Crosswalk - Office of Public Health Practice - University of Michigan

CrosswalkPrepared byMary Lynn Kushion, MSAforAn analysis of PHAB standards and Michiganlocal public health accreditationrequirementsOffice of Public Health PracticeUniversity of MichiganSchool of Public HealthAugust 2011

Contact InformationAuthorMary Kushion, MSAHealth OfficerCentral Michigan District Health Departmentmkushion@cmdhd.orgFUNDERMichigan Public Health Training CenterOffice of Public Health PracticeUniversity of Michigan School of Public Health1415 Washington HeightsAnn Arbor, MI 48109‐2029mphtc@umich.edu© 2011 by the Regents of the University of MichiganAppendix 1: Accreditation for Local Public Health: A Comparison of the Michigan Local Public Health AccreditationProgram (MLPHPAP) and the National Public Health Accreditation Program (PHAB) GREEN PAPER is used bypermission of Debra Scarmarchia Tews, MA, Accreditation & Quality Improvement Manager, Michigan Departmentof Community Health Local Health Services.

Table of ContentsIntroduction ............................................................................................................................ 1Author ..................................................................................................................................... 2Disclaimer ............................................................................................................................... 3Crosswalk Format .................................................................................................................... 3Crosswalk: Michigan and National Voluntary Public Health Accreditation ................................. 5Domain 1: Conduct and disseminate assessments focused on population health status andpublic health issues facing the community ........................................................................... 5Domain 2: Investigate health problems and environmental public health hazards to protectthe community ....................................................................................................................... 7Domain 3: Inform and educate about public health issues and functions ................................ 9Domain 4: Engage with the community to identify and address health problems ................. 11Domain 5: Develop public health policies and plans ................................................................ 12Domain 6: Enforce public health laws ...................................................................................... 13Domain 7: Promote strategies to improve access to health care services .............................. 15Domain 8: Maintain a competent public health workforce ..................................................... 16Domain 9: Evaluate and continuously improve processes, programs, and interventions ....... 17Domain 10: Contribute to and apply the evidence base of public health ............................... 18Domain 11: Maintain administrative and management capacity ............................................. 19Domain 12: Maintain capacity to engage the public health governing entity .......................... 20Appendix 1Accreditation for Local Public Health: A Comparison of the Michigan Local Public HealthAccreditation Program (MLPHPAP) and the National Public Health Accreditation Program(PHAB) GREEN PAPER.Green paper Prepared By: Debra Scarmarcia Tews, MA, Accreditation & Quality Improvement Manager,Michigan Department of Community Health Local Health Services, June 7, 2010 (Rev. 7/8/10, 8/31/10)

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IntroductionPublic health accreditation is a status that provides public notification that the public healthdepartment or program meets standards of quality set forth by an accrediting body. Publichealth accreditation demonstrates accountability to the community and measures performanceagainst established standards.In Michigan, public health accreditation for local public health departments (LHDs) wasembodied in the Michigan Local Public Health Accreditation Program (MLPHAP) 1 . The MLPHAP,formed in 1998, is a collaboration of Michigan’s state departments of Agriculture and RuralDevelopment, Community Health, and Environmental Quality, the Michigan Public HealthInstitute, the Michigan Association for Local Public Health, and Michigan’s local public healthdepartments. The purpose of MLPHAP is to monitor and evaluate Michigan’s 45 local healthdepartments for compliance with an established set of Minimum Program Requirements(MPRs). This MPR set is based on law, statute, or administrative rule for 13program/administrative functions. Michigan’s local health departments receive an on‐sitereview every three years. In 2011, Michigan is in the process of completing Cycle 4, its 4 thaccreditation cycle. Cycle 5 will begin in 2012.A national voluntary public health accreditation program was launched in July 2011 under theauspices of the Public Health Accreditation Board (PHAB). PHAB receives support from theCenters for Disease Control and Prevention (CDC) and The Robert Wood Johnson Foundation(RWJF), and works closely with national organizations, such as the National Association ofCounty & City Health Officials (NACCHO), the Association of State and Territorial Health Officials(ASTHO), the National Association of Local Boards of Health (NALBOH), the National IndianHealth Board, and APHA (American Public Health Association). PHAB’s national accreditationprogram is based on the 10 essential public health services and also includes Administrative andManagement Capacity and Capacity to Engage the Public Health Governing Authority. 2 Version1.0 is the initial release of its domains, standards and measures for the voluntary nationalaccreditation review for state, local, and tribal health departments. 3To aid in understanding how Michigan’s ongoing state‐wide accreditation work may be used tosupport and assist in meeting national voluntary accreditation through PHAB, the MichiganPublic Health Training Center, which is housed in the University of Michigan School of PublicHealth’s Office of Public Health Practice, commissioned a Crosswalk of the two programs in2011. The goal of this Crosswalk is to take each of the 12 PHAB standards and identify relevant1 Michigan Local Public Health Accreditation Program www.accreditation.localhealth.net2 Public Health Accreditation Board www.phaboard.org3 Public Health Accreditation Board www.phaboard.orgCrosswalk: Michigan and National Voluntary Public Health Accreditation page 1

