual, compiling documentation, developing policies and procedures, overseeing implementation of the measures, record keeping, and preparing plans of action or quality improvement initiatives.This is important to ensure the accuracy of findings of conformity and to provide sufficient knowledge to prepare plans of action or quality improvement initiatives.

Accreditation Team size and composition will vary according to the size and organizational structure of the health department.  Typically, productive teams have five to ten members.  The staff selected for the Accreditation Team should have the ability to make decisions for their respective departments.  In addition to these individuals, there should be an internal review committee composed of agency staff.  The purpose of the committee is to assess the adequacy of the documentation identified by the team.

The Accreditation Coordinator develops and maintains a regular meeting and review schedule for staff involved in the process.  Meetings are held for staff to report on their progress, review problem areas, and indicate when outside assistance may be needed to clarify measures or accreditation policy and procedure.  In addition, the agency may call on outside specialists, such as community partners, local health departments, and appointing authority, to assist in preparing compliant documentation for the measures.  The Accreditation Coordinator must ensure there is open communication on a regular basis from the Agency Administrator to line staff, stressing support and expectations for the process.


Domain Teams:

In addition to a core accreditation team, many states structure the Accreditation process with domain teams. The teams are generally 4-5 staff members with significant content expertise on the domain subject matter. Ideally, domain teams would have one named lead staff, who would be responsible for organizing the domains documentation collection, narrative writing, and the domain site visit. The domain team lead would work directly with the accreditation team to ensure that the domain teams are meeting deadlines and collecting relevant information.


Other Staff and Leadership Roles

Agency Staff and Leadership Orientations
Each agency should have an orientation process for its staff. The introductory orientation session includes an explanation of the purpose, goals, and organization of the PHAB; the process, the agency’s reasons for electing to pursue accreditation, and the benefits of the process for the health department. Time should be provided for the staff to ask questions of the health department administrator and the Accreditation Coordinator. There are a few key roles that apply to leadership and staff:

  • All on board!
  • Understand the purpose of accreditation
  • Be familiar with the domains, standards, and measures
  • Contribute ideas for documentation
  • Assist with arrangements for site visit
  • Be prepared for site visit
  • Enthusiasm and support for accreditation

In addition, specific attention should be given to these staff roles:

Agency Administrator
The health department administrator is essential in the support of the health department applying for accreditation. The agency administrator is vocal in the commitment to the agency’s participation in the process and support of the assigned accreditation staff. The health department administrator should:

  • Set the tone for accreditation and quality improvement
  • Attend the PHAB online orientation
  • Approve the Statement of Intent
  • Approve the Application
  • Monitor the progress of the health department through the next steps
  • Be present and engaged in the site visit
  • Monitor all accreditation related reports
  • Celebrate achievements

Governing entity
The governance structure of the health department will guide most of what the governing entity’s role will be in the accreditation process. Regardless of the structure, however, there are a few key roles that apply to the governing entity:

  • Support accreditation, both in concept and with a letter of support
  • Provide input and feedback
  • Engage in the process
  • Support quality improvement
  • Meet with Site Visit team
  • Celebrate achievements


Conducting an Organizational Self-Assessment

Prior to submitting their Accreditation application, some states have implemented an Organizational Self-Assessment, conducting a review of the documentation that PHAB requires, and determining the agency strengths and weaknesses. This process is most successful when coordinated with the Accreditation Team and the Domain Leads. The Accreditation Team meets with the Domain Leads to determine which standards and measures are met by the agency’s work, which have documentation to support them, and which require additional work. The agency can then prioritize those standards and measures that require additional attention from the domain leads and the team.


Communication Strategies about Accreditation

Department communication should begin early in the accreditation process so that everyone understands what accreditation is, what the benefits of accreditation will be, what their role in the accreditation process is, and how accreditation related activities are to be coordinated with their day-to-day responsibilities. A communications plan or strategy can help manage communications to those involved and those interested in the accreditation process.

The Accreditation Coordinator plays a vital role in communicating the importance of public health accreditation to staff, members of the governing entity department leadership, partners, and the community. It will be important to build and maintain health department enthusiasm and staff involvement. Staff should be engaged throughout the process. Others will want to know the status of the process.

As appropriate and when needed, the health department may want to develop presentations, events, and opportunities for involvement in order to demonstrate how the accreditation process is being conducted and to engage staff and stakeholders.
Once accredited, the health department will receive specific language they are to use to communicate their accreditation status with the public. Health departments must use the PHAB approved language when describing their accreditation status to the general public.