PRDA - B:Standards and Measures

Public Health Accreditation Board

STANDARDS

Measures

&

VERSION 1.0

APPLICATION PERIOD 2011-2012
APPROVED MAY 2011

Introduction
The Public Health Accreditation Board (PHAB) Standards and Measures document serves as the official standards, measures, required
documentation, and guidance blueprint for PHAB national public health department accreditation. These written guidelines are considered
authoritative and are in effect for the application period indicated on the cover page.

The Standards and Measures document provides guidance especially for public health departments preparing for accreditation, as well
as site visit teams that meet with health department staff and review documentation submitted by applicant health departments. It also
serves anyone offering consultation or technical assistance to health departments, including PHAB’s Board of Directors and staff as they
administer the accreditation program. This document will assist health departments and their Accreditation Coordinators as they select
documentation for each measure. It will direct the site visit team members in the review of documentation and in determining whether
conformity with a measure is demonstrated.

Credibility in accreditation results from consistent interpretation and application of defined standards and measures. The Standards and
Measures document sets forth the domains, standards, measures, and required documentation adopted by the PHAB Board of Directors.
The document also provides guidance on the meaning and purpose of a measure and the types and forms of documentation that are
appropriate to demonstrate conformity with each measure.

The Standards and Measures document provides assistance to health departments as they work to select the best evidence to serve as
documentation. It includes a “Purpose” statement for each standard and measure, a “Significance” statement for each measure, and
narrative guidance specific to each required documentation item. PHAB strongly recommends that the health department pay close
attention to this document when selecting the most appropriate documentation to meet a measure.
In general, a reference in this document to “the standards” includes references to the domains, the standards, the measures, and the
required documentation.

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Domains, Standards, and Measures
Domains are groups of standards that pertain to a broad group of public health services. There are 12 domains; the first ten domains
address the ten Essential Public Health Services. Domain 11 addresses management and administration, and Domain 12 addresses
governance.

Standards are the required level of achievement that a health department is expected to meet. Measures provide a way of evaluating if the
standard is met. Required documentation is the documentation that is necessary to demonstrate that a health department conforms to a
measure.
All of the standards are the same for Tribal, state and local health departments. The majority of the measures are the same for
Tribal, state and local health departments and these are designated with an “A” for “all.” Where the measure is specific to Tribal, state, or
local health departments, the measure addresses similar topics but has slight differences in wording or guidance and will be designated
with a “T” for Tribal health departments, “S” for state health departments, and “L” for local health departments. Some measures are
designated T/S, some are T/L, and some are S/L.
The structural framework for the PHAB domains, standards, and measures uses the following taxonomy:
Domain

Standard

Measure

Tribal, State, Local or ALL

(example – Domain 5)

(example – Standard 5.3)

(example – Measure 5.3.2)

(example – Measure 5.3.2 S for state health departments)
(example – Measure 5.3.2 L for local health departments)

(example – Measure 5.3.2 T for Tribal health departments)
(example – Measure 5.3.2 A for all health departments)

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Documentation
Health departments vary in size, organizational structure, scope of authority, resources, population served, governance, and geographic
region. PHAB’s standards, measures, and guidance for documentation apply to all health departments. PHAB does not intend to be
prescriptive about how or what the health department does to meet the standards and measures. The focus of the standards,
measures, and required documentation is “what” the health department provides in services and activities, irrespective of
“how” they are provided or through what organizational structure or arrangement.
Health departments are encouraged to use documentation from a variety of department programs. Both administrative and program
activities are appropriate for documentation to meet various measures. Documentation that is drawn from programs should be selected
from a variety of programs to illustrate department-wide activity. Documentation should include programs that address chronic disease
and should address the needs of the population in the jurisdiction that the health department has authority to serve.
There are many methods for development of the documents required in the standards. They may be developed by:
• health department staff,
• state health departments for use by local health departments,
• community partnerships or collaborations,
• partners such as non-profits and academic institutions, or
• contracted service providers.

The purpose of documentation review is to confirm that materials exist and are in use in the health department being reviewed, regardless
of who originated the material.
Additionally:
• In many cases a single department document is required (for example, a department-wide policy or procedure). Where
documentation requires examples, health departments must submit two examples, unless otherwise noted in the list of required
documentation or guidance for each measure.
• All documentation must be in effect and in use at the time of the final submission of documentation to PHAB.
• No draft documents will be accepted for review by PHAB.
• All documents must be signed and dated in order for reviewers to evaluate conformity to timeframes.
• Documentation submitted to demonstrate conformity to a measure does not have to be presented in a single document; several
documents may support conformity to a single measure. An explanation should be included that describes how the documents,
together, demonstrate conformity with the measure. The specific section(s) of the documents that addresses the measure should
be identified.
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• A single document may be relevant for more than one measure and may be submitted multiple times. The specific section(s) of
the document that addresses the measure should be identified.
• Documentation must directly address the measure. When selecting documentation, the health department should carefully
consider the standard and domain in which the measure is located, as well as the measure itself.
• Documentation should be limited to the most relevant to meet the documentation requirement; more is not better.
• Where documentation contains confidential information, the confidential information must be covered or deleted.
• Documents must be able to be submitted to PHAB electronically. Hard copies of documents must be scanned into an
electronic format for submission. PHAB will not keep hard copies of any documentation. This applies to documentation that is
submitted online to PHAB, as well as any additional documentation requested by the site visitors.

Generally, types of documentation that may be used to demonstrate conformity include:
• Examples of policies and processes: policies, procedures, protocols, standing operating procedures, emergency
response/business continuity plans, manuals, flowcharts, organization charts, and logic models.
• Examples of documentation for reporting activities, data, decisions: health data summaries, survey data summaries, data
analyses, audit results, meeting agendas, committee minutes and packets, after-action evaluations, continuing education
tracking reports, work plans, financial reports, and quality improvement reports.
• Examples of materials to show distribution and other activities: email, memoranda, letters, dated distribution lists, phone books,
health alerts, faxes, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website
screen prints, news releases, newsletters, posters, and contracts.

Further PHAB guidance concerning documentation can be found in the PHAB Documentation Guidance.

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Timeframes
Documentation used to demonstrate conformity with measures should be dated within the five years prior to the date of submission to
PHAB, unless otherwise directed in the measure, documentation requirements, or required documentation guidance. Other timeframes
are defined below and in the PHAB Acronyms and Glossary of Terms. There are references throughout the measures and required
documentation to timeframes, starting from the date of submission of the documentation to PHAB. For the purposes of consistency, these
are defined as:
• 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.

Quality Improvement
A goal of public health department accreditation is to promote high performance and continuous quality improvement. Domain 9 focuses
on the evaluation of all programs and interventions, including key public health processes, and on the implementation of a formal quality
improvement process that fosters a culture of quality improvement. Additionally, PHAB has incorporated the concept of continuous quality
improvement in the standards and measures and in the accreditation process.

PHAB Acronyms and Glossary of Terms
The PHAB Standards and Measures document is accompanied by a sourced PHAB Acronyms and Glossary of Terms for many of the
terms used in the Standards and Measures. The Glossary also contains a list of acronyms used in the standards. This companion
document offers assistance in understanding the standards and measures.
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Applicability of Public Health Accreditation Standards
The Public Health Accreditation Board (PHAB) is charged with administering the national public health department accreditation program.
To that end, PHAB’s scope of accreditation extends only to governmental public health departments operated by Tribes, states, local
jurisdictions, and territories.

Evaluate

a na g e

Diagnose
& Investigate

m

t

Link
to / Provide
Care

mM
te

en

Sy
s

Assure
Competent
Workforce

Monitor
Health

Research

Enforce
Laws
Develop
Policies

Inform,
Educate,
Empower
Mobilize
Community
Partnerships

PHAB’s public health department accreditation standards address the array of public health
functions set forth in the ten Essential Public Health Services. Public health department
accreditation standards address a range of core public health programs and activities
including, for example, environmental public health, health education, health promotion,
community health1, chronic disease prevention and control, communicable disease, injury
prevention, maternal and child health, public health emergency preparedness, access to
clinical services, public health laboratory services, management /administration, and
governance. Thus, public health department accreditation gives reasonable assurance of the
range of public health services that a health department should provide. The standards refer
to this broad range of work as health department processes, programs, and interventions.

While some public health departments provide mental health, substance abuse, primary
care, human, and social services (including domestic violence), these activities are not
considered core public health services under the ten Essential Public Health Services
framework used for accreditation purposes. PHAB’s scope of accreditation authority does not extend to these areas. Documentation from
these program areas will not be generally accepted for public health department accreditation. Similarly, documentation from health care
facilities and professional licensing programs and the administration of health care financing systems (e.g., Medicaid) cannot be used for
public health department accreditation purposes.
The Essential Public Health Services and Core Functions
Source: Core Public Health Functions Steering Committee,
Fall 1994

Public health activities may be provided directly by the health department or by another organization or entity through formal
arrangements, such as contracts, compacts, or memoranda of agreement. However, when public health functions are provided by another
entity, more than one entity, or through a partnership, the health department must demonstrate how the process, program, or intervention
is delivered and how the health department coordinates with the other providers.
Community health is a discipline of public health that is the study and improvement of the health-related characteristics of the relationships between people and their physical and
social environments. The term “community” in community health tends to focus on geographic areas rather than people with shared characteristics. From a community health
perspective, health is not simply a state free from disease but is the capacity of people to be resilient and manage life's challenges and changes. Community health focuses on a broad
range of factors that impact health, such as the environment (including the built environment), social structure, resource distribution (including, for example, access to healthful foods),
social capital (social cohesion) , and socio-economic status. A key approach or methodology of community health is the creation and empowerment of community partnerships to take
action that will improve the health of the community.  Community health partnerships include representation from a wide variety of sectors of the community, for example, recreation, the
faith community, law enforcement, city planners and policy makers, businesses, human and social services, as well as public health and health care providers.

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Sovereignty and Tribal Public Health Systems
There are 565 federally recognized Tribes (U.S. Federal Register) in the United States, each with a distinct language, culture, and
governance structure. Native American Tribes exercise inherent sovereign powers over their members and territory. Each federally
recognized Tribe maintains a unique government-to-government relationship with the U.S. Government, as established historically and
legally by the U.S. Constitution, Supreme Court decisions, treaties, and legislation. No other group of Americans has a defined
government-to-government relationship with the U.S. Government. See U.S. Constitution Article I, Section 8.