standards within the MLPHAP, indicate their applicability and point out current documentationefforts being done for MLPHAP that may serve national accreditation standards. This Crosswalkis a tool for Michigan’s local public health departments, as they work toward applying fornational public health accreditation.Given how recently the launch of national voluntary accreditation occurred—July 1, 2011—thisCrosswalk should be viewed as a work‐in‐progress, subject to updates and additions. Readerscan benefit from the documentation examples identified here and, hopefully, will contributetheir own examples of how work done under the Michigan accreditation process also fits withinthe framework of the national voluntary accreditation program.An accreditation green paper was written by Michigan Department of Community Health(MDCH) Local Health Services Manager Debra Tews in 2010 and provides an overview ofMichigan’s public health accreditation program and PHAB’s program, which was in beta test atthat time. The green paper is contained in Appendix 1 of the Crosswalk.AuthorThe Crosswalk was developed by Mary Lynn Kushion and represents her depth of knowledgewith both MLPHAP and the PHAB’s national voluntary public health accreditation program. Herblend of expertise and national, state and local experiences make her uniquely qualified toreflect on the two sets of standards and produce a Crosswalk.Ms. Kushion is the Health Officer of the Central Michigan District Health Department; aposition she has held since January 1993. Ms. Kushion had led her department through fouraccreditation cycles including the voluntary Quality Improvement Supplement (QIS) containedwithin the MLPHAP Powers and Duties section.In 2003, Ms. Kushion was asked to chair the Michigan Accreditation Quality Improvement(AQIP) Workgroup, a sub‐committee of the Michigan Local Public Health AccreditationCommission. The charge for the AQIP Workgroup is to ensure that improvement activitiesassociated with Michigan’s accreditation process engage all key stakeholders, to identifyopportunities for process improvement and to develop recommendations for ongoing processimprovement. Ms. Kushion has also been a member of the Michigan Local Public HealthAccreditation Commission since 2006.Ms. Kushion was a member of the Research and Evaluation Team for Exploring Accreditation,an RWJ‐funded project that provided final recommendations in 2006 for a voluntary nationalaccreditation program for state and local public health departments. She was also selected toserve as a member of the PHAB Standards Development Workgroup. In 2010 Ms. Kushionserved as a member on two PHAB beta test site visits.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 2

Ms. Kushion has also served on the NACCHO Public Health Infrastructure Workgroup and iscurrently the chairperson of the NACCHO Accreditation Preparation and Quality ImprovementWorkgroup.DisclaimerIt is the author’s belief that this report and its documentation examples may support and assistthe reader in meeting standards within the PHAB process. The author does not make anyguarantees that what is referenced in this report as suggested evidence to meet the PHABstandards will actually satisfy PHAB reviewers; the information is being provided as suggestionsonly.Crosswalk FormatThe Crosswalk includes: PHAB Version 1.0 domains and standards. All 12 PHAB domains are included. An indication of whether or not the standard is also measured within Michigan’s systemutilizing the minimum program requirements in the Cycle 4 tool. Suggestions for how local health departments within the state of Michigan may be ableto potentially meet the PHAB standards with documentation/evidence currentlyrequired to meet the minimum program requirements in MLPHAP. Evidence ordocumentation examples drawn from the Michigan Accreditation Program, Cycle 4,where available.The Crosswalk does not address the individual PHAB measures within standards; thecomparisons between the two accreditation systems are presented at the PHABStandard/MLHAP MPR level. Furthermore, the Crosswalk does not give all of the possibledocumentation necessary to meet the PHAB standards as they are contained in the PHABVersion 1.0 Standards and Measures, but rather gives examples to give the reader an idea ofthe types of documentation required. The elements and requirements contained as acomponent of the Powers and Duties Section were included in the Crosswalk and arereferenced as the Plan of Organization, 4 which is a document all local health departments inMichigan are required to submit to MDCH for approval every three years and the approvedplan is necessary to meet Powers and Duties indicator 1.6.4 The Plan of Organization is a Michigan Public Health Code Requirement for all local health departments which isreviewed and approved by the Michigan Department of Community Health once every three years. It includes theagency’s legal responsibilities, organizational structure, mission, collaborative initiatives, service delivery,evaluation and health officer and medical director qualifications. The Plan of Organization can be found athttp://www.michigan.gov/documents/mdch/PlanofOrganizationPackage3_5_07_189023_7.docCrosswalk: Michigan and National Voluntary Public Health Accreditation page 3

