1. Accreditation: Why?
Kentucky Department for Public Health
Commissioner’s Office
Center for Performance Management
Frankfort, Kentucky
Sept. 13, 2012 Oct. 29, 2012 Nov. 9, 2012
Rona Dawson: State Accreditation Coordinator (SAC)
“Brown Bag Series Two”

2. “Brown Bag” Basics
• Course name: Public Health Accreditation: Why?
• TRAIN ID (registration and attendance certificate) # 1034665
• Duration: 30 Minutes with 15 minutes for questions/answers. Total: 45 minutes
• Description: This non-CEU presentation for state public health staff answers:
1. Why is KDPH applying for PHAB accreditation and what is it?
2. Who is PHAB and when will site reviewers be at our agency?
3. How does accreditation affect me?
• Objective: To provide general, educational staff information in preparation for voluntary
agency accreditation for PHAB (Public Health Accreditation Board) application readiness
• Series two: (Three repeats); Series one: Video archived. See: TRAIN #1030870
Cabinet for Health and Family Services, Page 2

3. Accreditation is everywhere…we hope!
Accreditation provides public notification that an institution,
agency, or program meets standards of quality set forth by
an accrediting agency.
Health Care
Academia
Public Safety
Cabinet for Health and Family Services, Page 3

4. PHAB has Built the Track
PHAB www.phaboard.org
“Improve and protect the health of the public by
advancing the quality and performance of all health
departments in the country”
Cabinet for Health and Family Services, Page 4

5. All Aboard!
• PHAB is a non-profit, voluntary public health
accreditation organization founded in 2007 whose
goal is to advance public health performance by
providing a national framework of standards for
local, state, territorial and tribal health departments.
• PHAB is the national organization charged with
administering the public health accreditation
program.
• PHAB’s office and staff are in Alexandria, VA
Cabinet for Health and Family Services, Page 5

6. PHAB Beta Test Sites: 30
All sites agreed (n=9) or strongly agreed (n=21) that…
“Participating in the beta test will improve the performance
of our health department.”
Cabinet for Health and Family Services, Page 6

7. Debarking beta passengers say…
The process helped us “realize our organizational
weaknesses [which will serve] as a foundational
roadmap for improvement.”
“…Doing this accreditation process and standardizing certain procedures
across the state will help in so many ways.”
The beta test “helped jumpstart the process to
create a QI culture for the agency as a whole.”
Cabinet for Health and Family Services, Page 7

8. A PHABulous Journey has Started
• PHAB aims to have 60% of the U.S.
population served by an accredited
agency by the year 2015
• 97 HD’s currently awaiting a site visit
• 12 State Health Departments have already
“pushed the PHAB button” and applied
• Ky. LHD’s: Franklin, Three Rivers, NKY have
applied with Clark, Madison, Fayette, and
Christian, and others, coming down the track
Cabinet for Health and Family Services, Page 8

9. KDPH’s Journey Down the Track
• KDPH Statement of Intent (SOI): Oct. 2013
• KDPH Accreditation Application: June 2014
• Reapplication: 2019 (every five years)
• Accreditation requires an on-going health
departmental commitment to improvement
and adherence to national standards
Cabinet for Health and Family Services, Page 9

10. Advantages of Riding the Rail
• Streamlining federal grant application process
• Awareness of agency strengths and weaknesses
• Enhanced appreciation of opportunities for
improvement (OFI’s)
• Accountability and credibility
• Leverage for funding
• Visibility
Davis MV, Cannon MM, Stone DO, Wood BW, Reed J, Baker EL. (2011). Informing the national public health accreditation movement:
lessons from North Carolina’s accredited local health departments. Am J Public Health. Retrieved from:
http://ajph.aphapublications.org/cgi/content/abstract/AJPH.2011.300199v1.
Cabinet for Health and Family Services, Page 10

11. The Accreditation Train is Moving
• PHAB raises the bar with:
• Strategic planning
• Responsive to Change
• Shared Decision-Making
• Strong Partnerships
• Customer focus
• Services and programs
• Workforce development
• Evaluation, performance and quality improvement
• Checks and balances
Cabinet for Health and Family Services, Page 11

12. How does “PHAB” affect me?
• KDPH will meet:
12 Domains
32 Standards
103 State Measures
• PHAB Site Visit: Estimated Late 2014
• Each division has input (champions/liasons)
• Changes: gaps filled, policy adoptions,
required updates, system strengthening, etc.
Cabinet for Health and Family Services, Page 12