Treaties signed by Tribes and the federal government established a trust responsibility in which Tribes ceded vast amounts of land and
natural resources to the federal government in exchange for education, healthcare, and other services to enrolled members of federally
recognized Tribes. The Indian Health Service (IHS), among other federal agencies, is charged with performing the function of the trust
responsibility to American Indians and Alaska Natives. (See Section 3 of the Indian Health Care Improvement Act, as amended, 25
U.S.C. § 1602.) Public Law 93-638, the Indian Self-Determination and Educational Assistance Act of 1975 (ISDEAA), provides the
authority for Tribes (includes Alaska Native villages, or regional or village corporations, as defined in or established pursuant to the Alaska
Native Claims Settlement Act) to enter into contracts or compacts, individually or through Tribal organizations, with the Secretary of Health
and Human Services to administer the health programs that were previously managed by the Indian Health Service. More than half of the
Tribes exercise this authority under the ISDEAA and have established Tribal Health Departments to administer these programs, which are
often supplemented by other public health programs and services through Tribal funding and other sources.

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Format for the Standards and Measures
In this document, the PHAB Standards and Measures are preceded by the domain number and brief description of the domain. Standards
are repeated at the beginning of each measure for easy reference. The chart below provides an example of the layout for standards,
measures, required documentation and guidance for required documentation.

Standard: This is the standard to which the measure applies.
Measure

Purpose

Significance

This section states the measure on which the
health department is being evaluated.

The purpose of this measure is to assess the
health department’s . . .

This section describes the necessity for the
capacity or activity that is being assessed.

Required Documentation
This section lists the documentation that the
health department must provide as evidence
that it is in conformity with the measure.
The documentation will be numbered:
1. Xxx
2. Xxx
a) xxx
b) xxx

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This section describes the public health
capacity or activity on which the health
department is being assessed.

Guidance

This section provides guidance specific to the required documentation. Types of materials may
be described, e.g., meeting minutes, partnership member list, etc. Examples may also be
provided here.
This section will state if the documentation is department-wide or if a selection of programs’
documentation is required.
1. Xxx
2. Xxx
a) xxx
b) xxx

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Domain 1: Conduct and disseminate assessments focused on population health status and
public health issues facing the community
Domain 1 focuses on the assessment of the health of the population in the jurisdiction served by the health department. The domain includes:
systematic monitoring of health status; collection, analysis, and dissemination of data; use of data to inform public health policies, processes, and
interventions; and participation in a process for the development of a shared, comprehensive health assessment of the community.

DoMAIn 1 InCluDeS Four STAnDArDS:
Standard 1.1
Standard 1.2
Standard 1.3
Standard 1.4

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Participate in or Conduct a Collaborative Process Resulting in a Comprehensive Community Health Assessment

Collect and Maintain Reliable, Comparable, and Valid Data That Provide Information on Conditions of Public
Health Importance and On the Health Status of the Population
Analyze Public Health Data to Identify Trends in Health Problems, Environmental Public Health Hazards, and
Social and Economic Factors That Affect the Public’s Health
Provide and Use the Results of Health Data Analysis to Develop Recommendations Regarding Public Health
Policy, Processes, Programs, or Interventions

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STAnDArD 1.1: PArTICIPATe In or ConDuCT A
CollABorATIVe ProCeSS reSulTInG In A
CoMPreHenSIVe CoMMunITY HeAlTH ASSeSSMenT.
The purpose of the community health assessment is to learn about the health status of the population.
Community health assessments describe the health status of the population, identify areas for health

improvement, determine factors that contribute to health issues, and identify assets and resources that
can be mobilized to address population health improvement. Community health assessments are

developed at the Tribal, state, and local levels to address the health of the population in the jurisdiction
served by the health department.

A community health assessment is a collaborative process of collecting and analyzing data and information
for use in educating and mobilizing communities, developing priorities, garnering resources, and planning

actions to improve the population’s health. The development of a population health assessment involves the
systematic collection and analysis of data and information to provide the health department and the

population it serves with a sound basis for decision-making and action. Community health assessments are
conducted in partnership with other organizations and include data and information on demographics;
socioeconomic characteristics; quality of life; behavioral factors; the environment (including the built

environment); morbidity and mortality; and other social, Tribal, community, or state determinants of health
status. The Tribal, state, or local community health assessment will be the basis for development of the
Tribal, state, or local community health improvement plan.

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Standard 1.1: Participate in or conduct a collaborative process
resulting in a comprehensive community health assessment.
Measure
1.1.1 S
Participate in or conduct a state partnership
that develops a comprehensive state
community health assessment of the
population of the state

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Purpose

Significance

The purpose of this measure is to assess the
state health department’s collaborative
process for sharing and analyzing data
concerning state health status, state health
issues, and state resources towards the
development of a state level community
health assessment.

The development of a community health
assessment requires partnerships with other
organizations in order to access data, provide
various perspectives in the data analysis,
present data and findings, and share a
commitment for using the data. Assets and
resources in the state should be addressed in
the assessment, as well as health status
challenges. Data are provided from a variety
of sources and through various methods of
data collection.

Required Documentation

Guidance

1. Participation of representatives of various
sectors

1. The state health department must provide documentation that the process for the
development of a state level community health assessment includes participation of partners
outside of the health department that represent state populations and state health challenges.
The collaboration could include, but not be limited to, representatives of local or regional
health departments in the state, representatives of Tribal health departments in the state,
hospitals and healthcare providers, academic institutions, other departments of government,
and statewide non-profits (for example, Kids Count, Childhood Death Review organizations,
Cancer Society, environmental public health groups, etc.). A membership list and meeting
attendance records could provide this documentation.

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Measure 1.1.1 S, continued

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Required Documentation

Guidance

2. Regular meetings or communications with
partners

2. The state health department must document that the partnership meets or communicates
throughout the process on a regular basis to consider new data sources, review newly
collected data, consider changing assets and resources, and conduct additional data
analysis. The frequency of meetings or communications is determined by the partnership and
may change, as required by the process. Meetings and communications may be in-person,
via conference calls, or via other communication methods, such as email, list serves or other
electronic methods. Meeting agenda, meeting minutes, and copies of emails could provide
this documentation.

3. Description of the process used to identify
health issues and assets

3. The state health department must provide documentation of the collaborative process to
identify and collect data and information, identify health issues, and identify existing state
assets and resources to address health issues. The process used may be an accepted state
or national model; a model from the public, private, or business sector; or other participatory
process model. Examples of models include: Mobilizing for Action through Planning and
Partnership (MAPP), Healthy Cities/Communities, or Community Indicators Project. Examples
of other tools and processes that may be adapted for the assessment include: community
asset mapping, National Public Health Performance Standards Program (NPHPSP),
Assessment Protocol for Excellence in Public Health (APEX/PH), Healthy People 2020, and
Protocol for Assessing Community Excellence in Environmental Health (PACE-EH).

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.1: Participate in or conduct a collaborative process
resulting in a comprehensive community health assessment.
Measure
1.1.1 T/L
Participate in or conduct a Tribal/local
partnership for the development of a
comprehensive community health
assessment of the population served by the
health department

13

Purpose

Significance

The purpose of this measure is to assess the
health department’s collaborative process for
sharing and analyzing data concerning health
status, health issues, and community
resources to develop a community health
assessment of the population of the
jurisdiction served by the health department.

The development of a Tribal/local level
community health assessment requires
partnerships with other members of the
Tribe/community to access data, provide
various perspectives in the data analysis,
present data and findings, and share a
commitment for using the data. Assets and
resources in the Tribal/local community should
be addressed in the assessment, as well as
health status challenges. Data are provided
from a variety of sources and through various
methods of data collection.

Required Documentation

Guidance

1. Participation of representatives of various
sectors of the Tribal or local community

1. The health department must provide documentation that the process for the development of a
community health assessment included participation of partners outside of the health
department that represent Tribal/community populations and health challenges. The
collaboration could include hospitals and healthcare providers, academic institutions, local
schools, other departments of government, community non-profits, and the state health
department. Tribal health departments may include local health department representatives,
and local health departments may include Tribal health department representatives. A
membership list and meeting attendance records could provide this documentation.

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Measure 1.1.1 T/l, continued

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Required Documentation

Guidance

2. Regular meetings

2. The health department must document that the partnership meets or communicates on a
regular basis to consider new data sources, review newly collected data, consider changing
assets and resources, and conduct additional data analysis. The frequency of meetings or
communications is determined by the partnership and may change, depending on the stage
of the process. Meetings and communications may be in-person, via conference calls, or via
other communication methods, such as email, list serves or other electronic methods.
Meeting agenda, meeting minutes, and copies of emails could provide this documentation.

3. Description of the process used to identify
health issues and assets

3. The health department must provide documentation of the collaborative process to identify
and collect data and information, identify health issues, and identify existing Tribal or local
assets and resources to address health issues. The process used may be an accepted state
or national model; a model from the public, private, or business sector; or other participatory
process model. Examples of models include: Mobilizing for Action through Planning and
Partnership (MAPP), Healthy Cities/Communities, or Community Indicators Project. Examples
of other tools and processes that may be adapted for the community assessment include:
community asset mapping, National Public Health Performance Standards Program
(NPHPSP), Assessment Protocol for Excellence in Public Health (APEX/PH), Healthy People
2020, and Protocol for Assessing Community Excellence in Environmental Health (PACE-EH).

Public Health Accreditation Board • Standards & Measures

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Standard 1.1: Participate in or conduct a collaborative process
resulting in a comprehensive community health assessment.
Measure
1.1.2 S
Complete a state level community health
assessment

Significance

The purpose of this measure is to assess the
state health department’s completion of a
comprehensive state level community health
assessment of the population of the state.

The state level community health assessment
provides a foundation for efforts to improve
the health of the population. It is a basis for
setting priorities, planning, program
development, funding applications,
coordination of resources, and new ways to
collaboratively use assets to improve the
health of the population. A community health
assessment provides the general public and
policy leaders with information on health
status of the population and existing assets
and resources to address health issues. The
population health assessment provides the
basis for the development of the state health
improvement plan.