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Domain 1: Conduct and disseminate assessments focused on population health status and public health issuesfacing the communityPHAB Standards(Version 1.0)1.1 Participate In orConduct aCollaborativeProcess Resultingin aComprehensiveCommunity HealthAssessment1.2 Collect andMaintain Reliable,Comparable, andValid Data ThatProvideInformation onConditions ofPublic HealthImportance andOn the HealthStatus of thePopulationMichigan Accreditation Program Indicators(Cycle 4)Not addressed in Michigan’s Cycle 4 process.Many local health departments (LHD) in Michiganparticipate in community health assessments, butbecause it is not a state mandate and does not receivestate funding, it is not included in the accreditationprocess.MI accreditation sections contain specific examples ofthe types of data collected. Examples are cited asfollows:Section 1 Powers and Duties 1.2 (a &b): Demonstrateaccess to vital health statistics. Documents thatdemonstrates analysis and interpretation of vitalstats.Section 1 Powers and Duties 1.3 LHD shall makeinvestigations as to causes of disease, morbidity andmortality as well as environmental hazards.Plan of Organization 2.DSection 3 Food Service 7 Identify critical violationsduring field review.Section 4 Communicable Disease (CD) 1.2 Collects CDdataSection 4 CD 1.4 Data on annual reportSection 5 Hearing 1.2 Documentation of hearingscreenings between ages of 3‐5Section 5 Hearing 2.1 Report stats of Hearing screeningsin public and private schools.Section 6 Immunizations (Imms). 4.1 LHD shall sustainimmunization levels in Michigan ChildhoodImmunization Registry (MCIR)Section 7 On‐Site Sewage 5.1 Documentation on systemfailures and why they occurred.Section 8 Sexually Transmitted Disease (STD) 1.1 Ensurereporting and follow‐up with Michigan’s Public HealthCodeSection 9 Vision 1.2 Documentation of Vision screeningsfor children 3‐5.Section 9 Vision 2.1 Program reports that show LHDassured vision screenings for school age children.Section 12 HIV/AIDS 1.1 and 1.2 Conduct reporting andfollow‐up of HIV/AIDS cases.Meeting PHAB Standards:Evidence/Documentation ExamplesLHDs who have not yet begun acommunity health assessment processare encouraged to work with local nonprofithospitals that are mandated tocomplete a community healthassessment process.A completed community healthassessment report.PHAB will require evidence ofpartnerships/training/utilization ofsurveillance sites. Agencies need toshow evidence of where the surveillancesites are located and the types ofmeetings/trainings held with the sites.Documentation on general populationhealth data and its availability will berequired. Website screen shots, annualreports, press releases, county healthrankings data are possible examples.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 5

Domain 1: Conduct and disseminate assessments focused on population health status and public health issuesfacing the communityPHAB Standards(Version 1.0)1.3 Analyze PublicHealth Data toidentify Trends inHealth Problems,EnvironmentalPublic HealthHazards, and Socialand EconomicFactors That Affectthe Public’s Health1.4 Provide and Usethe Results ofHealth DataAnalysis toDevelopRecommendationsRegarding PublicHealth Policy,Processes,Programs, orInterventionsMichigan Accreditation Program Indicators(Cycle 4)Michigan’s indicators do not specifically include analysisof social and economic conditions, but rather focus onhealth problems and hazards.Section 1 Powers and Duties 1.2 (a & b) Demonstrateaccess to vital health statistics. Documents thatdemonstrates analysis and interpretation of vitalstats.Section 1 Powers and Duties 1.3 LHD shall makeinvestigations as to causes of disease, morbidity andmortality as well as environmental hazards.Section 4 CD 1.2 Collects/analyzes data.Section 7 On‐Site Sewage 5.1 Documentation on systemfailures and why they occurred.Section 8 STD 3 Analyze STD morbidity priority reportingsites and provide professional attention to those sites.Not addressed in Michigan Cycle 4 process, but twoexamples are listed here on how data collected to meetthe MLPHAP may be used to meet the PHAB standard.Section 6 Imms. 6.1 LHD uses the IAP mechanism toimprove immunization rates, clinic hours and tocoordinate services/communication with private/publicprovidersSection 8 STD 3.1 Analyze STD morbidity priorityreporting sites and provide professional attention tothose sites.Meeting PHAB Standards:Evidence/Documentation ExamplesExamples include informationdistributed to various audiences on thestatus of health behaviors, and/orenvironmental issues in order to informthe public on the health status of thecommunity. Evidence needs to showthat the information contained in thereport was distributed and how it wasdistributed, but does not necessarilyneed to include the report itself.Utilize the reports generated in PHABStandard 1.3; use the information in thereports to form county health profilesand show evidence of how they weredistributed to community stakeholdersand the public through the use ofwebsite screen shots, emaildistributions, press releases,presentations.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 6

