North Carolina Accreditation Learning Collaborative

NC MLC-3 Year Two Project

Accreditation Standards Comparison
A process to compare the NCLHDA Standards with the PHAB Standards

Disclaimer: This project is part of the NC MLC 3 initiative funded by the Robert Wood Johnson Foundation, it is NOT associated with the PHAB beta test of the national voluntary accreditation standards and assessment process.  This is a NC project to inform our Accreditation System as it looks for appropriate correlation and integration with PHAB.

There are two phases to the project. The phases will occur simultaneously.

Phase One – Desktop Review

10 Local Health Departments to participate

  • 5 currently accredited
  • 5 currently unaccredited

Project Steps

  1. Select an Accreditation Coordinator
  2. Review 5 standards and measures from the PHAB Accreditation Standards and Measures
    1. LHDs will select 5 from a pre-selected list of 7-8
  3. Self-Assess the agency’s ability to collect the required documentation
    1. Use of applicable sections of the PHAB Self-Assessment Tool (SAT)
  4. Collect the documentation from that already available in the department
    1. Note if documentation is not available and whether or not it could be created
    2. PHAB interpretation documentation will be available
  5. Submit the documentation electronically to the NCLHDA office
  6. Complete a summary review for the process

Compensation to the LHD - $1500 per participant

 

Phase Two – Full Review

Two Local Health Departments to participate:

  • 1 currently accredited
  • 1 currently unaccredited

Project Steps

  1. Select an Accreditation Coordinator
  2. Review all of the PHAB Accreditation Standards and Measures
  3. Self-Assess the agency’s ability to collect the required documentation
    1. Use of applicable sections of the PHAB Self-Assessment Tool (SAT)
  4. Collect the documentation from that already available in the department
    1. Note if documentation is not available and, if not available, if it could be created
    2. PHAB interpretation documentation will be available
  5. Submit the documentation electronically to the NCLHDA office
  6. Host a one-day site visit with limited interviews
  7. Complete a summary review for the process

Compensation to the LHD - $5000 per participant

The results of the project will be used to:

  • Recommend changes to the NCLHDA standards, if indicated.
    After 4 years in force, it is time to examine the standards in use in NC to determine if there are standards that need to be added, deleted or revised.  The purpose for this includes performance improvement for the NC system, review to assure that the standards reflect and assess current public health practice, and to parallel, to the extent possible, the NC standards with the PHAB standards. 
  • Inform NCLHDA on the use of electronic documentation and submission.
    While NC has some LHDs who have used electronic documentation, hard copy is also accepted.  Training for electronic documentation was scheduled but was postponed due to budget cuts.  The PHAB system will be web based and electronic.  The results will be used to develop any recommendation to the NC Board regarding current and future use of electronic documentation.
  • Inform PHAB on the similarities and differences between the NC system and the proposed national system.
    The relationships between PHAB and state-based programs, previously termed equivalency, has yet to be finalized and is still under consideration by PHAB.  Whether NC accreditation will, in some form, be accepted or rejected by PHAB is unknown.  The PHAB standards and process used many elements from the NC system.  The process comparisons in this project will be helpful in determining the level of equivalency present between the NC and national systems.