PHAB ACCREDITATION AND MCM ORR HOW TO MEET

PHAB ACCREDITATION AND MCM ORR: HOW TO MEET TWO REQUIREMENTS WITH ONE DOCUMENT Joshua Pikora, MPH Emergency Response Coordinator Knox County Health Department

Learning Objectives Identify areas where the MCM ORR and PHAB Accreditation requirements overlap. Use a crosswalk to identify documents that can be used for both PHAB Accreditation and the MCM ORR.

Overview Introduction to Accreditation and ORR Connection between Accreditation and ORR Introduction to Crosswalk Benefits and Limitations of Crosswalk How to Use Crosswalk and Examples Questions

PHAB Accreditation Public Health Accreditation Board (PHAB) formed in 2007 Standards and Measures Version 1. 0 released in 2011 � Version 1. 5 released in 2014 Voluntary program for health departments to compare their practices to national standards with the goal to improve public health

Accreditation Process Letter of Intent Submit Application Select and Submit Documents Site Visit Accreditation Decision Annual Reports Reaccreditation

MCM ORR Medical Countermeasure Operational Readiness Review (MCM ORR) Developed by the CDC in 2014 � Piloted during BP 3 � Updated for BP 4 Replacing the Technical Assistance Review Required program for health departments to compare their MCM plans and activities to national standards to measure the department’s ability to respond to an MCM event

ORR Process Self-Review � Select and Submit Documents Site Visit

Similarities Between Accreditation and ORR PHAB Accreditation National standards Document and proof of implementation Document selection and submission process Site review MCM ORR National standards Planning and operational implementation Document selection and submission process Site review

Connection Between Accreditation and MCM ORR PHAB Accreditation Existing Crosswalk Project Public Health Ready Existing Crosswalk Public Health Preparedness Capabilities New Crosswalk Based on MCM ORR

Creating the Crosswalk First Step: Follow the connection � Identified PHAB Standards and Measures that had corresponding Capabilities and Functions in the MCM ORR Reviewed the connected measures to see if the connections made sense � Imperfect Connection Different versions of PPHR measures used in existing crosswalks Not all PPHR measures had a corresponding PHEP Capability MCM ORR doesn’t cover all 15 PHEP Capabilities � Provided a starting point

First Step PHAB Accreditation PHAB Measures Existing Crosswalk Project Public Health Ready PHAB Measures Existing Crosswalk Public Health Preparedness Capabilities PHAB Measures Based on MCM ORR PHAB Measures Linked to ORR Measures

Creating the Crosswalk Second Step: Build off the starting point � Went through the accreditation standards and measures and ORR trying to identify other measures that fit together Initial Review – these measures are related and might fit together In-Depth Review – these two measures are related enough that the same document could be applied to both

Second Step PHAB Accreditation Existing Crosswalk Project Public Health Ready Existing Crosswalk Public Health Preparedness Capabilities PHAB Measures Linked to ORR Measures New Crosswalk Based on MCM ORR

Finalize the Crosswalk Third Step: Review, Review � Reviewed the crosswalk with KCHD’s Accreditation Coordinators Content – Do the matched measures make sense? Format – Is the crosswalk easy to use?

Test the Crosswalk Final Step: Trial run � Used the crosswalk to see if the documents KCHD identified for accreditation and ORR selfreview would fit for the other program.

Updating the Crosswalk BP 4 version of the MCM ORR tool was released in May � Updated crosswalk to meet BP 4 version Changes from BP 3 to BP 4 � Wording changes � Number of requirements within measures � Two new measures Capability 8 Function 1: Planning c. and Operational c. NACCHO released an MCM ORR-PPHR Crosswalk � Reviewed measures with PHAB-PPHR crosswalk to link more

The Finished Product Crosswalk between Public Health Accreditation Board Accreditation and Centers for Disease Control and Prevention Medical Countermeasure Operational Readiness Review

Acknowledgement This crosswalk was developed using: � � � � PHAB’s Standards and Measures Version 1. 5 CDC’s Medical Countermeasure Operational Readiness Review Tool for Budget Period 3 CDC’s Medical Countermeasure Operational Readiness Review Tool for Budget Period 4 NACCHO’s Documentation Selection Tools – Project Public Health Ready Overlap NACCHO’s Comparison of Project Public Health Ready Version 7. 1 Criteria and CDC Public Health Preparedness Capabilities CDC’s Public Health Preparedness Capabilities: National Standards for State and Local Planning NACCHO’s Medical Countermeasure Operational Readiness Review and Project Public Health Ready Crosswalk.