Domain 2: Investigate health problems and environmental public health hazards to protect the communityPHAB Standards(Version 1.0)2.1 Conduct TimelyInvestigations ofHealth ProblemsandEnvironmentalPublic HealthHazards2.2 Contain/Mitigate HealthProblems andEnvironmentalPublic HealthHazards2.3 Ensure Access toLaboratory andEpidemiologic/Environmental PublicHealth Expertiseand Capacity toInvestigate andContain/MitigatePublic HealthProblems andEnvironmentalPublic HealthHazardsMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers and Duties 1.2 LHD shall utilize healthstats for purposes of protecting the public’s health.Section 4 CD 1.2 Collects/analyzes data.Section 3 Food Service 7 Citing of critical violations duringfield review.Section 3 Food Service 8 Food Code complaintinspections are conducted.Prevention of public health disasters outside ofcommunicable disease and/or food borne outbreaks arenot addressed in Michigan’s accreditation process inCycle 4.Section 3 Food Service 10 Enforcement of food codeviolationsSection 3 Food Service 11 Unauthorized construction offood facilitiesSection 3 Food Service 14 Variances are reviewed forconditions that vary from the codeSection 3 Food Service 15 Complaint investigations aredone when reported.Section 4 CD 2.1 Initiate CD investigations required byMichigan law and executive ordersSection 2 Clinical Lab 1.1 LHD acts in accordance with theClinical Lab Improvement Amendment of 2003.Section 4 CD 1.3 Submit to MDCH.Section 4 CD 1.2 Collects data from labs, etc.Meeting PHAB Standards:Evidence/Documentation ExamplesCommunicable Disease/Food BorneOutbreak Policies/Protocols withreporting timelines and staffresponsibilities included in the policy(can be hard copy or availableelectronically).Examples of disease/environmentalhealth investigations conducted by theagency.After Action reports, results of foodservice investigation. Epidemiologicalreport sent to state withfindings/recommendations andconclusions.List of significant events within thejurisdiction and what promptsactivation of the All‐Hazard Plan.CLIA certificate, evidence of access tolab services 24/7, protocols for handlingspecimens.24/7 Call down lists and documentationthat it has been tested.Assurance of 24/7 coverage and surgecapacity.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 7

Domain 2: Investigate health problems and environmental public health hazards to protect the communityPHAB Standards(Version 1.0)2.4 Maintain a Planwith Policies andProcedures forUrgent and Non‐UrgentCommunicationsMichigan Accreditation Program Indicators(Cycle 4)Although this happens routinely throughout the state,emergency preparedness is not currently included inMichigan’s accreditation process. The examples cited inthis section relate to communications between the stateand local health departments to communicate specificdisease/program indicators.Plan of Organization 2.d IT capacity available to accessand distribute current public health information.Section 4 CD 2.3 Notify MDCH immediately if suspect CDin jurisdictionSection 4 CD 1.1, 2.1, 3.1, and 4.1 Policies andprocedures for CD reportingSection 4 CD 1.3 CD case reports submitted electronicallyvia MDSS (technology)Section 6 Imms 4.3 LHD submits immunization reports tothe MCIRSection 6 Imms 4.1 LHD conforms to on‐line reportingrequirementsSection 6 Imms 4.2 LHD uses web‐based reporting toassure accurate school records.Section 8 STD 5 Submission of quarterly STD medicationinventory report to MDCH.Section 12 HIV/AIDS 2.3 Maintain necessarytechnological capacity.Meeting PHAB Standards:Evidence/Documentation ExamplesAgency Risk Communications PlanMedia Relations PlanParticipation and use of Health AlertNetwork (HAN)Evidence that the media was usedduring a public health emergencyEvidence of joint exercises with stateand Tribal partnersCrosswalk: Michigan and National Voluntary Public Health Accreditation page 8

Domain 3: Inform and educate about public health issues and functionsPHAB Standards(Version 1.0)3.1 Provide HealthEducation andHealth PromotionPolicies,Programs,Processes, andInterventions toSupportPrevention andWellnessMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers and Duties 1.4 A local healthdepartment shall plan, implement, and evaluate healtheducation through the provision of expert technicalassistance, or financial support, or both.Section 1 Powers and Duties 1.7 LHD shall plan,implement and evaluate nutrition services.Section 3 Food Service. Important Factor I Addresseseducational outreach activities such as newsletters,website, training, etc.Section 4 CD 1 – General definition‐ The local healthdepartment must have a system in place that allowsfor the referral of disease incidence and reportinginformation from physicians, laboratories, and otherreporting entities to the local health department.Section 5 Hearing 6 A local health department shallconduct periodic free hearing programs for the testingand screening of children residing in its jurisdiction.The time and place of the programs shall be publicized.Section 9 Vision 6A Local health department shallconduct periodic free vision programs for the testingand screening of children residing in its jurisdiction.The time and place of the programs shall be publicized.Section 11 Family Planning 10.2 The agency must have anInformation and Education (I & E) committee to reviewand approve all informational and educationalmaterials developed or made available by the project.Section 12 HIV/AIDS 7 Establish, maintain and documentlinkages with community resources that are necessaryand appropriate to addressing the prevention and careneeds of clients receiving HIV‐related services.Meeting PHAB Standards:Evidence/Documentation ExamplesExamples of press releases, annualreports, presentations, flyers, brochureswhich address health issues, risks,behaviors, prevention or wellness andhow they were shared with public.Meeting minutes from advisory councilsregarding the formation of messaging.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 9