Required Documentation

Guidance

1. A state level community health assessment
dated within the last five years that
includes:

1. The state health department must provide documentation that identifies and describes the
state’s health status and areas of health improvement, the factors that contribute to the health
challenges, and the existing resources that can be mobilized to address them. The state’s
community health assessment must be dated within the last five years and include all of
the following:
a. Evidence that comprehensive, broad-based data and information from a variety of
sources were used to create the state health assessment. Sources may include: federal,
Tribal, state, and local data, hospitals and healthcare providers, schools, academic

a. Documentation that data and
information from various sources
contributed to the community
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Purpose

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Measure 1.1.2 S, continued

Required Documentation

Guidance

health assessment and how the
data were obtained

institutions, other departments of government (education, transportation, etc.),
statewide non-profits, surveys, asset mapping, focus groups, town forums and
listening sessions, and other data sources, such as the County Health Rankings.
The assessment must include both primary and secondary data.
b. A description of the demographics of the population served by the state health
department, such as gender, race, age, income, disabilities, mobility (travel time to
work or to health care), educational attainment, home ownership, employment
status, etc.
c. A narrative description of the health issues in the state and their distribution, based
on analyses of the data listed in a) above. The description should include heath
issues of the uninsured/low income and minority populations.

b. A description of the demographics
of the population

c. A general description of health
issues and specific descriptions of
population groups with particular
health issues
d. A description of contributing
causes of state health challenges

d. A discussion of the contributing causes of the health challenges, such as behavioral
risk factors, environmental (including the built environment), socio-economic factors,
morbidity and mortality, injury, maternal and child health, communicable and chronic
disease, and other unique characteristics of the state that affect health status. Health
status disparities, health equity, and high health-risk populations must be addressed.
e. A listing or description of state assets that can be mobilized and employed to
address health issues. These may include other sectors. For example, a state parks
system can encourage physical activity. Similarly, a department of agriculture can
promote healthful eating, and a state educational policy can encourage the provision
of health education.

e. A description of state assets or
resources to address health issues

2. Documentation that the state population at
large has had an opportunity to review
drafts and contribute to the community
health assessment

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2. The health department must provide documentation that preliminary findings of the state level
community health assessment were distributed to the population at large and that their input
was sought. Methods to seek input include: publication of a summary of the findings in the
press with feedback or comment forms, town forums, listening sessions, website comment
forms, newsletters, etc.

Public Health Accreditation Board • Standards & Measures

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Standard 1.1: Participate in or conduct a collaborative process
resulting in a comprehensive community health assessment.
Measure

1.1.2 T/L
Complete a Tribal/local community health
assessment

Significance

The purpose of this measure is to assess the
Tribal or local health department’s completion
of a comprehensive community health
assessment of the population of the
jurisdiction served by the health department.

The Tribal or local community health
assessment provides a foundation for efforts to
improve the health of the population. It is a
basis for setting priorities, planning, program
development, funding applications,
coordination of community resources, and new
ways to collaboratively use community assets
to improve the health of the population. A
community health assessment provides the
general public and policy leaders with
information on health status of the population
and existing assets and resources to address
health issues. The health assessment provides
the basis for development of the Tribal/local
community health improvement plan.

Required Documentation

Guidance

1. A Tribal or local community health
assessment dated within the last five years
that includes:

1. The health department must provide documentation that identifies and describes the Tribe or
community health status and areas for health improvement, the factors that contribute to the
health challenges, and the existing community resources that can be mobilized to address
them. The health assessment must be dated within the last five years and include all of
the following:
a. Evidence that comprehensive, broad-based data and information from a variety of
sources were used to contribute to the health assessment. Sources may include:
federal, Tribal, state, and local data; hospitals and health care providers; local
schools; academic institutions; other departments of government (recreation, public
safety, etc.); community non-profits; surveys, asset mapping, focus groups, town

a. Documentation that data and
information from various sources
contributed to the community
health assessment and how the
data were obtained
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Purpose

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Measure 1.1.2 T/l, continued
Required Documentation

Guidance
forums and listening sessions; and other data sources such as the County Health
Rankings. The assessment must also include both primary data and secondary data.
Non-traditional and non-narrative data collection techniques are acceptable. For
example, an assessment may include photographs taken by members of the Tribe or
community in an organized assessment process to identify environmental (including
the built environment) health challenges.
b. A description of the demographics of the population of the jurisdiction served by the
local health department, such as gender, race, age, income, disabilities, mobility
(travel time to work or to health care), educational attainment, home ownership,
employment status, etc.
c. A narrative description of the health issues of the population and the distribution of
health issues, based on the analysis of data listed in a) above. The description
should include heath issues of the uninsured/low income and minority populations.
d. A discussion of the contributing causes of the health challenges, including:
behavioral risk factors, environmental (including the built environment), socioeconomic factors, morbidity and mortality, injury, maternal and child health,
communicable and chronic disease, and other unique characteristics of the
community that impact on health status. Health status disparities, health equity, and
high health-risk populations must be addressed.
e. The assessment must include a listing or description of the assets and resources that
can be mobilized and employed to address health issues. These may include other
sectors. For example, a local park can encourage physical activity. Similarly, local
farmers’ markets can be vehicles to promote healthful eating, and a school district
can partner with the health department to provide health education.

b. A description of the demographics
of the population

c. A general description of health
issues and specific descriptions of
population groups with particular
health issues
d. A description of contributing
causes of community health issues

e. A description of existing
community or Tribal assets or
resources to address health issues

2. Documentation that the Tribal or local
community at large has had an opportunity
to review and contribute to the assessment

18

2. The department must provide documentation that preliminary findings of the assessment
were distributed to the community at large and that the community’s input was sought.
Methods to seek community input include: publication of a summary of the findings in the
local press with feedback or comment forms, publication on the health department’s web
page and website comment form, community/town forums, listening sessions, newsletters,
presentations and discussions at other organizations’ local meetings, etc.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.1: Participate in or conduct a collaborative process
resulting in a comprehensive community health assessment.
Measure
1.1.3 A
Ensure that the community health assessment
is accessible to agencies, organizations, and
the general public

19

Purpose

Significance

The purpose of this measure is to assess the
Tribal, state, or local health department’s
efforts to share the community health
assessment with other agencies and
organizations and to make the assessment
results available to the general public.

The community health assessment is a
resource for all members of the public health
system and the population at large. It is a
basis for collaborations in priority setting,
planning, program development, funding
applications, coordination of resources, and
new ways to collaboratively use assets to
improve the health of the population. Other
governmental units and non-profits will use
the community health assessment in their
planning, program development, and
development of funding applications.

Required Documentation

Guidance

1. Documentation that the community health
assessment has been distributed to partner
organizations

1. Health departments must provide two examples of how the community health assessment is
distributed to partners, stakeholders, other agencies, entities, and organizations. Samples of
emails to partners and stakeholders providing information of how to access the assessment
could be provided.

2. Documentation that the community health
assessment and/or its findings have been
made available to the population of the
jurisdiction served by the health department

2. Health departments must provide two examples of how they communicated the community
health assessment results to the public. Documentation of distribution to libraries could
provide evidence, as could the publication of the community health assessment on the
department’s websites. Summaries of the findings could also be published in newspapers.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STAnDArD 1.2: ColleCT AnD MAInTAIn relIABle,
CoMPArABle, AnD VAlID DATA THAT ProVIDe InForMATIon
on ConDITIonS oF PuBlIC HeAlTH IMPorTAnCe AnD on
HeAlTH STATuS oF THe PoPulATIon.
Reliable data are key building blocks of public health. Health departments must gather timely and accurate
data to identify health needs, develop and evaluate programs and services, and determine resources.

Health departments require reliable and valid data that can be compared between populations and across
time. To best use the information available, health departments require a functional system for collecting
data within their jurisdiction and for managing, analyzing, and using the data.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance
and on the health status of the population.
Measure
1.2.1 A
Maintain a surveillance system for receiving
reports 24/7 in order to identify health
problems, public health threats, and
environmental public health hazards

Purpose

Significance

The purpose of this measure is to assess the
health department’s capacity to receive and
monitor reports on the health status and
health issues of the population in a
standardized, systematic manner.

Surveillance is the systematic monitoring of
health status of a population. A surveillance
system provides data required to assess the
public’s health status. Surveillance data are
used to estimate the magnitude of a public
health problem, determine the geographic
distribution of an identified problem, detect
emerging problems, develop priorities,
develop public health responses, and
evaluate changes in infectious agents and
non-infectious health problems.

Required Documentation

Guidance

1. Processes and/or protocols to maintain the
comprehensive collection, review, and
analysis of data on multiple health
conditions from multiple sources

1. The health department must provide written processes and/or protocols to collect
comprehensive data from multiple sources and to review and analyze those data. Processes
and protocols must include how data are collected, such as fax, emails, web reports, phone
calls to the health department or to another site, such as emergency management or a 9-1-1
call center. The surveillance system must be able to receive reports at any time. The health
department defines from whom the reports are received.
A Tribal surveillance system may include a diverse set of partners, including, but not limited
to, federal entities, Tribal epidemiology centers, local and state health departments, or other

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.2.1 A, continued

Required Documentation

Guidance
system partners. Since many Tribal surveillance systems include multiple partners outside of
the Tribe, MOUs, MOAs or other formal written agreements may be used as documentation to
demonstrate processes, protocols, roles and responsibility, confidentiality protection (2 below)
and reporting.

22

2. Processes and/or protocols to assure
data are maintained in a secure and
confidential manner

2. The written processes and/or protocols must specify which surveillance data are and are not
confidential and assure that confidential data are maintained and handled in a secure and
confidential manner.

3. Current 24/7contact information

3. The health department must provide current 24/7 contact information. This may be a
designated telephone line (voice or fax), email addresses, or ability to submit a report on the
health department’s website. There may be a designated contact person for the health
department or a list of contacts. The list may be a call-down list that is used if the primary call
is received off-site or by another organization. Reports may be received by a contractor or by
a call center (for example a poison control center), or via regional or state agreements. If there
is a contract or other form of agreement to provide such services, the contract or agreement
must be submitted as part of the documentation.