Disclaimer This crosswalk was developed by the Knox County Health Department, and is not recognized by the Public Health Accreditation Board or the Centers for Disease Control and Prevention as an official tool. Use of this crosswalk in no way guarantees or implies that documents selected through its use will be accepted by an PHAB Accreditation Site Visitor or MCM ORR Site Visitor.

Uses of the Crosswalk Health Departments that have completed the MCM ORR � Identify potential documents for accreditation Accredited Health Departments and Health Departments in the accreditation process � Identify potential documents for the MCM ORR

Benefits of the Crosswalk Gives you a place to start Saves time and effort Uses your preparedness and response work towards accreditation Builds connections between programs

Limitations of the Crosswalk Broad topic area (PHAB) vs narrow topic area (MCM ORR) All or nothing standards (PHAB) vs Gradient Scale (MCM ORR) Document identified through crosswalk may not be the best document available Some PHAB standards need multiple documents Specific to PHAB Standards and Measures Version 1. 5 and MCM ORR for BP 4 Meant for local health departments

The Crosswalk Organized by PHAB Standards in the far left column � PHAB Measures under that Standard are in the next column The Documents Required to meet that Measure is in the next column The MCM ORR Capability and Function that corresponds to the PHAB measure is in the next column � The MCM ORR Measure is in the next column The far right column contains any notes or differences that may restrict document selection

The Crosswalk PHAB Standard 2. 4: Maintain a plan with policies and procedures for urgent and nonurgent communications. PHAB Measure(s) PHAB Required Documentation 2. 4. 1 A: Written protocols for urgent 24/7 communi cations 1. Protocol for urgent 24/7 communications 2. 4. 3 A: Timely communi cation provided to the general public during public health emergen cies 1. Communications plan, procedure, or process to provide emergency information to the public 2. Communications through the media to provide information during a public health emergency MCM ORR Capability & Function Capability 6 Function 1 Capability 4 Function 5 MCM ORR Measure Notes/Differences Planning a. Plans include procedures that 1) identify all stakeholders who would be involved in an MCM incident (including public health, medical, law enforcement and other disciplines), 2) outline communications pathways between and among these stakeholders and 3) show evidence that current contact list is exist that include multiple contact mechanisms/ devices for identified stakeholders. Planning a. Plans include procedures for 1) information verification; 2) message development, approval, and clearance; and 3) message dissemination to the public, as they relate to an MCM mission. Operational a. The jurisdiction can provide evidence of participation in an exercise or real incident within the last five years in which public messages that incorporate MCM elements are created and disseminated. Operational b. The jurisdiction can provide evidence of participation in an exercise or real incident within the last five years where MCM materials were translated or adapted for applicable at-risk populations. To meet PHAB measure must be from a real incident and to meet ORR measure messages must incorporate MCM elements and have been translated or targeted towards at-risk populations

How to Use for MCM ORR Find the PHAB standard and measure on the left Follow the crosswalk right to find the corresponding MCM ORR measure(s) Take the document identified for that PHAB measure Compare the document to the MCM ORR requirements and the notes/differences listed in the crosswalk Decide whether or not to use the document for the MCM ORR

PHAB to ORR – Good Fit PHAB Standard PHAB Measure(s) PHAB Required Documentation 5. 4: Maintain an All Hazards Emergency Operations Plan 5. 4. 1 A: Process for the development and maintenance of an All Hazards Emergency Operations Plan (EOP) 3. Collaborative revision of the All Hazards EOP that includes: , c) coordination with emergency response partners, MCM ORR Capability MCM ORR Measure & Function Capability 1 Planning a. Function 3 Plan addresses engagement with community partners, to include medical and mental/ behavioral health agencies to promote an understanding and connection to MCM activities. Notes/Differences To meet measures documents must show that MCM activities are included in preparedness meetings

PHAB to ORR – Good Fit PHAB Document: Sign-in sheet for partner meeting on PHEP CPG Assessment Why it fits: � Meeting topic includes MCM activities � Included medical partners

PHAB to ORR – OK Fit PHAB Standard 3. 2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences. PHAB Measure(s) 3. 2. 3 A: Communication procedures to provide information outside the health department PHAB Required Documentation 1. Procedures for communications that include: a. Dissemination of accurate, timely, and appropriate information for different audiences MCM ORR Capability MCM ORR Measure & Function Capability 4 Planning a. Function 3 Plans include procedures for 1) media notification (including an updated contact list) and credentialing; 2) press advisories and briefings; and 3) media monitoring and validation Notes/Differences Can be used to meet parts 2) press advisories and briefings; and 3) media monitoring and validation (including social media), of the ORR measure.