Domain 3: Inform and educate about public health issues and functionsPHAB Standards(Version 1.0)3.2 ProvideInformation onPublic HealthIssues and PublicHealth FunctionsThrough MultipleMethods to aVariety ofAudiencesMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers and Duties 1.4 LHD plans, implementsand evaluates health education through provision oftech. assist/financial support.Powers and Duties Plan of Organization 3 Contains aclear, formally written, publicized statement of thedepartment’s mission (may include Vision, Values,Goals, Objectives).Section 3 Food Service Important Factor I Addresseseducational outreach activities such as newsletters,website, training, etc.Section 6 Imms 1.4 LHD sends recalls to children not upto date.Section 11 Family Planning 13 Provide informational andeducational programs.Section 12 HIV/AIDS 8 Perform activities necessary tocontrol the spread of HIV infection.Meeting PHAB Standards:Evidence/Documentation ExamplesExamples of how the health departmentcommunicates its existence, mission,vision and role/ presence to thecommunity such as through use of logoon brochures, clothing, signage, flyers,etc.Agency written communication planwith evidence of annual updating ofcontacts (media, partners).Media Contact listWebsite/page with 24/7 emergencycontact number, health data, links topublic health laws and reportableconditions contact numberList of contractors for translation,interpretation and communicationserviceExamples of culturally appropriatematerialsUse of Facebook and Twitter ascommunication toolsCrosswalk: Michigan and National Voluntary Public Health Accreditation page 10

Domain 4: Engage with the community to identify and address health problemsPHAB Standards(Version 1.0)4.1 Engage with thePublic HealthSystem and theCommunity inIdentifying andAddressing HealthProblems ThroughCollaborativeProcessesMichigan Accreditation Program Indicators(Cycle 4)Identified in Plan of Organization rather than inaccreditation process.Plan of Organization Section 4 – Local planning andcollaboration initiatives.Meeting PHAB Standards:Evidence/Documentation ExamplesExamples of coalitions where publichealth is an active participant, such asTobacco Reduction, Complete Streets,Healthy Kids ‐ meeting minutes, emails.Documentation through emails,newsletters etc. on communityengagement models and how they wereshared with community partners4.2 Promote theCommunity’sUnderstanding ofand Support forPolicies andStrategies Thatwill Improve thePublic’s HealthNot addressed in Cycle 4 process.Examples (press releases,presentations) given to the communityand/or governing board on howpolicies/laws will impact/improve publichealth.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 11

Domain 5: Develop public health policies and plansPHAB Standards(Version 1.0)5.1 Serve as aPrimary andExpert Resourcefor Establishingand MaintainingPublic HealthPolicies, Practicesand CapacityMichigan Accreditation Program Indicators(Cycle 4)Identified in Plan of Organization rather than inaccreditation process.Plan of Organization – Section 4 Local Planning andCollaboration Initiatives.Meeting PHAB Standards:Evidence/Documentation ExamplesExamples of presentations given onpublic health to board, legislature,community groupsParticipation on Michigan Associationfor Local Public Health (MALPH) listserves and meetings where publichealth issues/laws/policies arediscussed.5.2 Conduct aComprehensivePlanning ProcessResulting in aTribal/State/Community HealthImprovement PlanNot addressed in Cycle 4 process.Evidence that health department hascollaborated with hospitals andcommunity partners to develop acommunity health improvement plan (aPHAB pre‐requisite) Meeting minutes,emails reports.Examples of how the plan wasimplemented, evaluated and revised5.3 Develop andImplement aHealthDepartmentOrganizationalStrategic PlanIdentified in Plan of Organization rather than inaccreditation process.Plan of Organization – Section 3 Mission, Vision andValues – Contains a clear statement of LHD’s mission,vision, values, goals and objectives.Agency strategic plan (a PHAB prerequisite).Annual progress reports5.4 Maintain an AllHazardsEmergencyOperations PlanNot addressed in Cycle 4 process; however it is amandated document from the Office of Public HealthPreparedness (MDCH).Evidence of an All‐Hazards Plan thatincludes roles and responsibilities ofpartners in an emergency.Evidence of testing and revisions to theplanEvidence of an agency EmergencyOperations PlanCrosswalk: Michigan and National Voluntary Public Health Accreditation page 12

