Accreditation Readiness Resource Kit

Step 4: PHAB Site Visit

The PHAB site visit has several purposes: to verify the accuracy of documentation submitted by the health department, to seek answers to questions regarding conformity with the standards and measures, and to provide opportunity for discussion and further explanation. The site visit will be conducted by a peer team of 3-4 PHAB trained site visitors and will typically last 2-3 days. Following the site visit, the site visit team will develop a report describing the level of conformity demonstrated with each of the measures, any areas of excellence, and any opportunities for improvement. The health department will have the opportunity to review the report before it is submitted to the PHAB Board for the final accreditation decision.

This section includes:

  • Overview of the Site Visit
  • Preparing Staff, Community Partners and Governing Entity for the Site Visit
  • Additional Planning and Recommendations for the Site Visit

Overview of the Site Visit:

The site visit consists of a team of public health practitioners and experts reviewing documentation submitted by the health department and conducting an on-site assessment of the health department. The accreditation site visit serves several purposes:

  • Verify the accuracy of documentation submitted by the health department
  • Seek answers to questions regarding conformity with the standards and measures, and
  • Provide an opportunity for discussion and further explanation

The agency Accreditation Coordinator and PHAB staff work together to schedule and make arrangements for the site visit. The Accreditation Coordinator will be asked to assist PHAB by providing information needed to plan the logistics, such as the nearest airport, hotel recommendation, and driving directions. PHAB will provide a site visit agenda to the Accreditation Coordinator prior to the site visit. PHAB will work with the Accreditation Coordinator to schedule any concurrent sessions to ensure that department staff are not scheduled to be in more than one place at a time.

The Accreditation Coordinator should reserve a room to serve as a “home base” for the site visit team during the duration of the visit. This room should be secured so that materials may be left overnight. The room should also have Wi-Fi capabilities (if available) and the site visit team should be provided the appropriate passwords. If Wi-Fi is not available, the health department should be set up with a screen and projector so that site visitors may view documents together.

In addition, meeting rooms should be reserved for concurrent interviews. Usually 3 additional rooms for interviews are sufficient. Meeting accommodations should be private.

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Preparing Staff, Community Partners and the Governing Entity for the Site Visit:

The Accreditation Coordinator must ensure that all staff involved in the accreditation process will be available for meetings during the site visit. This will include key staff from other departments or agencies that provides public health services through agreements or contracts cited as evidence of conformity to specific standards. Additionally, the health department Administrator and Accreditation Manager/Coordinator must be on site and available for the entirety of the site visit.

The Accreditation Coordinator and Accreditation Team should prepare health department staff for the site visit. All health department staff should know the date of and understand the purpose of the visit. Department staff should be aware that the site visit will include:

  • An Entrance Conference
  • An agency tour
  • Interviews with key staff
  • Sampling and collection of additional information, if requested by the Site Visit Team, and
  • An Exit Conference to review identified strengths and areas for improvement

To prepare staff for the site visit, review the documentation submitted to PHAB. Staff attending the domain site visit must be prepared to speak about the submitted documentation, and to discuss the relevance of the documents to the Standard and Measure. Prepare agency leadership to discuss the agency’s state health assessment, state health improvement plan and strategic plan, how they tie together, and how they inform the leadership’s vision for the health department. Prepare community partners and the governing entity to discuss their relationship with the health department, communication, and any initiatives that they have partnered on.

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Additional Planning and Recommendations for the Site Visit:

Be prepared for the following during the site visit: entrance conference, agency tour, staff interviews and exit conference:

Entrance Conference
An entrance conference is usually held the first morning of the site visit. In addition to the site visit team, those present may include the agency administrator, accreditation manager/coordinator, agency leadership, and other key staff involved in the accreditation preparation. During the entrance interview, team members introduce themselves and provide the agency with a brief summary of their backgrounds and credentials. The chairperson of the site visit team discusses the purpose of the site visit, presents a tentative schedule of the team’s activities, and responds to any questions that may arise concerning the conduct of the site visit.

During the entrance interview, the agency administrator introduces all key staff members to the site visit team. The Accreditation Coordinator should be available to the site visit team at all times during the site visit to answer questions, provide additional materials, and serve as liaison between the agency staff and the site visit team.

Agency Tour
Following the entrance conference, the site visit team tours the agency. Tours work in conjunction with an in-depth evaluation of written documentation to assist the site visit team in assessing compliance for individual standards through their observations of the facility during the tour.

There are four measures that require visual observation during the site visit. The measures are listed below. Please refer to Standards 1.0 for more information regarding the context of each measure below.

  • Measure 3.2.1 A, Required Documentation 2: "Documentation of branding or communication of presence of health department." The site visit team will supplement the submitted documentation with visual observations of signage inside and outside the health department.
  • Measure 3.2.5 A, Required Documentation 3: "Availability of assistive staff or technology devices to meet ADA requirements.” The site visit team will supplement the submitted documentation with their visual observations of TTY or other assistive technology.
  • Measure 11.1.6 A, Required Documentation 1: "Demonstrate the use of technology to support public health functions." The site visit team will supplement the documentation with their visual observations of the use of technology.
  • Measure 11.1.7: "Maintain facilities that are clean, safe, accessible, and secure." The site visit team will supplement the submitted documentation with their visual observations of the factions.

The site visitors do not tour clinical or personal health services areas, and the tour is approximately 30 minutes long. The tour serves mainly to familiarize the site visitors with the layout of the facility, such as the location of particular offices and program areas. In addition, the tour allows the site visit team to meet department heads, supervisors, and program staff.

Staff Interviews
The site visittTeam members conduct interviews with agency staff during the site visit. The agency selects the individuals to interview for the 12 domains in order to obtain verbal confirmation of standards compliance or clarify problems that may surface during reviews of documentation. It’s ideal to ensure that there is a scribe in each interview, who can capture notes, guidance, and any opened measures. During this time, the PHAB site visitors might request additional documentation or examples to verify compliance with the measures. If a measure is reopened, the health department has the opportunity to submit additional documentation. Documentation must be dated prior to the initial submission date of the final documentation.

The site visit team also meets with community partners to learn more about the health departments external relationships within the community. Some health department staff choose to join these meetings, to learn from the feedback provided by the community partners and agencies, while other agencies do not join these meetings, with the understanding that partner agencies will be able to speak more freely without agency staff in the room. A third, alternative option is for health department staff to join most of the meeting, and step out for the last 10-15 minutes; this provides the agency both the opportunity to learn from the community partner meeting and to allow PHAB to hear confidential feedback about the health department.

Exit Conference
At the conclusion of the site visit, the site visit team meets with the agency administrator, accreditation manager/coordinator, and appropriate staff to discuss the results of the site visit. As with the entrance interview, the agency administrator determines the staff and guests who will be present. The site visit team will share the agency’s strengths and opportunities for improvement.

The exit interview is not a forum for debate on the merits of the standards or the site visit team’s assessment of agency documentation. The process for resolving disagreements between the agency and the site visit team occurs through the agency’s response to the site visit team report and at the time of a requested hearing. All final decisions regarding accreditation rest with PHAB’s Accreditation Committee.

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