PHAB to ORR – OK Fit PHAB Document: Personnel Policy – Press Release and Media Contact Why it fits: � Includes policies for press releases Why it doesn’t fit: � Doesn’t include media notification or monitoring

PHAB to ORR – Bad Fit PHAB Standard PHAB Measure(s) 1. 1: Participate in or lead a collaborative process resulting in a comprehensive community health assessment. 1. 1. 2 T/L: A Tribal/local community health assessment PHAB Required MCM ORR Capability Documentation & Function Capability 1 1. A Tribal or Function 1 local community health assessment that includes: c. Description of health issues and specific descriptions of population groups with particular health issues and inequities. d. Description of factors that contribute to specific populations’ health challenges. MCM ORR Measure Notes/Differences Planning a. MCM planning elements include the following based on risk assessment: 1) definition of risk; 2) mapped locations of atrisk populations in accordance with JRA; 3) evidence of community involvement; 4) assessment of loss or disruption of essential services If CHA is used to inform MCM planning this measure can meet 1) definition of risk, if the descriptions are used to define risk to the population, and 2) mapped locations of at-risk populations in accordance with JRA, if the description of population groups includes mapping.

PHAB to ORR – Bad Fit PHAB Document: Knox County IPLAN 2011 (CHA) Why it doesn’t fit: � Findings Health not used in MCM planning care access and transportation issues identified in CHA but not accounted for in MCM plans

How to Use for Accreditation Find the PHAB standard and measure on the left Follow the crosswalk right to find the corresponding MCM ORR measure(s) Retrieve the document used for the MCM ORR measure Compare the document to the PHAB requirements and the notes/differences listed in the crosswalk Decide whether or not to use the document for accreditation

ORR to PHAB – Good Fit PHAB Standard PHAB Measure(s) 2. 2: Contain/ mitigate health problems and environmental public health hazards 2. 2. 2 A: A process for determining when the All Hazards Emergency Operations Plan (EOP) will be implemented PHAB Required Documentation 1. Protocols that addresses infectious disease outbreaks describing processes for the review of specific situations and for determining the activation of the EOP. MCM ORR Capability MCM ORR Measure & Function Capability 3 Function 1 Planning a. Plans describe strategies to coordinate with appropriate epidemiology, laboratory, medical, chemical, biological, and radiological subject matter experts (SMEs) to inform MCM decision -making. Plans should include the following elements: 1) analyze data, 2) assess emergency conditions, and 3) determine the activation levels based on the complexity of the event or incident required to support an MCM response. Notes/Differences Can be used if plan is used to inform MCM planning and meets the requirement set in the ORR measure

ORR to PHAB – Good Fit ORR Document: KCHD EOP: Surveillance and Investigation Annex Why it fits: � Includes: Activation sequence Situations indicative of a public health emergency

ORR to PHAB – OK Fit PHAB Standard 3. 2: Provide information on public health issues and public health functions through multiple methods to a variety of audiences. PHAB Measure(s) 3. 2. 3 A: Communication procedures to provide information outside the health department PHAB Required Documentation 1. Procedures for communications that include: d. A designated staff position as the public information officer MCM ORR Capability & Function Capability 4 Function 1 Capability 4 Function 3 MCM ORR Measure Notes/Differences Planning a. Plans document public information and communication primary and back-up personnel who are trained in MCM responsibilities and current contact lists exists for these individuals. Planning b. Public health public information officer (PIO) responsibilities are documented in the job aid for the PIO or other MCMdesignated staff and include the following elements: 1) coordinating information with the lead PIO and/or joint information center (JIC); 2) serving as the point-ofcontact for the media, and 3) controlling public information messages and materials. To meet PHAB measure must document which staff position is assigned as public information officer, and include the duties of the PIO. Can be used together with Capability 4 Function 3 Planning b. to meet measure. To meet PHAB measure job aid must include which staff position is assigned as public information officer. Can be used together with Capability 4 Function 1 Planning a. to meet measure.