Domain 6: Enforce public health lawsPHAB Standards(Version 1.0)6.1 Review ExistingLaws and Workwith GoverningEntities andElected/AppointedOfficials to Updateas NeededMichigan Accreditation Program Indicators(Cycle 4)The MLPHAP does not specifically require a review ofexisting laws, and does not address working withgoverning entities but does have several sections whereevidence of enforcement is required. Examples of theserequirements are as follows and included in PHAB 6.3:Section 1 Powers and Duties 1.1 LHD enforces lawsvested in the LHD.Section 1 Powers and Duties 1.6 Plan of Organizationadopted by local governing entity and approved byMDCH.Meeting PHAB Standards:Evidence/Documentation ExamplesMeeting minutes from board ofhealth/county/city commissionmeetings regarding public health lawsand enforcement of them.Examples within Michigan include theSmoke Free Air law, licensing of bodyart facilities, the food code and localsanitary code.Evidence that laws have been reviewedand evaluated for consistency withpublic health evidence‐based and/orpromising practices.6.2 EducateIndividuals andOrganizations Onthe Meaning,Purpose,Compliance, andBenefit of PublicHealth Laws andHow to ComplySection 3 Food Service Important Factor 1 Educationaloutreach to educate public.Section 3 Food Service 16, 17 and 18 Technical, field andspecialty food training all required for inspection staff.Section 4 CD 3.3 Adequately prepared staff capable ofenforcing MI law for control of CD.Staff training logs, conferenceattendance documents pertaining totraining on public health laws.Availability of laws on websiteEvidence that laws have beencommunicated to individuals andentities required to abide by them.Examples may include public schoolsthat have to enforce immunizationrequirements and restaurants that needto abide by food code laws.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 13

Domain 6: Enforce public health lawsPHAB Standards(Version 1.0)6.3 Conduct andMonitor PublicHealthEnforcementActivities andCoordinateNotification ofViolations amongAppropriateAgenciesMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers and Duties 1.6 Plan of Organizationadopted by local governing entity and approved byMDCH.Section 3 Food Service 3 Conducting food inspections inaccordance with the law.Section 3 Food Service 10 Enforcement policy must be inplace and demonstrate use.Section 4 CD 1.3 electronic submission of all reports,treatment and follow up to MDCH via MDSSSection 4 CD 4.2 Policy/procedure for responding toindividuals who failed or refused to comply withtreatment.Section 4 CD 4.3 Have policy/procedure to issueemergency orders for involuntary detention andtreatmentSection 6 Imms 5.1 LHD uses MCIR to assure accurateschool data has been entered by assigned deadlines.Section 6 Imms. 5.2 LHD assures daycare reporting toMDCH by assigned deadline each year.Section 7 On‐Site Sewage 1.2 The local regulationauthorizes enforcement measures.Section 7 On‐Site Sewage 1.3 Evidence that enforcementmeasures are utilized.Section 10 BCCCP 9 Assure that screening and follow‐upservices meet minimum state/fed. Requirements.Section 12 HIV/AIDS 8.1 Protocol to enforce health threatto others and duty to warn.Meeting PHAB Standards:Evidence/Documentation ExamplesFood inspection reports; responding tocommunicable disease investigationsEvidence of enforcement hearings;appeals board meeting minutes. Oneexample has to be for communicablediseaseExamples of authority to conductenforcement activities (state/localcodes)Inspection schedules for two programs(food service, campgrounds, publicswimming pools)Log of inspection reports and thefollow‐up conductedAgency compliance planAnnual report of complaintsProtocol on how to notify public incases of non‐compliance.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 14

Domain 7: Promote strategies to improve access to health care servicesPHAB Standards(Version 1.0)7.1 Assess HealthCare ServiceCapacity andAccess to HealthCare Services7.2 Identify andImplementStrategies toImprove Access toHealth CareServicesMichigan Accreditation Program Indicators(Cycle 4)Technically, the Michigan Cycle 4 does not require healthdepartments to assess health care capacity and/or assureaccess. The examples provided program‐specificmeasures within the MLPHAP which assure access tovarious services provided by public health agencies.Section 5 Hearing 1.1 system in place to schedulechildren between ages 3‐5 for hearing screening uponrequest.Section 5 Hearing 2.1 Hearing screening for all children ingrades K, 2 and 4.Section 8 STD 1.1 Use STD clinic protocol to ensure timelyservice.Section 8 STD 4.1 Maintain protocols and personnelneeded to control spread of disease.Section 9 Vision 1.1 System in place to schedule childrenbetween 3‐5 for vision screening upon requestSection 9 Vision 2.1 LHD to provide vision screenings toschool age children.Section 10 BCCCP 10.4 All women requiring immediatefollow‐up are receiving services defined in the CDCCompleteness Performance Indicators.Section 11 Family Planning 6 Provide that priority in theprovision of services will be given to persons from lowincomefamilies.Section 11 Family Planning 11 Provide for medicalservices related to family planning (includingphysician's consultation, examination prescription, andcontinuing supervision, laboratory examination,contraceptive supplies) and necessary referral to othermedical facilities when medically indicated, andprovide for the effective usage of contraceptivedevices and practices.Section 11 Family Planning 18 Provide coordination andreferral arrangement with providers of health careservices.Section 12 HIV/AIDS 4.1 Referral system into earlyintervention and care services.Not specifically addressed in Cycle 4 process.Meeting PHAB Standards:Evidence/Documentation ExamplesFederally Qualified Health Center(FQHC) planning grant participation,hospital community health assessmentmeeting minutes, local collaborativecouncil meeting minutes where accessto healthcare was discussed.Participation in the activities of countyhealth plans.Reports regarding the health care needsof the population within thejurisdiction.Evidence of process used to identifygaps in service.Examples of active relationships withcommunity providers to increasehealthcare access. Many of the samedocuments as listed above, but withexamples of strategies identified andimplemented.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 15

