Accreditation Preparation in Small Local Health Departments

Thu, 02/27/2014 - 11:48 -- karnold

Wondering if anyone has suggestions or experience in organizing the process for the gathering of required documentation in small local health departments? (10-15 employees, including Management). Assigning a Domain Leader (comfortable with the types of required documentation or the sometimes development of new documentation/process/policies) is challenging with few staff.

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Submitted by susanfec on

We are a small, rural, county public health department preparing for accreditation. We plan to apply in May. We have 17 employees, including management. We basically asked each employee to sign up for 2-3 domains. Each domain has 2-3 people who work as a team. They collect/create the documentation and will eventually be meeting with PHAB reviewers to go over the documentation. They will be comfortable with the domain by working on it and will be able to support the documentation to the reviewers. As the accreditation coordinator, I help where needed and as documentation is sent to me electronically, I add it to folders by domain/measure and hyperlink it to a master document.

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jloewe's picture
Submitted by jloewe on

We are also a small rural county health department with only 6 staff members. It is very challenging. We also assigned domains to people; however, the ability to which some staff can contribute to the "work" is limited. You really do need an Accreditation coordinator to keep the process moving forward, help meet deadlines, and be the "go-to" person that can help everyone. As you discover new documentation/policy needs etc--many are things that need to be implemented department-wide. While it is fine for staff to work on these things---MANAGEMENT involvement is a MUST and often there is lots of decision-making that has to happen that often--only a manager can do. Therefore, in our experiences in our state (Wisconsin), we have found that a huge part of the work-load will end up defaulting to the manager/health officer/whoever has authority in the department. Make sure to recognize that and have the right people in place/on-board.

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Jeri Loewe

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Submitted by LowrieWard on

NACCHO is happy to connect you with other LHDs that are similar in size/demographics, etc. we've worked with several smaller LHDs as they prepare for accreditation. Please shoot us an email at and we can discuss your questions/thoughts.


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cgizzi's picture
Submitted by cgizzi on

I'm curious if there are any smaller LHDs that have ever shared an accreditation coordinator. It seems like this could be a potential candidate for a shared services approach where one person could be hired to help 2 or 3 neighboring jurisdictions prepare accreditation documentation at the same time.

Cindan Gizzi
Tacoma-Pierce County Health Dept.

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Submitted by agoon on

Responding to cgizzi's questions, sharing an accreditation coordinator is an idea we are exploring here in northwest Ohio. Our 6 counties range in population from 19,000 to about 40,000; our departments have between 11 staff (smallest) to 60 staff (largest, with 2/3 of these providing personal health services). Only 1 of us has a position solely dedicated to quality improvement or accreditation (and it's a 0.8FTE position), 1 dept doesn't have anyone working on accreditation at all, and the other 4 have accreditation added on to staff's current duties. (Here in Ohio, we must apply for accreditation by 2018 and achieve accreditation by 2020 or lose our state funding, and potentially all pass-through funding.) Our coordinators do meet regularly, which helps share best practices, interpretation of standards, etc.
As part of a Local Government Innovation Fund grant we were awarded, we are looking at areas where we can expand shared services, with accreditation being one of them. We're preparing to narrow the potential list from 13 areas to 1-3 areas for further exploration by the end of October, so I can possibly share more info after then.
Anne Goon, Health Commissioner
Henry County Health Department
Napoleon, OH

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Anne Goon, MS, RD, LD
Health Commissioner
Marietta/Belpre City Health Department

Submitted by Kpreihs on

Kane County Health Department has teams for each Accreditation Domain. Staff were chosen to be on domains based on their job description and applicability to impact the domain topic area. Teams meet quarterly to discuss accreditation documents and gather/collect applicable forms. They then save them in their domain folders on our intranet. Each team has an implementation plan to rollout over a five year period so all documentation is collected prior to applying for accreditation. The agency will then do an audit of the documents collected and use community partners to identify documentation that does not meet the required standards. It's a fun activity and really prepares everyone for accreditation.

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