ORR to PHAB – OK Fit ORR Documents: � KCHD EOP: Public Information Annex � PIO Job Action Sheet Why they fit: � Annex identifies primary and backup PIO � Job Action Sheet identifies PIO’s responsibilities Why they don’t fit: � Need documents from both ORR measures to meet the PHAB measure

ORR to PHAB – Bad Fit PHAB Standard 11. 1: Develop and maintain an operational infrastructure to support the performance of public health functions. PHAB Measure(s) 11. 1. 3 A: Policies regarding confidentiality, including applicable HIPAA requirements PHAB Required Documentation 1. Confidentiality policies MCM ORR Capability & MCM ORR Measure Function Capability 6 Planning a. Plans Function 2 document minimum requirements for information sharing during an MCM incident, including 1) when information should be shared, 2) who is authorized to receive and/or share information, 3) what types of information can be shared, 4) information use and rerelease parameters, and 5) protection of information (including legal considerations). Notes/Differences Can be used for PHAB measure if confidentiality policy is specifically stated in MCM plan. Can be used for ORR measure under the idea that confidentiality policies would apply to all situations including MCM incidents and meets the ORR measure requirements

ORR to PHAB – Bad Fit ORR Document: KCHD EOP Medical Countermeasure Annex - Communication Why it doesn’t fit: � Plan only includes when data should be shared � Confidentiality not specifically stated in MCM plan

Special Circumstances: Various For some PHAB measures the MCM ORR capability and function is listed as “Various” PHAB measure can be applied to numerous MCM ORR measures � Notes/Differences states why and gives some specification as to what MCM ORR measures Applicable PHAB measures: � 2. 2. 1. 1 � 2. 2. 3. 3 � 2. 3. 4. 2 � 5. 4. 1. 2. b � 5. 4. 2. 2. b

Various Example 1 PHAB Standard PHAB Measure(s) 2. 3: Ensure access to laboratory and epidemiological/ environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards 2. 3. 4 A: Collaboration among Tribal, state, and local health departments to build capacity and share resources to address Tribal, state, and local efforts to provide for rapid detection, investigation, and containment/mitigation of public health problems and environmental public health hazards PHAB Required Documentation 2. Joint exercises for rapid detection, investigation, and containment/miti gation of public health problems and environmental public health hazards MCM ORR Capability & Function Capability 1 Function 2 Capability 3 Function 1 Various MCM ORR Measure Operational a. Jurisdiction can provide evidence of how the roles and responsibilities of these partners have been used within the last five years. Operational a. Participation of appropriate subject matter experts to inform MCM decisionmaking has been exercised within the last five years. Notes/Differences Can be used if jurisdiction partners participated in an exercise with a scenario involving a public health or environmental health hazard within the last 5 years Can be used if have exercised with partners within 5 years and if partners included epidemiology and/or environmental health subject matter experts While this PHAB measure is most applicable to the ORR measures listed above it can be applied to most ORR Operational measures with the caveat the AAR is from an exercise/event that involved response partners, and that is meets the specific requirements of the ORR measure.

Various Example 1 Document: “Knox Cough” After Action Report Why it fits: � Scenario was a Pertussis outbreak � Included jurisdictional partners, including healthcare � Exercised drop site, transportation, and security What it fits � PHAB Measure: 2. 3. 4 A-2 � ORR Measures: Capability 1 Function 2: Operational a Capability 9 Function 1: Operational a, Operational b, and Operational c Capability 9 Function 4: Operational a and Operational c

Various Example 1 PHAB Standard PHAB Measure(s) 2. 3: Ensure access to laboratory and epidemiological/ environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards 2. 3. 4 A: Collaboration among Tribal, state, and local health departments to build capacity and share resources to address Tribal, state, and local efforts to provide for rapid detection, investigation, and containment/mitigatio n of public health problems and environmental public health hazards PHAB Required Documentation 2. Joint exercises for rapid detection, investigation, and containment/miti gation of public health problems and environmental public health hazards MCM ORR Capability & Function Various Capability 9 Function 1 Capability 9 Function 4 MCM ORR Measure Operational a. Receiving sites have been exercised (functional exercise, full scale exercise or real incident) according to distribution plans (RSS/RDS/LDS) within the last five years. Operational b. Transportation assets have been exercised according to distribution plans within the last five years. Operational c. Jurisdiction has participated in exercises (tabletop, functional or full-scale) or real incidents with healthcare partners related to closed PODs, MCM asset request procedures, or other MCM activities within the last five years. Operational a. Security plans for receiving site (RSS, RDS, LDS) have been exercised (tabletop, functional, or full-scale exercise or real incidents) within the last five years. Operational c. Transportation security plans for the applicable phases referenced in the planning element have been exercised (tabletop, functional, full-scale exercises or real incidents) within the last five years. Notes/ Differences