4. Reports of testing 24/7 contact systems

4. The health department must provide reports of testing the 24/7 contact system. The health
department determines how the system is tested and the frequency of such testing (which
should also be defined in the processes and/or protocols). The testing process can include
receipt of a sample report by the various elements of the system. For example, if the system is
set up to receive reports by internet, fax, email and a designated phone line, then all elements
must be tested to ensure the ability to receive reports.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance
and on the health status of the population.
Measure
1.2.2 A
Communicate with surveillance sites at least
annually

23

Purpose

Significance

The purpose of this measure is to assess the
health department’s regular contact with sites
who report surveillance data to the health
department.

The department ensures that sites are
providing timely, accurate, and
comprehensive data by communicating with
them at least annually about their surveillance
responsibilities.

Required Documentation

Guidance

1. Identification of providers and public health
system partners who are surveillance sites
reporting to the surveillance system

1. The health department must provide a list of the individuals or organizations that provide
surveillance data to the health department. These will be health care providers, schools,
laboratories, Tribal epidemiology centers, and other public health system partners who report
to the health department’s surveillance system.

2. Documentation of trainings/meetings held
with surveillance sites regarding reporting
requirements, reportable
diseases/conditions, and timeframes

2. The health department must provide at least one example of a training or a meeting held with
surveillance site members regarding reporting requirements, reportable diseases/conditions,
and timeframes. Records must include when the training or meeting was held, who attended
the training, and what topics were covered. Sign-in sheets and agendas could provide
this documentation.

3. Surveillance data concerning two different
topics by reporting sites

3. The health department must provide two examples of reports of surveillance data that
address two different topics (for example, reports of flu cases, animals with confirmed rabies,
or environmental public health monitoring data) itemized by reporting site.

4. Documentation of distribution of
surveillance data

4. The health department must provide documentation of the distribution of surveillance data to
others. Documentation may be copies of emails, documented phone calls, newsletters,
presentations, and meetings.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance and on the
health status of the population.
Measure
1.2.3 A
Collect additional primary and secondary
data on population health status

Purpose

Significance

The purpose of this measure is to assess the
health department’s collection of public health
status data other than surveillance data.

Data collected by the health department
(primary data) provides data specific to the
health department’s priorities and plans. It is
important that health departments collect
primary data to provide insights into particular
health issues in the community. Data collected
by others (secondary data) can be very useful
in assessing the health status of the
population. These two types of data used
together can provide a robust comprehension
of the contributing factors to specific health
issues of the community or state, as well as
provide information about the overall health of
the population.
The scope of public health data assessment
is broad and includes collection of information
by other Tribal, state, and local departments,
health agencies, and partners on
communicable disease (food/water/air/
waste/vector-borne), injuries (including
needle-stick injuries), chronic
disease/disability and morbidity/mortality
for the purpose of analysis and use in health
data reports.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.2.3 A, continued

Required Documentation

Guidance

1. Documented aggregated primary and
secondary data collected and the sources
of each

1. The health department must provide two reports, each of which aggregates primary and
secondary data. That is, each report must include data that have been collected by the health
department (or by others under contract or on behalf of the department) and data collected by
others (governmental departments or levels of government, academic institutions, non-profits, or
other researchers). The sources of the data used for each report must also be provided.
Primary data are collected by or on behalf of the health department. Examples of primary data
include: communicable disease reports, healthcare provider reports of occupational conditions,
and environmental public health hazard reports. Other primary data sources include:
community surveys, registries, vital records and other methods of tracking chronic disease and
injuries, as well as focus groups and other methods for qualitative data.
Secondary data are data published or collected in the past by other parties. Examples include:
data from other governmental departments, such as law enforcement, EPA, OSHA, Bureau of
Labor Statistics, and workers’ compensation bureaus. It may include: graduation rates, Census
data, hospital discharge data, Behavioral Risk Factor Surveillance System data, and academic
research data.

2. Documentation of standardized data
collection instruments

2. The health department must provide two examples of standardized data collection instruments
that they have used. These two examples must collect data in two different program areas.
Standardized instruments are those that are recognized as national, state-wide, or local
collection tools. They may also be standardized from the standpoint that the same tool was used
with all respondents, such as a local survey developed and distributed to a representative
sample of potential respondents. The tool may collect quantitative or qualitative data. The health
department can provide the tools used for the required documentation listed under the first
required documentation for this measure. Or they can be examples from different data collection
activities, showcasing four different data sets.
Tribes often use qualitative data collection methods, such as focus groups, interviews and other
methodologies with elders, traditional healers, or ceremonial/cultural leaders. Documentation of

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.2.3 A, continued

Required Documentation

Guidance
qualitative data collection using indigenous methodologies of this type of data and methodology
are acceptable. Cultural adaptations of nationally or state-wide recognized data collection tools
and methods can be included as examples of data collection instruments. Tribal specific data
collection tools that are nationally recognized may or may not exist, in which case, Tribal surveys
adapted for their communities should be accepted.

26

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance and on the
health status of the population.
Measure
1.2.4 S
Provide reports of primary and secondary
data to Tribal and local health departments
located in the state

Purpose

Significance

The purpose of this measure is to assess the
state health department’s role in and process
for sharing data with Tribal and local health
departments located in the state.

Tribal and local health departments should
have access to data that pertains to the health
status of the population they serve. States
should have a process in place to share data
that they have collected or to which they
have access.

Required Documentation

Guidance

1. Written reports to local health departments

1. The state health department must provide two examples of reports of primary and secondary
data that it has distributed to local health departments located in the state.

2. Written reports to Tribal health departments
in the state (if one or more is located in
the state)

2. If there is one or more Tribal health departments located in the state, the state health
department must provide two examples of reports of primary and secondary data that it has
distributed to the Tribal health department located in the state.
For documenting 1 and 2 above, data can be aggregate for the state, the Tribal or local
health department, or for a region of the state. Examples can include data collected at the

27

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.2.4 S, continued

Required Documentation

Guidance
local level and submitted to the state. Some data may be available only at a regional or state
level because some local populations are small, and the small data set could impact the
statistical power and/or compromise confidentiality. Data distributed may be in electronic or
hard copy format. Examples include: registries, such as cancer registries or immunization
registries; vital records reports; environmental public health data; or data in web-based
communicable disease reporting systems. The reports may also address social conditions
that affect the health of the population served, such as unemployment, poverty, or lack of
accessible facilities for physical activity.
Documentation showing distribution of these reports to local and Tribal health departments may
include distribution lists, distribution protocols, email confirmation of receipt of reports, etc.

28

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance and on the
health status of the population.
Measure
1.2.4 L
Provide reports of primary and secondary
data to the state health department and Tribal
health departments in the state

Purpose

Significance

The purpose of this measure is to assess local
health department’s role and process for
sharing data with their state health
departments and nearby Tribal health
departments.

State health departments should have access
to local data that pertains to health status of
the state’s population. Likewise, Tribal health
departments should have access to local data
that pertains to the health status of the Tribe’s
population. Local health departments should
have a process in place to share local data to
which they have access with the state and
nearby Tribes (if applicable).

Required Documentation

Guidance

1. Reports of data to the state health
department and to a Tribal health
department (if one or more is located in
the state)

1. The local health department must submit two examples of reports of primary and secondary
data that it has provided to the state health departments and one report of primary and
secondary data that it has provided to local Tribal health departments. Local health
departments that do not have jurisdictions that overlap with the Tribal health departments do
not have to demonstrate that they share local data with Tribes, but must provide documented
evidence that there is no jurisdictional overlap. Data distributed may be in electronic or hard
copy format. Examples include: registries, such as cancer registries or immunization
registries; vital records reports; environmental public health data; or data in web-based
communicable disease reporting systems. The reports may also address social conditions
that affect the health of the population served, such as unemployment, poverty, or lack of
accessible facilities for physical activity.
Documentation showing distribution of these reports to state and Tribal health departments may
include distribution lists, distribution protocols, email confirmation of receipt of reports, etc.

29

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.2: Collect and maintain reliable, comparable, and valid data that
provide information on conditions of public health importance and on the
health status of the population.
Measure
1.2.4 T
Provide reports of primary and secondary
data to the state health department and local
health departments in the state

Purpose

Significance

The purpose of this measure is to assess Tribal
health department’s role and process for
sharing data with the state health departments
and nearby local health departments.

Tribal health departments should have access
to data that pertains to health status of the
state’s population. Likewise, state and local
health departments should have access to Tribal
data that pertains to the health status of the
state population and nearby communities. Tribal
health departments should have a process in
place to share relevant Tribal health data to
which they have access with the state and
nearby local health departments (if applicable).

Required Documentation

Guidance

1. Reports of data to the state health
department and one example of reports of
data to a local health department

1. The Tribal health department must provide two examples of reports of primary and secondary
data that it has provided to the state health departments and one report of primary and
secondary data that it has provided to a local health department. Tribal health departments
that do not have jurisdictions that overlap with local health departments do not have to
demonstrate that they share Tribal data with local health departments, but must provide
documented evidence that there is no jurisdictional overlap. Data distributed may be in
electronic or hard copy format. Examples include: registries, such as cancer registries or
immunization registries; vital records reports; environmental public health data; or data in
web-based communicable disease reporting systems. The reports may also address social
conditions that have an impact on the health of the population served, such as
unemployment, poverty, or lack of accessible facilities for physical activity.
Documentation showing distribution of these reports to state and local health departments
may include distribution lists, entries in registries, faxed paper reports, distribution protocols,
email confirmation of receipt of reports, etc.

30

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STAnDArD 1.3: AnAlYZe PuBlIC HeAlTH DATA To IDenTIFY
TrenDS In HeAlTH ProBleMS, enVIronMenTAl PuBlIC
HeAlTH HAZArDS, AnD SoCIAl AnD eConoMIC FACTorS
THAT AFFeCT THe PuBlIC’S HeAlTH.
Data analysis involves the examination and interpretation of data with the goal of drawing conclusions that

inform planning, decision making, program development, and evaluation. The purpose of data analysis is to
identify and understand current, emerging, or potential health problems or environmental public health

hazards. Data can identify trends in behaviors, disease incidence, opinions, and other factors that aid in
understanding health issues and in designing and evaluating programs and interventions.