13. Standard Example
Cabinet for Health and Family Services, Page 13

14. Examples of Mile Markers
• Required 3 plans: “in the works”
• QI projects: “going well” (Thank you CPM
team! )
• Checks and balances: identification phase
• Committees initiated: QI, Safety, PM, etc.
• Forward momentum drivers: (performance
management & quality improvement)
Cabinet for Health and Family Services, Page 14

15. ART: The Fuel for the Train
• ART: Accreditation Readiness Team, est. Aug. 2010
(Construct, charter, logic model, meeting frequency,
content varies, server archives, direction, announcements)
• 2011 Completed agency SAT (Self-assessment tool)
• 2012-2013 Goals: Complete our “Big 3” plans (SHA, SHIP,
Strategic Plan)
• Evidence collection, gap analysis, PIM, QI Specialist,
improvement initiatives, action items, work plans, PHAB
documents review & process completion, strategy, etc.
Cabinet for Health and Family Services, Page 15

16. Internal Education and Momentum Building
Cabinet for Health and Family Services, Page 16

17. KDPH Conductors
Domain # Domain Champion/Liaisons(s)
1 OHE: Vivian Lasley-Bibbs
2 Epi/Lab: Dr. Humbaugh, Dr. Mayfield, Sara Robeson,
Sandy Kelly, Karim George, Laura Iwig
3 MCH: Dr. Shepherd, Marvin Miller
4 Sue Thomas-Cox
5 PQI: Gary Kupchinsky
6 PHPS: Kathy Fowler, Jennifer Bell
7 Women’s Health: Joy Hoskins
Please send your
8 Trish Okeson
potential evidence
suggestions to your
9 CPM: Janie Cambron, Jim Rousey
division contact for
10 Sarah Wilding
their consideration.
11 AFM: Rosie Miklavcic, Shelly Canada
12 Charles Kendell
Cabinet for Health and Family Services, Page 17

18. KDPH Planning
The standards and measures are the tools to:
• Review and revise processes, procedures, and
programs
• Develop capacity and performance excellence
• Guide the internal development of quality
• Prepare for documentation selection and
submission and site visit
Cabinet for Health and Family Services, Page 18

19. KDPH Journey Timeline
Cabinet for Health and Family Services, Page 19

20. Benefits and Value of Accreditation
KDPH Preparation thus far has yielded:
• Quality and Performance Improvement Focus
• Accountability and Credibility
• Recognition and Validation
• Clarification of Expectations
• Increased Visibility
• Collaboration and Team Building
Cabinet for Health and Family Services, Page 20

21. The Big Three Plans: KDPH
• Agency Strategic Plan
- 2001, CHFS
- Dec. 2011: Mission, Vision, Values adopted
- SMART objectives under development
• Health Improvement Plan
- (KRS 194A.001) Latest: March 1998; Seeds in process
- Working with Healthy People 2020, Healthy Kentuckians 2020 with other division
program plans, such as the Coordinated Chronic Disease Prevention and Health Promotion
State Plan
- Center for Performance Management (CPM) Assisting Office of Health Equity
• Health Assessment
- Draft in process
- Center for Performance Management (CPM) leading the effort in coordination with
division staff and external partners
Cabinet for Health and Family Services, Page 21

22. Stoking the Engine
• KDPH is creating a culture with:
– A Quality Improvement (QI) focus
– A Performance Management (PM) philosophy
– A teamwork atmosphere in step with PHAB
– Many more miles to go…
Cabinet for Health and Family Services, Page 22

23. Seatbelt Time in Kentucky
• We’re all on the train together
• The train runs on two tracks (state & local)
• We’ll all get there together; it’s the same path
• Its all forward momentum
• The ride is half the fun; sightsee some
• Talk to people along the way; this is a
consensus oriented process
Cabinet for Health and Family Services, Page 23

24. KDPH Leadership
Commissioner: Stephanie Mayfield Gibson, MD, FCAP
Commissioner’s Office: Charles Kendell, Patricia Okeson, Sarah Wilding
Center for Performance Management: Janie Cambron (Performance
Improvement Manager), Rona Dawson (State Accreditation Coordinator),
Brandon Hurley (LHD/State Liaison), James Rousey (Quality
Improvement Specialist & Consultant), Daniele Bray (Quality
Improvement Nurse)
Cabinet for Health and Family Services, Page 24

25. Contact Information
Rona Dawson, MPA, BA, AA, CMF
Kentucky Cabinet for Health and Family Services
Department for Public Health
State Accreditation Coordinator (SAC)
(502) 564-7212, ext. 3650
Rona.Dawson@ky.gov
Agency homepage: http://chfs.ky.gov/dph/default.htm
Cabinet for Health and Family Services, Page 25