Accreditation Readiness Resource Kit

Step 6: Reports and Sustaining Improvements

The accreditation period is five years, during which time the agency must maintain conformity with the standards and measures demonstrated during the site visit and work towards conformity of those standards found in non-conformity. All accredited health departments must submit annual reports to PHAB. Reports describe how the health department has addressed the priority areas for improvement identified by PHAB. Annual reports also indicate that the health department is still in conformity with the measures.

This section includes:

  • Sustaining Continued Improvement at the Health Department


Sustaining Continued Improvement at the Health Department:

When 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.

Submission of annual reports is required for the health department to maintain their accreditation status for the five year period. The purpose of the annual reports is to describe progress made towards addressing areas of improvement identified by the Accreditation Committee. Annual reports to PHAB will include a description of the improvements made to areas identified as needing improvement and other efforts toward continuous quality improvement. Reports must:

  • Include a statement that the health department continues to be in conformity with all standards and measures contained in the version under which accreditation was received.
  • Include leadership changes and other changes that may affect the health department’s ability to be in conformity with the standards and measures.
  • Describe how the health department has addressed areas of improvement noted by the Accreditation Committee.
  • Describe how the health department will continue to address areas of improvement identified by the Accreditation Committee and/or by the health department in their accreditation action plan, and
  • Be signed (authorized through e-PHAB) by the administrator of the health department.

Ideally, the health department will maintain and sustain the improvements gained through the accreditation process during this time. From the beginning of the accreditation process, health departments should consider strategies to ensure that accreditation is one step in an ongoing process and not the end of the road. Health departments have considered establishing continued regular meetings to determine if measures are being maintained; roles and responsibilities for ensuring improvements continue; and that documentation strategies are being incorporated into daily work.