31

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.3: Analyze public health data to identify trends in health problems,
environmental public health hazards, and social and economic factors
that affect the public’s health.
Measure
1.3.1 A
Analyze and draw conclusions from public
health data

32

Purpose

Significance

The purpose of this measure is to assess the
health department’s capacity to analyze and
utilize public health data to identify trends
over time, clusters, health problems,
behavioral risk factors, environmental public
health hazards, and social and economic
conditions that affect the public’s health.

Valid analysis of data is important for
assessing the contributing factors, magnitude,
geographic location(s), changing
characteristics, and potential interventions of
a health problem. This analysis is critical for
program design and for evaluation of
programs aimed at continuous quality
improvement.

Required Documentation

Guidance

1. Reports containing analysis of data
collected and conclusions from review of
the data with the following characteristics:

1. The health department must provide two examples of reports, each containing analysis and
conclusions drawn from data. Data reports used in the analysis are not required, but
evidence of the health department’s analysis and conclusions is required. Examples of
reports include: epidemiologic reports, workplace fatality or disease investigation reports,
cluster identification or investigation reports, outbreak investigation reports, environmental
and occupational public health hazard reports, population health status or key health
indicator reports, community survey results and conclusions, outbreak after action reports,
reports of hospital data, reports of non-profit organizations’ data (for example, poison control
center data or child health chart book), health disparities reports, environmental justice

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.3.1 A, continued

Required Documentation

Guidance
reports, and community health indicator reports. Since Tribal Epidemiology Centers provide
surveillance data, analysis and reporting on behalf of the Tribes, one example of Tribal
Epidemiology Center reports may be used as documentation. However, these reports should
not be the sole source of surveillance data collection and analysis. The Tribal health
department must provide another example of data analysis and reporting from in-house that
clearly focuses on specific Tribal indicators, conditions and data.

a. Reports are within defined
timelines based on policy
guidelines and/or evidence-based
practice

Program examples could include an After Action Report for an H1N1 outbreak, an investigation
report for a food borne disease outbreak involving a local restaurant, environmental hazard
trends with arsenic in well water, or a trends report of all reported communicable diseases over
the past five years. The reports may also point out social conditions that have an impact on the
health of the population served, such as unemployment, poverty, or lack of accessible facilities
for physical activity.
a. Data used in the report must be distinct to a specific time period, such as fiscal year
08-09, calendar year 2008, years 2003-2007. The type of analytic process used must
be stated in the report and/or be evidence-based with the citation available. The intent
is to have conclusions based on solid analysis, not just collections of data.
b. The analysis and conclusions must have the quality of comparability. The reports
should compare data to (1) other similar socio-geographic areas, sub-state areas, the
state, or nation, or (2) similar data for the same population gathered at an earlier time to
establish trends. Examples of trend analysis are conclusions based on rates of sexually
transmitted diseases over the past five years, or childhood immunization rates over the
past eight quarters.

b. Reports compare data to other
agencies and/or the state or nation,
and/or other Tribes, and/or similar
data over time to provide trend
analysis

2. Documentation of meetings to review and
discuss selected data reports

33

2. The health department must provide documentation of review of data analysis reports. Minutes
or documentation of meetings must be provided to show the presentation, review and
discussion of data reports. The meetings may be internal, with governing entities, with
community groups, with other health or social service organizations, or provided to elected
bodies.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.3: Analyze public health data to identify trends in health problems,
environmental public health hazards, and social and economic factors
that affect the public’s health.
Measure
1.3.2 S
Provide statewide public health data to
various audiences on a variety of public
health issues at least annually

Purpose

Significance

The purpose of this measure is to assess the
state health department’s provision of
statewide public health data and analysis to
various audiences in the state.

Governmental and other public data about the
health of the state’s population should be
shared with others in the state. Other
organizations cannot effect change if they are
not aware of the status of the health of the
state. Sharing data can lead to partnerships to
address public health issues.

Required Documentation

Guidance

1. Two examples of analytic reports designed
to address public health issues, distributed
to specific audiences with proof of
distribution

1. The state health department must document the distribution of two analytical public health
reports to specific audiences in the state. Reports must be provided at least annually, so the
two examples must be from two different years.
Each report should include data on one or more specific public health issues, such as health
behaviors; disease clusters or trends; or health indicators, such as infant mortality rate.
Distribution of the reports may be targeted to a variety of audiences, including: public health
and health care providers, employers, governing entity, labor unions and other public health
stakeholders, partners, and the public.

34

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.3.2 S, continued

Required Documentation

Guidance
The documentation could provide evidence of a range of methods of distributions, including:
mailing lists, email lists, presentations, workshops, web postings, meeting minutes, published
editorials, and press releases.
The report itself does not have to be distributed, but the contents must be communicated.
Thus, while distribution of a hard copy of the report meets the requirement of the measure, so
could a verbal presentation to an audience of the contents of the report.
The report does not have to be produced by the state health department. The state health
department could use reports produced by CDC, or other federal government agencies, an
academic institution, or other organization. However, reports developed by others must have
a connection to the state and the state’s population and contain information of public health
significance.

35

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.3: Analyze public health data to identify trends in health problems,
environmental public health hazards, and social and economic factors
that affect the public’s health.
Measure
1.3.2 L
Provide public health data to the community in
the form of reports on a variety of public
health issues, at least annually

Purpose

Significance

The purpose of this measure is to assess the
local health department’s provision of
community public health data and analysis to
the community it serves.

Governmental and other public data about the
health of the community should be shared
with the community. Community members
cannot effect change if they are not aware of
the status of the health of the community.
Sharing data can lead to partnerships to
address public health issues.

Required Documentation

Guidance

1. Analytic reports designed to address
community public health issues, distributed
to specific audiences with proof of
distribution

1. The local health department must document distribution of two analytical public health reports
to specific audiences in the community. Reports must be provided at least annually, so the
two examples must be from two different years.
Each report should include data on one or more specific public health issues, such as health
behaviors; disease clusters or trends; public health laboratory reports; environmental public
health hazards reports; or health indicators, such as infant mortality rate. Distribution of the
reports may be targeted to a variety of audiences, including: public health and health care
providers, community service groups, local schools, key stakeholders, and the public.

36

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.3.2 l, continued

Required Documentation

Guidance
The documentation could provide evidence of a range of methods of distribution, including:
mailing lists, email lists, presentations, workshops, web postings, meeting minutes, published
editorials, and press releases.
The report itself does not have to be distributed, but the contents must be communicated.
Thus, while distribution of a hard copy of the report meets the requirement of the measure, so
could a verbal presentation to an audience of community members of the contents of the
report.
The report does not have to be produced by the local health department. The local health
department could use reports produced by the state, an academic institution, or other
organizations. However, reports developed by others must have a connection to the
jurisdiction and the populations served by the health department and contain information of
public health significance.

37

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.3: Analyze public health data to identify trends in health problems,
environmental public health hazards, and social and economic factors
that affect the public’s health.
Measure
1.3.2 T
Provide public health data to the Tribal
community on a variety of public health
issues, at least annually

Purpose

Significance

The purpose of this measure is to assess the
Tribal health department’s provision of Tribal
public health data and analysis to the Tribe it
serves.

Governmental and other public data about the
health of the Tribe should be shared with the
Tribal community. Tribal members cannot
effect change if they are not aware of the
status of the health of the Tribe. Sharing data
can lead to partnerships to address public
health issues.

Required Documentation

Guidance

1. Analytic reports designed to address
community public health issues, distributed
to specific audiences with proof of
distribution

1. The Tribal health department must document distribution of two analytical public health
reports to specific audiences in the community. Reports must be provided at least annually,
so the two examples must be from two different years. The reports must reflect a focus that is
inclusive of all Tribal communities within the Tribe’s jurisdiction.
Each report should include data on one or more specific public health issues, such as health
behaviors; disease clusters or trends; public health laboratory reports; environmental public
health hazards reports; or health indicators, such as infant mortality rate. Distribution of the
reports may be targeted to a variety of audiences, including: public health and health care
providers, community service groups, local schools, key stakeholders, and the public.

38

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.3.2 T, continued

Required Documentation

Guidance
The documentation could provide evidence of a range of methods of distribution, including:
mailing lists, email lists, presentations, workshops, web postings, meeting minutes, published
editorials, and press releases.
The report itself does not have to be distributed, but the contents must be communicated.
Thus, while distribution of a hard copy of the report meets the requirement of the measure, so
could a verbal presentation to an audience of community members of the contents of the
report.
The report does not have to be produced by the Tribal health department; the Tribal health
department could use reports produced by the state, an academic institution, Tribal
epidemiology center, or other organizations. However, reports developed by others must have
a connection to the jurisdiction and the populations served by the health department and
contain information of public health significance.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STAnDArD 1.4: ProVIDe AnD uSe THe reSulTS oF HeAlTH
DATA AnAlYSIS To DeVeloP reCoMMenDATIonS
reGArDInG PuBlIC HeAlTH PolICY, ProCeSSeS, ProGrAMS or
InTerVenTIonS.
The development of public health policies, processes, programs, and interventions should be informed by
the use of public health data. Data should be shared with others so that they can use it for health
improvement efforts.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.4: Provide and use the results of health data analysis to
develop recommendations regarding public health policy, processes,
programs or interventions.
Measure
1.4.1 A
Use data to recommend and inform public
health policy, processes, programs, and/or
interventions

Purpose

Significance

The purpose of this measure is to assess the
health department’s use of data to impact
policy, processes, programs, and
interventions.

Public health policy, priorities, program
design, and interventions should be based on
the most current and relevant data available.

Required Documentation

Guidance

1. Data used to inform public health policy,
processes, programs and/or interventions

1. The health department must provide documentation that public health data has been used to
impact the development of policy, process, program or intervention or the revision or
expansion of an existing policy, process, program or intervention. Examples could include:
minutes of a meeting, changes to the health department web site, documented program
improvements, or a revised or new policy and procedure. Examples could also include: Tribal
Council resolutions and Health Oversight Committee meeting minutes, which demonstrate
that data was used to inform policy, processes, programs and/or interventions.
The data used to inform the policy, process, program or intervention should also be included.
The data alone will not serve as evidence for this measure. The health department must
demonstrate the use of the data. The two examples used for this measure must show the use
of two different data sets.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.4: Provide and use the results of health data analysis to
develop recommendations regarding public health policy, processes,
programs or interventions.
Measure
1.4.2 S
Develop and distribute statewide health data
profiles to support health improvement
planning processes at the state level

Purpose

Significance

The purpose of this measure is to assess the
state health department’s development and
distribution of statewide health profiles to
inform and support others’ health
improvement efforts at the state level.

