Public Health Accreditation Saving Naming and Describing Documents

Public Health Accreditation: Saving, Naming, and Describing Documents Susan Ramsey Pearls of Wisdom Consulting sramsey_1@comcast. net 253 -606 -0956 Lia Katz ASTHO lkatz@astho. org (202) 371 -9090 1

SAVING, NAMING, AND DESCRIBING DOCUMENTS 2

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Using the PHAB Guidance � Read the statement of the specific measure, including the “Intent” � Read each requirement carefully. You will need to validate that each of these requirements are present in the documentation to receive a score of “Fully Demonstrates” � Review the guidance section in detail and highlight every “active” verb statement � Review the PHAB acronyms and glossary and use to clarify definition of terms and how they are used in the PHAB Standards 4

Domains Cross all Programs Domains Programs Use of Quality Improvement Workforce Development Food Safety Program Health Policy & Plans On-site Septic Program Community Involvement Immunization Program Monitor Health Status Family Planning Program STD HIV/AIDS Programs 5

Selecting Documentation � Reflects the work of the health department � Representative of the entire range of programs and services (sources of documentation) � Most applicable to what the measure requires � Talk with peers when stuck 6

Many Types of Documentation � Written descriptions of process: policies and procedures, protocols, emergency response plan, manuals, flowcharts, logic models or other documentation � Reports: health data summaries, survey data summaries, data analysis, audit results, meeting agendas, committee minutes and packets, after-action evaluations, continuing education, tracking logs, work plans, financial reports, QI reports or other documentation � Materials: email, memorandum, letters, dated distribution lists, phone books, health alerts, Fax, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website screen prints, news releases, newsletters, posters, contracts or other documentation 7

Documentation Requirements � No “wet ink” - documents must be in use, not designed only for the review � Documents must show their effective date � No draft documents will be allowed � If no specific timeframe is cited, all documentation should be from the last five years � Standardized footer – name, date � Anyone as long as the document is in use by the health department (May require proof of the relationship) 8

Documentation Timeframes PHAB Standards Introduction page 5 � Annually – within the previous 14 months of documentation submission; � Current – within the previous 24 months of documentation submission; � Biennially – within each 24 -month period, at least, prior to documentation submission; � Regular – within a pre-established schedule, as determined by the health department; and � Continuing – activities that have existed for some time, are currently in existence, and will remain in the future 9

Preparing Documentation � PHAB’s handout, Preparing Documentation, has the details on: ◦ How to write a good Document Description or Measure Narrative; ◦ The rules on the types of characters allowed in document titles; ◦ The rules for character and word length in titles, Document Descriptions, and Measure Narratives. You must meet these length rules in order to upload your documents. �To check character or word count in Word, highlight the text you want to count; go to the Review tab in Word; click on Word Count in the left-most box of the menu ribbon. A box pops up with the info. To check title length, you have to cut and paste it into a Word document then check it per above instructions 10

Acceptable File Formats 11

Displaying Your Documents � Documents ◦ Include a title or cover page ◦ Highlight: �Title �Date �Text in the document that meets the measure �Page of … total pages in document if extracted ◦ Use only what you need to meet the standard � Websites ◦ Create screen shots of web sites 12

Folder Structure � � This is a screen shot of a common drive folder. We have mirrored PHAB’s Domain, Standard and Measure structure. Each measure folder, create a Doc_x subfolder for each instance of what PHAB calls required documentation. For example, Measure 1. 1. 1 of the Standards has three instances of required documentation, so it contains three Doc_x folders, numbered 1, 2 and 3. 13

Folder Structure � Put your documents into the correct Doc_x folder, along with its document description. � If you create a Measure Narrative, save it in the Measure folder, not a Doc folder, since it covers all the documents you submitted to prove the entire measure 14

Naming Files � Use a system that makes sense to you � Use a system so that you will know what is in a file and what it is for � Use a system so that anyone in your department who looks at the name will know what the file contains � Titles and descriptions 15

Document Naming Rules � It is likely that someone other than you will upload documents from your common drive into e-PHAB. They’ll depend on your document names to put them in the correct e-PHAB location. If you don’t follow the naming rules, you’ll be asked to spend extra time to rename everything you created � Include the date of the document to distinguish documents from one another, put it here, in this format � Titles may contain only letters, numbers, periods, commas and spaces – no underscores or other special characters 16

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Explaining Your Documentation There are three different ways e-PHAB allows us to explain how our documentation meets the measures: 1. 2. 3. A really descriptive document title A Document Description (we called this a “read-me” note) telling the reviewer why the document proves we meet the measure, and where to look in the document for the proof. Suggestion: Each of our documents must have a companion Document Description A Measure Narrative telling how multiple documents submitted for one measure work together to provide proof. These are optional, but recommended. Be conservative – do not assume a reviewer will understand your intentions 18

Preparing Document Narratives � Document title � Document description ◦ Identify documents ◦ 250 characters limit ◦ Describe document: what it is, what is in it, where the relevant section is ◦ 150 works limit � Measure narrative ◦ Explain how documents demonstrate the measure ◦ 10, 000 character limit (including spaces, punctuations) 19

E-PHAB Title Box Use the title boxes to provide a concise name for the document so the Site Visitors know what they are about to read ◦ Character Limit: 250 characters ◦ Required ◦ Letters, numbers and spaces 20

E-PHAB Description Boxes Use the description boxes to help provide the link between the Measure and the uploaded document for the Site Visitors ◦ Character Limit: 150 words ◦ Optional (recommended) �Describe how the document demonstrates conformity �Identify specific location within the document �Provide context if upload is part of a larger document �Describe the author, if not a health department document 21

E-PHAB Measure Narrative Use the measure narrative to explain to the Site Visitor the reason for selecting ALL documents submitted for the measure ◦ Size Limit: 10, 000 characters ◦ Optional (recommended) �Give context to the evidence �Describe how all evidence demonstrates conformity �Explain why the HD is using the documents 22

Tell Your Story… � Site reviewers will not be familiar with your HD or even your state � Provide short summary or note that describes your processes for the topic addressed by the measure � Be laser-focused on the specific requirement of that measure � State page number (or highlight with text box) where specific information addressing the measure is located if document more than three pages long � Provide only the documentation that is needed to demonstrate performance. More is not better! 23

Sample of a Read Me File Office Measure # How Meets Standard Office of Non-Infectious Conditions Epidemiology Measure 1. 1 S Non-Infectious Conditions Epidemiology is responsible for coordinating the production of The Health of Washington State report, a comprehensive assessment of trends in population health status, communicable disease, environmental health risks, health disparities, and access to critical health services. A sample of chapters from the 2007 update of The Health of Washington State is included for documentation of this measure. Additional chapters may be viewed at: http: //www. doh. wa. gov/hws/HWS 2007. htm. Written definitions and descriptions of the data used in The Health of Washington State are included at the top, righthand corner of each chapter. Additional description of the data sources is shown in Appendix B of the report. Where located in document Barrier analysis (qualitative data) is incorporated into most chapters off The Health of Washington State. An additional example of using qualitative date in assessment is the WIC Listens Project Report. NICE staff (Amira El-Bastawissi) provided epidemiological consultation and served as a project team member for this report. 24

E-PHAB’s Description Boxes 25

E-PHAB’s Description Boxes 26

E-PHAB’s Description Boxes 27