Supplementation Process and Documentation Guidance for Tribal Public Health Department Accreditation Kaye Bender, RN, PhD, FAAN NIHB Webinar March 6, 2018 Webinar Objectives Review the new document entitled
Supplementation Process and Documentation Guidance for Tribal Public Health Department Accreditation Discuss how Tribal health departments can use this document in their accreditation preparation. final document Purpose and Use of the Document The document was developed to be used with the PHAB Standards and Measures, Version 1.5 in order to provide some
Tribal specific guidance related to the documentation and process requirements. PHAB recommends that the user of this document put it side-byside with the standards and measures so as to appropriately apply the supplemental guidance. This webinar does not attempt to re-state the language in the document. It is a guide to use the document. Tribal health departments should refer to the specific language in the document and not these slides when working on their documentation. How Was The Document Developed? The document was developed in
partnership with the Tribal Public Health Accreditation Advisory Board, part of the National Indian Health Board. It was reviewed by the PHAB Board of Directors. It was placed for public comment on PHABs website for approximately three months. Overarching Comments for the Document The original standards and most measures remain the same.
The original process for review remains the same. In many cases, the documentation guidance remains the same. The documentation guide that is being developed is a supplement to S/M 1.5 The documentation guide contains both clarifications and changes in requirements. Each will be specified accordingly. There are definitional terms that were clarified or amended throughout the document. Some Tribal public health examples were included, as PHAB had those to include. However, PHAB hopes to add to these examples as more Tribal public health examples are available to PHAB.
PHABs Suggestions for Using the Document Read the standard and measure in Version 1.5 of the PHAB Standards and Measures. Also read the purpose and significance. Often reading the measure requirements in the context of the standard and measure purpose and significance will provide the user with the appropriate context for understanding the measure.
If the user is still having difficulty understanding how the measure applies in Tribal public health, see if there is additional information in the supplemental guidance. The measure numbers are the same in both documents. Domain 1 Conduct and Disseminate Assessments Focused on Population Health Status and Public Health Issues Facing the Community
Who is the population that the Tribal health department covers in their community health assessment? Each Tribal health department can determine who their population is. Some may include Tribal members only; some include descendants, family members, and Tribal employees; others may include all who are eligible to receive their services. The Tribal health department needs to make this decision early in their accreditation process and be able to describe who their population is to PHAB. Throughout the document, population and
community are viewed as the same terms. Measures 1.1.1 and 1.1.2 (pages 7-8) Who Does the Tribal Health Department Have to Share Their CHA With? Tribal health departments should share their CHA with the broadest community possible in the context of their Tribal setting. In respecting the sovereignty of the Tribe to make the most appropriate decision about sharing their reports, PHAB does not require that the Tribal health department post them on their
website. Documentation must be submitted that indicated with whom and how the CHA was shared. Measure 1.1.3 (page 8) Who Does the Tribal Health Department Have to Share Their Data With? Tribal health departments may use data collected or analyzed by their Tribal Epidemiology Centers; form state or other federal sources; or from contract providers. Tribal health departments can use sharing data with their regional TEC as an example. Provision of
summary data, as opposed to raw data, is acceptable. Measures 1.2.3 and 1.2.4 (page 8) Who Does the Analysis of Data and Who Do Tribal Health Departments Share That With? Data do not have to be collected or analyzed by the Tribal health department. The data do have to be specific to the population served. Reports could be produced by the state, an academic institution, a TEC, or others. Once the reports have been completed, sharing them with Tribal Councils, Tribal Health Boards, or Tribal Health Committees would be acceptable.
Summaries, reports or fact sheets that are used to support public health improvement planning could also some from the TEC or other contractors. Measures 1.3.1, 1.3.2, and 1.4.2 (pages 9-11) Domain 2 Investigate Health Problems and Environmental Public Health Hazards to Protect the Community How Do Tribal Health Departments Document
Their Process for Investigating Disease Outbreaks or Environmental Issues? If the Tribal health department does not have the capacity to conduct disease investigations on their own, they can use their agreement with the IHS or any other organization or entity that might conduct this work on their behalf. If the Tribal health department has not had an investigation need with the five years prior to going through the accreditation process, they can use documentation of an exercise or drill to test how it works in their setting. Measures 2.1.1, 2.1.2, 2.1.3, and 2.1.4 (page 10-11)
How Can a Tribal Health Department Document Their 24/7 Access for Investigations and Reporting? Tribal health departments who do not have the capacity to have 24/7 access for investigations and reporting may have agreements with other entities within the Tribal government to accomplish this work. In that is the case, then documentation can be provided by memos, emails, or MOUs that describe that work and who does it. If access to laboratory capacity is outside the Tribal government, then, more formal documentation such as a contract or MOU is required.