In addition to the state health assessment, the
state health department should provide
health-issue or program specific data profiles.
These will focus on a particular issue, such as
health behaviors or the incidence of flu. It is
important that others have access to health
data profiles to inform their program planning
and activities at the state level. Health profiles
are used to inform stakeholders and partners
about state health issues and to advocate for
the health of the state and for the needs
identified in the profile.
Statewide health data profiles are not the
same as a comprehensive state health
assessment. A profile can take several forms.
It can be an overview, summary, or synopsis
of a particular health issue, such as cancer.
Or it can address a set of issues, such as the
health issues of the states’ adolescents. It
may also focus on select key indicators of the
health of the state, such as health behaviors
like tobacco use or healthful eating.

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Public Health Accreditation Board • Standards & Measures

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Measure 1.4.2 S, continued

Required Documentation

Guidance

1. Completed state health data profiles at
least every five years

1. The state health department must provide two examples of data profiles that summarize the
state’s data concerning a particular health issue regarding the population served. The profiles
may be a set of fact sheets, each dedicated to a single topic, or a single document
comprised of several profiles of data.
The state health data profiles must have been completed within the last five years. The
profiles may be updated more frequently, as desired. Health profiles must include a broad
array of assessment indicators, supported by primary and secondary data.

2. Documented distribution of state health
profiles to public health system partners,
community groups and key stakeholders

43

2. The state health department must provide documentation of the distribution of health profiles
to public health system partners, community groups, Tribal health departments, local health
departments, elected officials, and key stakeholders, such as governing entities or
community advisory groups. This may include partners, such as community based
organizations, civic groups and any others who receive services, help in the delivery of
services or support public health services. Distribution may be documented by a mailing list,
email list serve, posting on the web site, press releases, meeting minutes documenting
distribution of the profile, presentations and inserts or flyers.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.4: Provide and use the results of health data analysis to
develop recommendations regarding public health policy, processes,
programs or interventions.
Measure
1.4.2 T/L
Develop and distribute Tribal/community
health data profiles to support public health
improvement planning processes at the Tribal
or local level

Purpose

Significance

The purpose of this measure is to assess the
Tribal and local health department’s
development and distribution of health profiles
to inform and support others’ health
improvement efforts at the Tribal and local
level.

In addition to the Tribal and local health
assessment, Tribal and local health
departments should provide health-issue or
program specific data profiles. These will
focus on a particular issue, such as health
behaviors or the incidence of flu. It is
important that others have access to health
data profiles to inform their program planning
and activities at the local or Tribal community
level. The profile is used to inform
stakeholders and partners about the health
status of the community and to advocate for
the health of the Tribe of locality and for the
needs identified in the profile.
A health data profile is not a comprehensive
health assessment. A profile can take several
forms. It can be an overview, summary, or
synopsis of a particular health issue, such as
cancer. Or it can address a set of issues, such
as the health issues of a community’s
adolescents. It may also focus on select key
indicators of a community’s health, such as
health behaviors like tobacco use or healthful
eating.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.4.2 T/l, continued
Required Documentation

Guidance

1. Completed health data profiles at least
every five years

1. The Tribal or local health department must provide two examples of Tribal/community health
data profiles that summarize the community’s data concerning a particular health issue
regarding the population served. The profiles may be a set of fact sheets, each dedicated to
a single topic, or a single document comprised of several profiles of data.The health data
profiles must have been completed within the last five years. The profiles may be updated
more frequently, as desired. Health profiles must include a broad array of assessment
indicators, supported by primary and secondary data.
Tribal health profiles produced by Tribal Epidemiology Centers for the Tribal health
departments are insufficient documentation of the measure, unless the Tribal health
department demonstrates how the Tribal Epi Center profile was supplemented with additional
data collected and analyzed by the Tribe.
Community health profiles produced by the state health department for the local health
departments are insufficient documentation of the measure, unless the local health
department demonstrates how the profile developed by the state was supplemented with
additional data collected and analyzed by the local health department.

2. Documented distribution of health profiles
to public health system partners,
community groups and key stakeholders
such as governing entities or community
advisory groups, via email and websites,
etc.

45

2. The Tribal or local health department must provide documentation of the distribution of health
profiles to public health system partners, community groups, other Tribal and local health
departments, and key stakeholders, such as governing entities or community advisory
groups. This may include partners, such as governing entities and elected/appointed
officials, community based organizations, civic groups and any others who receive services,
help in the delivery of services or support public health services. Distribution may be
documented by a mailing list, email list serve, posting on the web site, press releases,
meeting minutes documenting distribution of the profile, presentations and inserts or flyers.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 1.4: Provide and use the results of health data analysis to
develop recommendations regarding public health policy, processes,
programs or interventions.
Measure
1.4.3 S
Provide support to Tribal and local health
departments in the state concerning the
development and use of community health
data profiles

46

Purpose

Significance

The purpose of this measure is to assess the
state health department’s support to Tribal
and local health departments within the state
concerning the development and use of
community or Tribal health data profiles.

State health departments have access to and
compile data that are not available to Tribal
and local health departments. State health
departments should share these data with
Tribal and local health departments. State
health departments also should provide
assistance to the Tribal and local health
departments on how to use this data both to
develop and implement community health
profiles.

Required Documentation

Guidance

1. Tools and guidance

1. The state health department must provide documentation that data analysis and/or data
presentation tools were provided to Tribal and local health departments in the state. The state
may also offer guidance – by phone, electronically, or in person – to help with Tribal or local
profile development.

2. Completed community health data profiles

2. The state health department must provide completed profiles of the Tribal or local community.
These must be general profiles and may include data collected by other state agencies, such
as educational attainment, unemployment, types of employment, or crime statistics.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 1.4.3 S, continued

Required Documentation

Guidance

3. Documentation of the state health
department asking the Tribal and local
health departments about what support or
assistance is needed

3. The state health department must provide documentation that it has asked the Tribal and
local health departments about what support or technical assistance is needed or requested.
Documentation could be through documented phone calls, faxes, newsletters, memos,
meeting minutes, etc.

4. Documentation of technical assistance to
Tribal and local health departments on the
use of health data profiles

4. The state health department must provide documentation of the assistance that it has
provided to Tribal or local health departments concerning the use of data profiles.
Documentation could be through documented phone calls, faxes, newsletters, memos,
meeting minutes, etc.
States without Tribal health departments are excluded from providing support to Tribal health
departments, but must provide evidence that there is no Tribal health department in the state.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Domain 2: Investigate health problems and environmental public health hazards to protect the community
Domain 2 focuses on the investigation of suspected or identified health problems or environmental public health hazards. Included are epidemiologic
identification of emerging health problems, monitoring of disease, availability of public health laboratories, containment and mitigation of outbreaks,
coordinated response to emergency situations, and communication.

DOMAIN 2 INCLUDES FOUR STANDARDS:
Standard 2.1

Conduct Timely Investigations of Health Problems and Environmental Public Health Hazards

Standard 2.2

Contain/Mitigate Health Problems and Environmental Public Health Hazards

Standard 2.3
Standard 2.4

48

Ensure Access to Laboratory and Epidemiologic/Environmental Public Health Expertise and Capacity to
Investigate and Contain/Mitigate Public Health Problems and Environmental Public Health Hazards
Maintain a Plan with Policies and Procedures for Urgent and Non-Urgent Communications

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STANDARD 2.1: CONDUCT TIMELY INVESTIGATIONS OF HEALTH
PROBLEMS AND ENVIRONMENTAL PUBLIC HEALTH HAZARDS.
The ability to conduct timely investigations of suspected or identified health problems is necessary for the
detection of the source of the problem, the description of those affected, and the prevention of the further
spread of the problem. When public health or environmental public health hazards are investigated,
problems can be recognized and rectified, thus preventing further disease outbreaks or illness.

49

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.1 A
Maintain protocols for investigation process

Significance

The purpose of this measure is to assess the
health department’s ability to conduct
standardized investigations with consistent
procedures and a set of rules to follow.

Health departments require standard
operations, assigned roles and
responsibilities, and well thought out
coordination to study patterns of health and
illness and their associated factors. A
standardized approach ensures timely
response and thorough investigation into the
cause of a public health problem or
environmental public health hazard so that
further disease and illness can be prevented.

Required Documentation

Guidance

1. Current written protocols that include:

1. The health department must provide current written protocols that include a procedure for
conducting investigations of suspected or identified health problems and environmental and
occupational public health hazards. Health problems that require investigation include:
communicable disease, sexually transmitted disease/infection, injury, chronic disease,
chemical emissions, and drinking water contamination.
a. The protocol must delineate the assignment of responsibilities for investigations of
health problems and environmental public health hazards. The assignment may be to
a specified position or positions, such as all environmental public health sanitarians,
epi-diagnostic teams, and/or community health outreach staff in the health department

a. Assignment of responsibilities for
investigations of health problems,
environmental, and/or occupational
public health hazards
50

Purpose

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 2.1.1 A, continued

Required Documentation

Guidance
or may be assigned to a named individual. Documentation must include specific
responsibilities shown in a procedure or flow chart.
If this function is carried out in full or in part by a federal agency, other health
department, or other entity, then an MOU/MOA or other agreement, must be provided
to demonstrate the formal assignment of responsibilities for investigation of health
problems and environmental and occupational public health hazards.

b. Identifying information about the
health problem or hazard, case
investigation steps and timelines,
and reporting requirements

b. The protocol must contain information about the health problems or hazards that will
be investigated, case investigation steps and timelines related to those problems or
hazards, and reporting requirements.
The protocols may be in separate documents, may be contained in a manual format,
or may be in a single compiled document. They may be in paper form or electronic.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.2 S
Demonstrate capacity to conduct and/or
support multiple investigations of infectious or
communicable diseases simultaneously

52

Purpose

Significance

The purpose of this measure is to assess the
state health department’s capacity to engage
in more than one investigation of infectious or
communicable disease health problems at the
same time.