Domain 8: Maintain a competent public health workforcePHAB Standards(Version 1.0)8.1 Encourage theDevelopment of aSufficient Numberof Qualified PublicHealth Workers8.2 Assess StaffCompetencies andAddress Gaps byEnablingOrganizationaland IndividualTraining andDevelopmentMichigan Accreditation Program Indicators(Cycle 4)Not addressed in Michigan’s Cycle 4 process.Section 1 Powers and Duties 1.7 Health Officer andMedical Director Qualifications.Section 3 Food Service 16, 17 and 18 Technical, field andspecialty food training all required for inspection staff.Section 4 CD 3.3 Adequately prepared staff capable ofenforcing MI law for control of CD.Section 5 Hearing 5.1 All techs attend MDCH training andmust pass written and practical application.Section 5 Hearing 5.2 All techs attend at least one MDCHapproved workshop every 24 months.Section 9 Vision 2.3 and 3.2 Based on observation of 5screenings, staff is tested to assure that all proceduresare administered correctly.Section 9 Vision 5.1 All vision techs trained in accordancewith MDCH guidelines and attend vision tech approvedworkshop every 24 months.Section 12 HIV/AIDS 6.1 Engages in technical assistance,program evaluation and/or capacity developmentactivities.Section 11 Family Planning 8.2 MPR 14 Provide fororientation and in‐service training for all projectpersonnel.Meeting PHAB Standards:Evidence/Documentation ExamplesSamples of presentations made toschools/colleges/universities and othercommunity groups to increaseawareness of public health andpotential careers in public health.Evidence of internship experiences.Google log of staff training, staff sign‐insheets of trainings with agendas/meeting materials.Staff development plan.Documentation that managers andleadership staff have attendedleadership training.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 16

Domain 9: Evaluate and continuously improve processes, programs, and interventionsPHAB Standards(Version 1.0)9.1 Maintain aPerformanceManagementSystem toImproveOrganizationalPractice,Processes,Programs, andInterventionsMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers/Duties Quality ImprovementSupplement (QIS) MPR 2 Process in place fordevelopment of process and/or program goals andperformance measures.Section 4 CD 1.2 Collects/collates and analyzes CDsurveillance data.Section 6 Imms 2.1 1 LHD shall sustain immunizationlevels in Michigan Care Improvement Registry (MCIR)Section 12 HIV/AIDS Indicator 5.4 A minimum of 70% ofall sex or needle‐sharing partners/contacts located,and who accept PCRS, and who have an unknown orpreviously negative HIV serostatus will receive an HIVtest subsequent to PCRS notification.Meeting PHAB Standards:Evidence/Documentation ExamplesThe results from the MLPHAP and thecorresponding corrective plans of actionmay be able to be used as examples ofperformance management as it involvesthe entire staff within the agency.Agency must have a performancemanagement system in place thatincludes assessment, monitoring andresults.Evidence to support staffinvolvement(agendas, meeting minutes,packets)Customer satisfaction surveys andanalysis of resultsEvidence to indicate staff was providedtraining opportunities in the area ofperformance management.9.2 Develop andImplementQualityImprovementProcessesIntegrated IntoOrganizationalPractice,Programs,Processes, andInterventionsCycle 4 of the MLPHAP does include a voluntary QualityImprovement Supplement (QIS). The QIS has 3 MPR’srelated to quality improvement:1. Establish a culture of quality improvement (QI) withinthe local health department.2. Evaluate the effectiveness of public health processesand/or program goals and performance measures.3. Implement quality improvement of public healthprocesses and/or program goals.Complete the elements of the QIS andutilize same documentation.Evidence must include implementationof an agency quality improvement planwith one example from a program areaand the other must be from anadministrative area.Evidence to indicate staff participationin plan (meeting minutes,presentations)Crosswalk: Michigan and National Voluntary Public Health Accreditation page 17