Measures 2.3.1, 2.3.2, and 2.3.3 (page 12) Domain 3 Inform and Educate about Public Health Issues and Functions How Can a Tribal Health Department Document Their Work in Providing Information to the Public on Protecting Their Health? Tribal health departments may use Tribal or other governmental proclamation; documentation from talking circles, Tribal committees, or community meetings.
Partnership with the health care side of the Tribe to develop health education for the population is acceptable as long as the health education is about health promotion and disease prevention and not about individual health care or clinical services. Health literacy examples can be used. Sub-populations within the Tribe can be identified to address health equity. Measures 3.1.1, 3.1.2, and 3.1.3 (pages 13-14) How Can a Tribal Health Department Document Its Provision of Information?
Examples of providing information on public health functions could come from Tribal advisory committees, the Tribes legislative advisor, or others. Tribal health departments can use the Tribal logo or seal if that is the organizational branding that is used. If a Tribal health department works with a Tribal Office of Public Affairs, documentation from that office can be used. Measures 3.2.1, 3.2.2, 3.2.3, 3.2.4, and 3.2.5 (pages 14-15) Domain 4 Engage with the Community
to Identify and Address Health Problems Who Are the Partners That Tribal Health Departments Should Engage? Tribal health departments may partner with other Tribal or local partners. Examples could include Head Start, emergency management, schools, coalitions, and social services. These partnerships are intended to include community members other than the health department staff. Tribal health departments are a community resource for partners and stakeholders who are seeking information about
engaging with a specific Tribal community. Technical assistance refers to the provision of feedback and input to partners and stakeholders about how best to engage with the Tribal community. Measures 4.1.1 and 4.1.2 (page 15) Domain 5 Develop Public Health Policies and Plans How Does a Tribal Health Department Demonstrate That They Inform Others About
Potential Impacts of Proposed Policies? Tribal health departments may consider documenting the work that they have participated in to develop or revise Tribal ordinances or Tribal codes that describe public health policies. Tribal health departments may select information from a Tribal Health Council or Tribal Board meetings. Measure 5.1.3 (page 16) Domain 6 Enforce Public Health Laws
How Does a Tribal Health Department Document Review of Laws? For Tribal health departments who are part of a Tribe that makes its own laws, rules, and regulations, the health department must be able to document how it participates in the review of public health laws and provides input into changes that need to be considered.
For Tribal health departments who are part of a Tribe that does not make its own laws, then, the Tribal health department can document how it reviewed laws, rules, and regulations passed by others and how the Tribal health department provided input into needed or proposed changes. The Tribal health department is not responsible for the actions taken by the entity that is ultimately responsible to changing the laws, rules or regulations; just for the review and input using their public health expertise. Measures 6.1.1 and 6.1.2 (page 19)
How Does a Tribal Health Department Document Regulatory Responsibilities? Tribal health departments that do not have regulatory enforcement responsibility still have a responsibility to maintain knowledge of laws that impact public health and to ensure that the laws are applied consistently. For example, the school system may have the responsibility to ensure that all children entering kindergarten have had age appropriate vaccinations. The health department
should work with the schools to ensure that those laws are consistently enforced. Another example is the assurance that the prohibition against the sale of commercial tobacco products to minors is enforced consistently. If the laws are enforced by a different Tribal entity, the health department needs to provide documentation that it knows about the enforcement activity. For Tribal health departments, accessible to the public means accessible to the population or community that the Tribal health department has determined that it is responsible for. The Tribal health department may or may not be responsible to administering or enforcing the law. This measure is about the provision of information. The Tribal health department might also partner with another administrative unit or agency to document conformity with this measure. Measures 6.2.1,6.2.2. and 6.2.3 (page 20)
Domain 7 Promote Strategies to Improve Access to Health Care How Can a Tribal Health Department Document Strategies to Improve Access to Health Care? Tribal health departments may document access to traditional or Tribal healers as part of the assessment and assurance of access to health care. Culturally competent initiatives for Tribal health departments could include examples from community
health representatives; efforts to employ traditional health workers/healers/practitioners; or developing a peer support group. Measures 7.2.1 and 7.2.3 (page 23) Domain 8 Maintain a Competent Public Health Workforce How Can a Tribal Health Department Document That It Ensures a Competent Workforce? Tribal health departments can use a policy that the
Tribe may have regarding preference in hiring American Indians or Alaska Natives. Tribal health departments need to demonstrate how they work with the broader Tribal human resource office if the health department does not manage its own human resource functions. Measure 8.2.2 (page 24) Domain 9 Evaluate and Continuously Improve Health Department Processes, Programs and