More than one health problem that requires an
investigation may occur simultaneously.
Health problems may occur simultaneously in
more than one location in the state or may be
contained in the jurisdiction of a single or
multiple Tribal or local health departments. It
is important that the state health department
has the capacity to investigate or help support
multiple investigations of infectious or
communicable disease at the same time. The
focus of this measure is on investigation of
infectious or communicable diseases such as
influenza, measles, food borne illnesses, or
Lyme disease.

Required Documentation

Guidance

1. Procedures for the conduct of multiple,
simultaneous investigations

1. The state health department must provide written procedures that describe how it conducts
multiple, simultaneous investigations of infectious or communicable diseases. Documentation
could include: response plans, internal plans, staff capacity and expertise, and resources
available to the health department from other state governmental departments, such as the
Department of Agriculture or the Department of Environmental Resources. State health
departments often work together with Tribal health departments and local health departments
to conduct investigations; the state health department can include contractors and/or
relationships with Tribal health departments, local health departments, or other local
governmental departments to show the capacity to conduct multiple investigations.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Measure 2.1.2 S, continued

Required Documentation

Guidance
The state health department does not have to perform all functions of an investigation, but
must have the capacity to respond when needed.

53

2. Audits, programmatic evaluations, case
reviews or peer reviews of investigation
reports against protocols

2. The state health department must provide audits, programmatic evaluations, case reviews, or
peer reviews of investigation reports (as compared to written protocols). The documentation
must reference the state health department’s capacity to respond to outbreaks of infectious or
communicable disease.

3. Completed After Action Reports (AARs)

3. The state health department must provide two completed After Action Reports (AARs). The
AAR provided as documentation for this measure should address the capacity of the
department to conduct multiple investigations.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.2 T/L
Demonstrate capacity to conduct an
investigation of an infectious or communicable
disease

Required Documentation

Purpose

Significance

The purpose of this measure is to assess the
Tribal/local health department’s capacity to
implement its protocols for an investigation of
infectious or communicable disease.

Investigations of infectious disease or
communicable disease provide information
that allows the health department to
understand the best way to control a current
outbreak of a disease and to prevent further
spread of an outbreak. Sometimes a health
problem or hazard requiring investigation
occurs where local and state and/or local and
Tribal jurisdictions overlap or are adjacent to
one another requiring response and
coordination between health departments.
The focus of this measure is on investigation
of infectious or communicable diseases, such
as influenza, measles, food borne illnesses, or
Lyme disease.

Guidance

The Tribal/local health department can include contractors and/or relationships with the state
health department, Tribal health departments in the state, local health departments, or other
local government departments to demonstrate the capacity to conduct an investigation. The
health department does not have to perform all functions of an investigation of an infectious or
communicable disease, but must have formal arrangements with others who will participate and
support the local health department in its investigations.

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Public Health Accreditation Board • Standards & Measures

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Measure 2.1.2 T/L, continued

55

Required Documentation

Guidance

1. Audits, programmatic evaluations, case
reviews or peer reviews of investigation
reports against protocols

1. The Tribal/local health department must provide two examples of audits, programmatic
evaluations, case reviews, or peer reviews of investigation reports (as compared to written
protocols). The documentation must reference the health department's capacity to respond to
outbreaks of infectious or communicable disease.

2. Completed After Action Report (AAR)

2. The Tribal/local health department must provide a completed After Action Report (AAR). The
focus for this measure is on the capacity of the department to conduct investigations. The
AAR provided as documentation for this measure should address this aspect.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.3 A
Demonstrate capacity to conduct
investigations of non-infectious health
problems, environmental, and/or occupational
public health hazards

Required Documentation

Purpose

Significance

The purpose of this measure is to assess the
health department’s capacity to implement
protocols for an investigation of non-infectious
diseases and illnesses and of environmental
public health hazards.

Investigations of non-infectious diseases and
illnesses and of environmental public health
hazards allow the health departments to learn
how to prevent or mitigate health problems
caused by non-infectious health problems
and environmental public health hazards.

Guidance
Non-infectious health problems include: morbidity and mortality associated with emergent and
non-emergent health problems that are not infectious, such as chronic disease, injuries, and
environmental public health hazards, as well as their risk factors and root causes. An example of
a non-infectious health problem would be an increase in diagnosed diabetes cases or a
geographic area with a higher than normal rate of a cancer type. An example of an
environmental public health hazard could be arsenic or lead in drinking water, as opposed to an
infectious public health hazard, such as a restaurant food-borne outbreak.

1. Completed investigation of a non-infectious
health problem or hazard

56

1. The health department must provide one example of an investigation of a non-infectious
health problem or hazard that was completed within the previous five years. There is no
specified format for the contents. Departments can provide a report of the investigation,
executive summary, presentation or investigation records, including logs and notes. If this
activity is provided through a contract/MOA/MOU, then written assurance that the
investigation was completed must be provided.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.4 A
Work collaboratively through established
governmental and community partnerships on
investigations of reportable/disease outbreaks
and environmental public health issues

57

Purpose

Significance

The purpose of this measure is to assess the
health department’s working relationships that
are needed to investigate reports of
reportable diseases and environmental public
health problems.

As a part of conducting investigations, the
health department must partner with other
governmental agencies and community
partners to investigate reports on reportable
diseases and environmental public health
investigations.

Required Documentation

Guidance

1. Established partnerships with other
governmental agencies/departments
and/or key community stakeholders that
play a role in investigations or have direct
jurisdiction over investigations

1. The department must provide two examples of contracts/MOAs/MOUs/agreements that
document partnerships for the investigation of outbreaks of disease or environmental public
health hazards. These partnerships are with other governmental agencies/departments and
key community stakeholders, and the agreement must state or show that the partner plays a
role in investigation. The agreement may state that the partner may have a direct jurisdiction
over a specified type of investigation.

2. Evidence of working with partners to
conduct investigations

2. The department must provide two examples of working with partners to conduct
investigations. The examples must be from two different investigations of reportable diseases
or environmental public health investigations. This can be demonstrated through investigation
reports and records, AARs, meeting minutes, presentations, and news articles.

3. Provision for laboratory testing for
notifiable/reportable diseases

3. The department must provide a public health laboratory list of services that includes testing
for notifiable/reportable diseases.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.5 A
Monitor timely reporting of
notifiable/reportable diseases, lab test results,
and investigation results

Purpose

Significance

The purpose of this measure is to assess the
health department’s assurance of timely
reporting of notifiable/reportable diseases,
laboratory test results, and investigation
results.

A component of conducting timely
investigations is the reporting of
notifiable/reportable diseases, laboratory
testing, and investigation of results as
appropriate and required by law. When
reporting is timely, all partners can work
together to stop the spread of disease.

Required Documentation

Guidance

1. Current tracking log or audit of reports of
disease reporting, laboratory tests reports,
and/or investigations with actual timelines
noted

1. The health department must provide a tracking log on reporting, including lab test results and
investigation results. The department can choose between a log and a report. The log would
be used to track various elements of an investigation. Note: If a log is provided, it must
include timelines.

2. Copy of applicable laws

2. The department must provide a copy of laws relating to the reporting of notifiable/reportable
diseases. This can be a hard copy or a link to an electronic version. This can include a
posting on a website or a department intranet, or a link to another website.
State health departments can include laws for local health departments to report to the state,
as well as for states reporting to CDC.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.1: Conduct timely investigations of health problems
and environmental public health hazards.
Measure
2.1.6 S
Provide consultation, technical assistance,
and/or information to Tribal and local health
departments in the state regarding disease
outbreak and environmental public health
hazard management

59

Purpose

Significance

The purpose of this measure is to assess the
consultation, technical assistance, and
information that a state health department
provides to Tribal and local health
departments in the state concerning disease
outbreaks and public health hazard
management.

The state health department’s provision of
technical assistance, information, and
consultation to Tribal and local health
departments on epidemiological, laboratory,
and environmental public health assistance
improves the effectiveness of the public health
response locally and state-wide. The measure
includes assistance concerning identifying,
analyzing and responding to infectious
disease outbreaks, as well as environmental
and occupational public health hazards.

Required Documentation

Guidance

1. Documentation of consultation, technical
assistance, and/or information provided

1. The state health department must provide documentation to demonstrate how it provided
assistance to Tribal or local departments. This may be at the request of locals or can be
initiated by the state. This can include: communications that have gone to one or more Tribal
or local health departments; meetings at the Tribal, state or local level, and training sessions
and presentations. It can also include email communication – both to individuals and to listserves. State health department assistance can be onsite, phone consultation, conference
calls, webinars, presentations, training sessions, written guidelines, and investigation
protocols and manuals.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STANDARD 2.2: CONTAIN/MITIGATE HEALTH PROBLEMS AND
ENVIRONMENTAL PUBLIC HEALTH HAZARDS.
Health departments must be able to act on information concerning health problems and environmental

public health hazards that was obtained through public health investigations. Health departments must
have the ability to contain or mitigate health problems and hazards. The containment or mitigation of
health problems and environmental public health hazards must be coordinated with other levels of
government, other government departments, and other stakeholders.

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Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.2: Contain/mitigate health problems and environmental
public health hazards.
Measure
2.2.1 A
Maintain protocols for containment/mitigation
of public health problems and environmental
public health hazards

61

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to contain or
mitigate health problems or environmental
public health hazards. This includes disease
outbreaks. This measure assesses the
existence of protocols for the containment or
mitigation of public health problems or public
health environmental hazards.

Health departments are responsible for acting
on information concerning health problems
and environmental public health hazards in
order to contain or lessen the negative effect
on the health of the population.
Health departments require standard
operations, assigned roles and
responsibilities, and well thought out
coordination in order to effectively address
disease outbreaks. A standardized approach
ensures timely response.

Required Documentation

Guidance

1. Current written protocols that address
containment/mitigation of public health
problems and environmental public health
hazards

1. The health department must provide two examples of written protocols for
containment/mitigation of health problems and hazards. This includes disease-specific
procedures for follow-up and reporting during outbreaks. To “maintain” means that the
department keeps the protocols up-to-date. The protocols must address mitigation, contact
management, clinical management, use of prophylaxis and emergency biologics,
communication with the public health laboratory, and the process for exercising legal
authority for disease control. These protocols may be in a single document or be comprised
of many separate documents.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 2.2: Contain/mitigate health problems and environmental
public health hazards.
Measure
2.2.2 A
Demonstrate a process for determining when
the All Hazards Emergency Operations Plan
(EOP) will be implemented

62

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to know when their
All Hazards Emergency Operations Plan
(EOP) needs to be put into operation.