Domain 10: Contribute to and apply the evidence base of public healthPHAB Standards(Version 1.0)10.1 Identify andUse the BestAvailable Evidencefor MakingInformed PublicHealth PracticeDecisions10.2 PromoteUnderstandingand Use ofResearch Results,Evaluations, andEvidence‐basedPractices WithAppropriateAudiencesMichigan Accreditation Program Indicators (Cycle 4)Not addressed in Michigan Cycle 4 process, but routinelyLHDs are given special recognition when best‐practicesare demonstrated.Not addressed in Michigan Cycle 4 process, howeverwithin the Plan of Organization 2.d IT must demonstratecapacity available to access and distribute current PHinformation.Meeting PHAB Standards:Evidence/Documentation ExamplesResult of interaction with consultantson use of the CDC Community Guide toPreventive Services and/or NACCHOModel Practices.2 examples illustrating when healthdepartment used evidence‐based orpromising practice. Examples must befrom two separate program areas.Screen shots from agency websitewhere research findings are cited;medical director reports distributed;press releases which discuss researchfindings.Institutional Review Board review policyor a policy stating that the healthdepartment is never involved in humansubject research.Evidence of access to outside expertswho analyze research.Examples of communicating researchfindings to the stakeholders/public.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 18

Domain 11: Maintain administrative and management capacityPHAB Standards(Version 1.0)11.1 Develop andMaintain anOperationalInfrastructure toSupport thePerformance ofPublic HealthFunctionsMichigan Accreditation Program Indicators (Cycle 4)Plan of Organization 2 – LHD Organization Organizationalchart, agency policies/procedures.Meeting PHAB Standards:Evidence/Documentation ExamplesCopy (hard copy or electronic version) ofagency’s approved Plan of Organization.Written operating procedures,organizational chart and evidence ofreview every 5 years.Confidentiality Policy and signedemployee formsCultural and linguistically interventionsand materials are developed andapplicable to jurisdiction it serves.Human Resource system in placeStaff qualifications checkedUse of technology to support thedepartment; hardware and softwareinventoryCertificate of OccupancyADA Compliance Audit11.2 EstablishEffectiveFinancialManagementSystemsPlan of Organization 2 –LHD Organization Boardapproval of operating budget.Copy of meeting minutes where budgetis approved by board; copy of lastagency independent financial audit.Evidence of submission of grantapplicationsEvidence of asking for additionalinvestment in public health.Crosswalk: Michigan and National Voluntary Public Health Accreditation page 19

Domain 12: Maintain capacity to engage the public health governing entityPHAB Standards(Version 1.0)12.1 MaintainCurrentOperationalDefinitions andStatements of thePublic HealthRoles,Responsibilities,and Authorities12.2 ProvideInformation to theGoverning EntityRegarding PublicHealth and theOfficialResponsibilities ofthe HealthDepartment andof the GoverningEntity12.3 Encourage TheGoverning Entity’sEngagement inthe Public HealthDepartment’sOverallObligations andResponsibilitiesMichigan Accreditation Program Indicators(Cycle 4)Section 1 Powers and Duties 1.6 (Plan of Organization1. Legal Responsibilities) State and local laws,statutory authority and governing entity relationship.Not addressed in Cycle 4 process.Not included in Cycle 4 process, but board members areencouraged to attend the Powers and Duties ExitConference during the accreditation on‐site review.Meeting PHAB Standards:Evidence/Documentation ExamplesCopy (hard copy or electronic version)of Plan of Organization; sanitary code,public health code.Board of Health/County Commissionmeeting minutes, Samples of Boardmember orientation/PowerPointpresentation. Meeting minutes where apublic health issue is discussed withgoverning entity.Evidence indicating governing entitymembers have received a copy of“Michigan’s Guide to Public Health forLocal Governing Entities CountyCommissioners, Boards of Health andCity Councils” (Nov. 2006 MDCH)Governing entity orientation materialsBoard of Health/County/CityCommission meeting minutes wherepublic health issues are discussed;decisions made.Documentation of annual review ofissues discussed, actions taken andpolicies set by governing entity (meetingminutes, presentation packet, report)Documentation of annual agencyperformance and improvement effortsas reviewed by governing entity(meeting minutes)Crosswalk: Michigan and National Voluntary Public Health Accreditation page 20

Appendix 1

The Michigan Public Health Training Center (Michigan PHTC) works to promote and protect the health and qualityof life in Michigan’s communities by strengthening public health practices of organizations, practitioners, andfuture workers. The Michigan PHTC collaborates with organizations to advance strategic planning, education andresources development. The Training Center improves public health workforce competency through training,collaborations, mentoring students in field placements, and technical assistance to organizations.Michigan Public Health Training Center is funded by a grant from the Health Resources and ServicesAdministration (HRSA) Bureau of Health Professions.