Accreditation Readiness Resource Kit

Step 5: Accreditation Decision

The PHAB Accreditation Committee determines the accreditation status of the health department based on the site visitors report. The Committee may decide that the health department is ‘Accredited’, Not Accredited, or needs to submit additional information. If the health department is accredited, the status lasts for five years, and the health department submits annual reports to PHAB. If the Committee determines that the health department cannot be accredited without more work on the part of the health department, they will have an opportunity to submit an action plan to PHAB. If the action plan is approved by the accreditation committee, is implemented by the health department, and the site visitors positively assess the documentation of implementation, the health department could be accredited at that time.

This section includes:

  • The Site Visit Report
  • Responding to an Action Plan

The Site Visit Report:

Within two weeks of the close of the site visit, the site visit team will develop and submit a site visit report to PHAB. The results of the standards’ conformity review are contained in the site visit report. The finished report consists of an assessment of each of the measures, statements that explain the assessments, as well as a general overview of the health department.

PHAB will provide the health department access to review the report for factual accuracy only. The health department will have 30 days to respond to PHAB through e-PHAB to correct factual errors. Health Departments cannot submit additional documentation at this time; the health department can only correct any factual errors in the site visit team report.

The accreditation decision is made by the PHAB Accreditation Committee based on the site visit report. Applicants will be notified of the date of the Accreditation Committee meeting but are not permitted to attend any Accreditation Committee meetings. Within two weeks of the conclusion of the Accreditation Committee meeting, PHAB will notify the health department administrator of the accreditation decision via email and copy to the Accreditation Coordinator.

If the health department receives a status of “accredited,” the Accreditation Committee will provide the health department with a list of opportunities for improvement from the site visit report. This will support the department’s continuous quality improvement efforts and will be the basis for annual reports to be submitted by the accredited health department to PHAB. If the health department does not receive a status of “accredited,” a list of opportunities for improvement will support the department’s development of an accreditation action plan.

Developing an Action Plan:

The Accreditation Coordinator will manage the development of an accreditation action plan. The action plan must be submitted to PHAB within 90 days of notification that the health department did not receive the status of “accredited,” and must be implemented within a year. The action plan must:

  • Specify the actions and improvements that the health department will implement in order to achieve “accredited” status, and
  • Specify the amount of time required to implement each action to reach conformity (no more than one year from the date of PHAB’s approval of the action plan).

If the action plan is approved by PHAB, the health department must submit documentation of its implementation. The documentation will be reviewed and assessed by Site Visitors, and the assessments will be forwarded along to the accreditation committee for accreditation status determination. If the action plan is not implemented satisfactorily per the Accreditation Committee and accreditation is not achieved within one year from the date of the original accreditation status notification letter from PHAB, the status of the health department will be “not accredited.” The department must then begin the accreditation process again in order to become accredited.

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