Various Example 2 PHAB Standard PHAB Measure(s) 5. 4: Maintain an All Hazards Emergency Operations Plan 5. 4. 2 A: Public health emergency operations plan (EOP) PHAB Required Documentation 2. Testing the public health EOP, through the use of drills and exercises: b) afteraction report (AAR). MCM ORR Capability & Function Various MCM ORR Measure Notes/Differences This PHAB measure can be used meet most Operational measures within the ORR with the caveat the AAR pertains to MCM activities, and meets the specific requirements of each ORR measure.

Various Example 2 Document: “Adult Dental Day” After Action Report Why it fits: � � Planned event to provided free dental care using ICS structure Exercised responder health and safety, volunteer management, and medical materiel management through requesting medical materiel from private partners, and waste management What it fits � � PHAB Measure: 5. 4. 2 A -2 b. ORR Measures: Capability 9 Function 2: Operational a Capability 9 Function 6: Operational a Capability 14 Function 1: Operational a Capability 14 Function 4: Operational a Capability 15 Function 1: Operational a

Various Example 2 PHAB Standard 5. 4: Maintain an All Hazards Emergency Operations Plan PHAB Measure(s) 5. 4. 2 A: Public health emergency operations plan (EOP) PHAB Required Documentation 2. Testing the public health EOP, through the use of drills and exercises: b) after-action report (AAR). MCM ORR Capability & Function Various Capability 9 Function 2 Capability 9 Function 6 Capability 14 Function 1 Capability 14 Function 4 Capability 15 Function 1 MCM ORR Measure Operational a. Processes (as referenced in the planning element) for requesting medical materiel have been exercised within the last five years. Operational a. Recovery and waste disposal procedures have been exercised within the last five years. Operational a. All procedures (as referenced in the planning element) for protecting public health staff and volunteer responders have been exercised within the last five years. Operational a. Procedures for monitoring responder safety and health actions have been exercised within the last five years. Operational a. Plans related to volunteer registration systems, pre-incident screening, credentials verification, and pre-incident training have been exercised within the last five years. Notes/ Differences

Thank You KCHD Accreditation Coordinators Summit Planning Committee You for coming to this session

References Public Health Accreditation Board Standards and Measures Version 1. 5 (December 2013). Public Health Accreditation Board (PHAB). Accessed online at: http: //www. phaboard. org/wpcontent/uploads/SM-Version-1. 5 -Board-adopted-FINAL-01 -24 -2014. docx. pdf Document Selection Tools – Project Public Health Ready Overlap (2013). National Association of County and City Health Officials (NACCHO). Accessed online at: http: //www. naccho. org/topics/emergency/PPHR/upload/DST-PPHR-v-1 -5. pdf Comparison of Project Public Health Ready Version 7. 1 Criteria and CDC Public Health Preparedness Capabilities (2014). NACCHO. Accessed online at: http: //www. naccho. org/topics/emergency/PPHR/upload/PPHR-PHEP-Crosswalk-Criteria-7 -1 FINAL. pdf Public Health Preparedness Capabilities: National Standards for State and Local Planning (March 2011). Centers for Disease Control and Prevention (CDC). Accessed online at: http: //www. cdc. gov/phpr/capabilities/DSLR_capabilities_July. pdf Centers for Disease Control and Prevention Medical Countermeasure Operational Readiness Review Tool Budget Period 3 (2014). CDC. Accessed online at: https: //partner. cdc. gov/ Centers for Disease Control and Prevention Medical Countermeasure Operational Readiness Review Tool Budget Period 4 (2015). CDC. Accessed online at: https: //partner. cdc. gov/ Medical Countermeasure Operational Readiness Review and Project Public Health Ready Crosswalk. (2015). NACCHO. Accessed online at: http: //www. naccho. org/toolbox/tool. cfm? id=4692%20%20 http: //www. phaboard. org/

Questions? Joshua Pikora, MPH Emergency Response Coordinator Knox County Health Department 1361 W Fremont st. Galesburg, IL 61401 (309) 344 -2224 ext 238 jpikora@knoxcountyhealth. org