Interventions What Is An Acceptable Performance Management System? Performance management is a systematic process which helps a Tribal health department achieve its mission and strategic goals by improving effectiveness, empowering employees, and streamlining decision making. In practice, performance management often means actively using data to improve performance. PHAB expects that Tribal health departments will establish a system for the whole health department (the system) that addresses performance management. To do that, Tribal health department leadership must be
engaged. Tribal health departments can decide who that leadership should be. Examples might include the Health Department Director; a Tribal Council; a Tribal Health Advisory Board; an internal Division or other administrative unit within a Tribe; a Tribal Health Commission or Committee; a Tribal Health Board; or a Tribal Advisory Board of Commissioners. A performance management system is a single, comprehensive approach of using objectives and measurement to evaluate performance of programs, policies, and processes, and achievement of outcome targets for the Tribal health department. The Tribal health department performance management system may be part of a larger
performance management system for the Tribe (such as in the health care arena). However, if that is the case, specific application to the public health programs and/or initiatives must be described in the required documentation. Measures 9.1.1, 9.1.2, 9.1.3, 9.1.4 and 9.1.5 (pages 25-26) Where Can A Tribal Health Department Find Good Examples of Quality Improvement Work? The definition or description of a culture of quality that PHAB uses is the one that NACCHO developed and continues to improv. It can be located at http://qiroadmap.org
Examples of quality improvement activities can be found on many of the national public health partner websites (ASTHO, NACCHO, and PHF) and on the PHQIX website. Clinical (health care) examples may not be used for PHABs accreditation examples. Measures 9.2.1 and 9.2.2 (page 26)
Domain 10 Contribute To and Apply the Evidence Base of Public Health How Can Tribal Health Departments Manage the Requirements Related to Research? The Tribal health department does not have to conduct research. The purpose of these measures is to ascertain how the Tribal health department promotes and supports innovations in public health practice and research.
For protection of human subjects, documentation for a Tribal health department could be a Tribal policy or protocol that describes the process for research review and approval by the Tribal Council, Health Oversight Committee, or other body or authority. It could also be the official Tribal IRB process, which may be the IHS area IRB. Tribal health departments must document that they have the availability of expertise (internal or external) for analysis of research and interpretation of research findings. Interpreting research findings is important
when communicating the public health implications of those findings to others within the Tribal setting. It is also important when incorporating research findings into department processes, programs, or interventions. This could be a relationship with the Tribal Epidemiology Center. If the expertise is outside the Tribal health department, but still within the Tribe itself, a written agreement is not needed. If the expertise is outside the Tribe, then, a written form of agreement is needed to document the authenticity of the arrangement. It can be a letter of agreement, a contract or a MOU/MOA. It does not have to include payment for the expertise described above, although it may. Measures 10.1.2, 10.2.1, and 10.2.2 (pages 27-28) Domain 11 Maintain Administrative and Management Capacity
How Does a Tribal Health Department Document Its Administrative Functions? For all of these measures, the work may actually be led by another Tribal department. The Tribal health department should work with those other offices, departments and divisions to provide the documentation. This is especially applicable to the measures related to budget, audit, HIPAA training, and information systems.
Examples of ethical issues include, for example, privately constructed sewers, distribution of vaccine in a shortage situation, staff mandatory immunizations, an employees use of social media, an employees acceptance of gifts. Tribal health departments should redact any confidential employee information before submitting an example of an ethical issue related to human resources. Measures 11.1.1, 11.1.2, 11.1.5, 11.1.6, 11.1.7 (pages 29-31) How Can a Tribal Health Department Document Socially, Culturally, and Linguistically Appropriate?
For Tribal health departments, examples could include the provision of health education materials in a native language; provision of information for individuals who are hearing or visually impaired; provision of information for individuals with lower reading levels; etc. This is one of the measures that is also related to the topic of health equity. In a given Tribal situation, populations at higher risk for a specific condition (such as elders with diabetes or teens at risk for
pregnancy or drug use) are identified by the Tribal health department according to the data in their Tribal health assessment and initiatives described in their Tribal community health improvement plan. Measure 11.1.4 (page 34) Domain 12 Maintain Capacity to Engage the Public Health Governing Entity Who Is a Tribal Health Departments Governing Entity?
The Tribal health department can decide who their governing entity is. The relationship between the governing entity and the health department must be included in the description of the governing entity. Examples could be a Tribal Council; a Tribal Health Advisory Board; an internal Division or other administrative unit within a Tribe; a Tribal Health Commission or Committee; a Tribal health board; or a Tribal Advisory Board of Commissioners. The Tribal health department must produce some evidence of documentation of
its roles and responsibilities. It may be as formal as a Tribal law or regulation or less formal as a memo designating their authorities. This document must also describe how the health department works with its governing entity to carry out its roles and responsibilities for public health. Measures 12.1.1 and 12.1.2 (page 32-33) Thank you!
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