Accreditation Readiness Resource Kit

Step 3: Documentation Selection and Submission

Following PHAB's approval of the application, payment of PHAB's fees, and the completion of the Accreditation Coordinator training, health departments have up to one year to submit documentation to prove conformity with each of the PHAB Standards and Measures. This is one of the most time consuming and pivotal parts of the Accreditation process. Documentation must be submitted through the e-PHAB system, which accommodates multiple users and allows the health department to work on different parts of the submission at the same time. The documentation submitted will be reviewed by the site visit team.

This section includes:

  • Identifying and Selecting Documents for Submission
  • Organizing and Storing Documentation
  • Reviewing Documentation for Conformity
  • Uploading to e-PHAB

Identifying and Selecting Documents for Submission

The process of identifying, selecting, and uploading documents that demonstrate the health department’s conformity with the standards and measures is one of the most important components of any accreditation process. In order to substantiate a finding of conformity with a measure, the health department must be able to demonstrate to the site visitors that it is in conformity with all parts of a measure at all times. This is accomplished through presentation of written documentation, interviews with staff and community partners, and observations which clearly demonstrate that the health department is meeting the requirements of the measure. It is perhaps the most time consuming and demanding aspect of the accreditation process for the health department.

Documentation should be selected carefully to ensure that it accurately reflects the health department, how it operates, what it provides, and its performance. Consider selecting documents that best reflect the health department operations, meet specifics of the Required Documentation, represent a variety of programs, and demonstrate conformity with the measure. When considering conformity, the health department must consider the required documentation within the context of the measure, standard and domain. Additional guidance is given in the measure’s purpose, significance, required documentation, guidance, number of examples, and date requirements.

Documentation should be current and in use. Draft documents are not accepted. The health department should ensure no confidential information is shared within the documentation. Documents may be used for more than one measure i.e., can use same document more than once. Several documents may be needed to demonstrate conformity. Documents must be dated within the past 5 years unless otherwise required. Submission of documentation is a paperless process. All documents are submitted electronically in e-PHAB. Documents must be submitted in PHAB’s acceptable file formats. See below for a link to the acceptable formats. Documentation should be limited to the most direct and applicable documentation available to meet the documentation requirement. Additional information is not necessary and will not be helpful. All documents must show evidence of authenticity and include a date.

Generally, types of documentation that may be used to demonstrate conformity include:

  •  Examples of policies and processes: policies, procedures, protocols, standing operating procedures, emergency response/business continuity plans manuals, flowcharts, organization charts, and logic models.
  • Examples of documentation for reporting activities, data, decisions: health data summaries, survey data summaries, data analyses, audit results, meeting agendas, committee minutes and packets, after-action reports, continuing education tracking reports, work plans, financial reports, and quality improvement reports. When minutes from meetings are used as evidence for documentation requirements, relevant attachments that are referenced in the minutes or were discussed must be included.
  • Examples of materials to show distribution and other activities: email, memoranda, letters, dated distribution lists, phone books, health alerts, faxes, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website screen prints, news releases newsletters, posters, and contracts.

The Accreditation Coordinator should develop a process for accessing, reviewing and considering, and selecting documentation. Documentation identification and review should include several processes:

  • Assignments, by Domains or other grouping of standards, should be made to individual members or sub-teams of the Accreditation Team. Responsibilities of the Accreditation Team members or sub-teams will be to identify potential documentation for the Team to consider.
  • There should be a process for health department staff to propose documentation to Accreditation Team members or sub-team members.
  • A process to ensure that documents meet minimal PHAB requirements, including signed, dated, are not in draft form. See sample checklists below.
  • A process is needed for evaluating potential documentation to determine the most appropriate document to demonstrate that the health department is in conformity with the measure.
  • A process should be in place for developing and organizing notes concerning which specific parts of documents address the documentation requirement. Health departments will have an opportunity to include notes for each piece of documentation uploaded on to e-PHAB.
  • A process should be in place for developing and approving contextual notes that describe how a specific document demonstrates conformity with a specific measure.

Ideally, the Accreditation Coordinator will involve the domain teams in selecting and reviewing documentation. Standardizing saving and naming procedures, and ensuring that each submitted document includes a descriptive narrative, will help streamline the uploading process later on – see more information below.


Organizing and Storing Documentation:

The Accreditation Coordinator will need to develop an internal system for organizing and storing documentation electronically before they are uploaded into e-PHAB. In preparing for the accreditation process, documentation is compiled for each measure. The documentation materials contained in the files are organized in a logical sequence. File folder protocols provide more specific direction regarding file documentation. There are many successful methods of building file folders for PHAB accreditation. The common folder protocols among many of the methods are as follows:

  • Maintain a central location to store all documents related to accreditation.
  • Develop and use a consistent file labeling process (i.e., label files with the Domain, Standard, and Measure number, Document name, date of the most recent version, and responsible party name) will help to organize and identify documentation.
  • Clearly distinguish between domain, standard, and measure. This can be done with different main folders and sub-folders.
  • When responding to measures with multiple bullets or lists for conformity requirements, it is helpful to number the bullets/lists. Be consistent in your method. This can be done with adding additional sub-folders for each Required Documentation and sub-element within the Required Documentation.
  • Develop a process to manage paper or hard copy documents that need to be scanned and stored electronically to help prepare documentation for submission.
  •  Include sufficient documentation to establish conformity with measures which require a specific number of examples or a specific review period such as annual, quarterly, or monthly.This can also be done with adding additional sub-folders which include the identified number of examples and timeframe requirements. For example multiple review periods would have two consecutive monthly documents or two consecutive quarterly documents, thus illustrating conformity with the more frequent review requirements. Other monthly or quarterly documentation should be available if requested.

Reviewing Documentation for Conformity:

The Accreditation Team will adopt a process to identify policies, procedures, plans, memos, reports, meeting agenda, and other documents in order to select documentation for each measure. The final document submitted to PHAB for any measure may be different than the document that was first proposed by the team for submission: the Accreditation Team and the Accreditation Coordinator should assess the available documents and select the documentation that best demonstrates conformity with the measure and best reflects the health department. Changes and revisions to documentation can continue to be made until the final submission is made to PHAB through e-PHAB.

The Accreditation Coordinator and their Accreditation Team should keep in mind that the site visitors’ review of documentation will be primarily qualitative. In selecting the documentation, the intent of the standards and the measure should always be considered. The Accreditation Team should review the measure’s Required Documentation and its Guidance within the context of the measure and the “Purpose” statement of the measure. The measure should be considered in the context of the Standard and the Domain to ensure that the intent of the measure is being demonstrated by the selected documentation.

Along with the submitted documentation, many health departments include a narrative – describing the documentation and the justification for submission for conformity for that particular measure. To streamline the process, consider requiring narratives from staff who submit documentation. There are sample templates for measure narratives below.

Prior to submission, it is recommended that each document is reviewed by the Accreditation Team, and another reviewer. External reviewers can be either internal to the health department, from a different department or area of expertise, or can be external to the health department, from a partner or community agency.


Uploading to e-PHAB:

The Public Health Accreditation Board (PHAB) is the official accrediting body for national public health department accreditation. e-PHAB is PHAB’s online information system that health departments, site visitors, PHAB staff, and PHAB’s Accreditation Committee use throughout the accreditation process. Users are granted access to different information, depending on their role and the step in the accreditation process.