Protocols for a health department to determine
that they need to implement their All Hazards
Emergency Operations Plan are necessary to
ensure that the plan is put into action when
needed. An All Hazards Emergency
Operations Plan is an action plan for
addressing a natural disaster, terrorist event,
disease outbreak or cluster, environmental
public health hazard or other emergency that
threatens the population’s health.

Required Documentation

Guidance

1. Infectious disease outbreak protocols
describing processes for the review of
specific situations and for determining the
activation of the All Hazards Emergency
Operations Plan

1. The health department must provide its infectious disease outbreak protocols. Though these
may be the same protocols from 2.2.1 A, the department must highlight the description of the
process for determining when the All Hazards or Emergency Operations Plan will be
implemented.

2. Environmental public health protocols
describing processes for the review of
specific situations and for determining the
initiation of the All Hazards Emergency
Operations Plan

2. The health department must provide protocols that specifically address environmental public
health hazards and that describe the process for determining when the All Hazards
Emergency Operations Plan will be implemented.

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Required Documentation

Guidance

3. Cluster evaluation protocols describing
processes for the review of specific
situations and for determining initiation of
the All Hazards Emergency Operations
Plan

3. The health department must provide protocols that include cluster evaluation protocols
describing the process for determining when the All Hazards Emergency Operations Plan will
be implemented. Cluster evaluations will provide evidence of an unusual number of health
events, such as an outbreak of SARS, grouped together in time and location.

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Standard 2.2: Contain/mitigate health problems and environmental
public health hazards.
Measure
2.2.3 A
Complete an After Action Report (AAR)
following events

Required Documentation

Purpose

Significance

The purpose of this measure is to assess the
department’s ability to contain or mitigate
health problems and environmental public
health hazards. This measure assesses the
existence of After Action Reports.

An After Action Report provides a description
and analysis of the department’s performance
during an emergency operation, identifies
issues that need to be addressed, and
includes recommendations for corrective
actions for future emergencies and disasters.

Guidance
An AAR is to be completed when a communicable disease outbreak occurs, when an
environmental public health risk has been identified, when a natural disaster occurs, and when
any other event occurs that threatens the public’s health. While AARs have been used for drills
and exercises as part of All Hazards Plans (see 5.4.3 A), the intent of this measure is to apply
the AAR methodology to actual events that threaten the health of the people living in the
jurisdiction of the health department.

1. Protocols describing the processes used
to determine when events rise to
significance for an AAR review

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1. The health department must provide a written description of how it determines if an event has
risen to the level of significance requiring an AAR. Not every event will require an AAR. For
example, a food borne outbreak may have 10 positive cases before being designated as
significant enough to require an AAR. The process must address communicable disease
outbreaks, environmental public health hazards, natural disasters, and other threats.

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Required Documentation

Guidance

2. List of significant events that occurred,
including outbreaks and environmental
public health risks

2. The health department must provide a list of significant events that have occurred within the
last five years. Reports may address outbreaks, environmental public health risks, natural
disasters, or other events that threaten the public’s health. The list must include all events that
met and did not meet the level of significance to require an AAR. The listing must include, at
minimum, the event name, event type, and dates of the event.

3. Completed AAR for two events that
document successes, issues, and
recommended changes in investigation
and response procedures or other process
improvements

3. The health department must provide examples of completed AARs for two separate events.
The AARs must report what worked well, what issues arose, identify potential improvement
areas in protocols, and recommend improvements.

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STANDARD 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.
Successful investigation and mitigation of public health problems and environmental hazards will often

depend upon laboratory testing, epidemiologist involvement, and environmental public health expertise.
These areas of expertise provide vital support to an investigation and are a part of the capacity that a
department should have to respond to health problems and environmental public health hazards.

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Standard 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.
Measure
2.3.1 A
Maintain provisions for 24/7 emergency
access to epidemiological and environmental
public health resources capable of providing
rapid detection, investigation, and
containment/mitigation of public health
problems and environmental public
health hazards

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Purpose

Significance

The purpose of this measure is to assess the
department’s capacity for rapid detection,
investigation, and containment/mitigation of
public health problems and environmental
public health hazards.

Health departments should have the capacity
to respond to public health emergencies. The
department should have access to
epidemiological and environmental public
health resources that can support the rapid
detection, investigation, and mitigation of
problems and hazards. This access should be
available to the department 24/7.

Required Documentation

Guidance

1. Policies and procedures ensuring 24/7
coverage

1. The health department must provide policies and procedures outlining how the health
department maintains 24/7 access to the support services in emergencies. These policies
and procedures may be contained in the All Hazards Emergency Operations Plan or may be
separate policies and procedures. These resources may be within the department, or the
department can have agreements with other agencies, individual contractors, or a
combination in order to be responsive 24/7.

2. Call Down lists

2. The health department must provide a call down list that is used to contact epidemiological
and environmental public health resources.

3. Contracts/MOAs/MOUs/mutual assistance
agreements detailing relevant staff

3. The health department must provide a list and description of contracts, MOA/MOUs, or
mutual assistance agreements that define access to resources to assist in 24/7 capacity for
emergency response.

Public Health Accreditation Board • Standards & Measures

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Standard 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.
Measure
2.3.2 A
Maintain 24/7 access to laboratory resources
capable of providing rapid detection,
investigation and containment of health
problems and environmental public health
hazards

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Purpose

Significance

The purpose of this measure is to assess the
capacity of the department’s laboratory
services to provide rapid detection,
investigation, and containment/mitigation of
public health problems and environmental
public health hazards.

Laboratory services are critical to recognize
agents in an emergency for the development
of an appropriate public health rapid response.
The department should have access to public
health laboratory resources that can support
the rapid detection, investigation, and
containment of problems and hazards. This
access should be available to the department
24/7.

Required Documentation

Guidance

1. Laboratory certification

1. The health department must provide documentation of laboratory capacity. Laboratory
capacity may be within the health department, may be provided by reference laboratories, or
a combination of both internal and external support. The health department must provide
documentation that the laboratory has accreditation, certification, and licensure appropriate
for all the testing that it performs (i.e., CLIA License, EPA Drinking Water Certification, FDA
Certification for Milk Testing, etc.).

2. Policies and procedures ensuring 24/7
coverage

2. The health department must provide policies and procedures that assure 24/7 laboratory
coverage. These policies and procedures may be contained in the All Hazards Emergency
Operations Plan or may be separate policies and procedures. These resources may be within
the department, or the department can have agreements with other agencies, individual

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Measure 2.3.2 A, continued

Required Documentation

Guidance
contractors, or a combination in order to be responsive 24/7. Contracts, MOAs/MOUs, or
mutual assistance agreements that the department has with other public and private
laboratories to provide support services may be provided.

3. Protocols for handling and submitting
specimens

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3. The department must provide protocols for the handling and the submission of specimens.

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Standard 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.
Measure
2.3.3 A
Maintain access to laboratory and other
support personnel and infrastructure capable
of providing surge capacity

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Purpose

Significance

The purpose of this measure is to assess the
department’s support personnel and
infrastructure capacity for providing additional
surge capacity for rapid detection,
investigation, and containment/mitigation of
public health problems and environmental
public health hazards.

Access to additional support personnel is
important in the case of an emergency, such
as a bio-terrorism event or disease outbreak
when response needs of the health
department exceed normal capacity of health
department staff.

Required Documentation

Guidance

1. Protocol that pre-identifies support
personnel to provide surge capacity

1. The health department must provide a protocol, procedure or policy that identifies support
personnel who will be called on to provide surge capacity. This could refer to support staff
within the health department who can assist during times of response and who would be
performing duties outside their routine assignments. Or it could be a listing of support
personnel from outside the health department who would be available to assist the
department.

2. Staffing list for surge capacity and
description of how staff accesses this
information

2. The health department must provide a staffing list for surge capacity that refers to both the
staffing needed for a surge response and how department staff will fill those roles. Positions
may include: nursing, health education specialist, communications, IT, logistics,
environmental health specialist, and administrative personnel. Included with this
documentation must be a description of how staff will access this information. This could be a
part of an All Hazards/ERP or a separate protocol. Access could be through various methods,
including: web or intranet, hard copy, central location in the facility, or distributed to those
positions that have surge capacity assignments.

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Required Documentation

Guidance

3. Documented availability of equipment

3. The health department must provide a document detailing the availability of equipment to
support a surge to demonstrate additional infrastructure for a response. For example,
equipment may be used for transportation, field communications, PPE, etc.

4. Training/exercise schedule for surge
personnel

4. The health department must provide a schedule for training or exercises to help prepare
personnel who will serve in a surge capacity (for example, ICS or PPE training). This does not
have to be the sole focus of the training or exercise, but must be a component of the training.

5. Contracts/MOAs/MOUs/Mutual assistance
agreements for additional staff capacity for
surge situations

5. The health department must provide a list and description of contracts, MOAs/MOUs, and/or
mutual assistance agreements providing additional staff and services, including laboratory
services, for surge capacity. Any of the contracts or agreements for this measure can consist
of separate documents or a single agreement covering several aspects of support.

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Standard 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.
Measure
2.3.4 A
Demonstrate that Tribal, state, and local health
departments work together 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

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Purpose

Significance

The purpose of this measure is to assess
coordination and collaboration between Tribal
health departments, state health departments,
and local health departments in order to share
resources for rapid detection, investigation,
and containment/mitigation of public health
problems and environmental public health
hazards.

Public health problems and environmental
public health hazards are not always
contained in the jurisdiction of the health
department. Tribal, state, and local health
departments have the responsibility to work
together to provide rapid detection,
investigation and containment/mitigation. In
most public health situations requiring
investigation and mitigation, the state health
department and local health department must
be partners in the response. Likewise, Tribal
health departments network with local and
state entities for mitigation, detection, and
containment with contracts, memorandums of
understanding or agreement, as approved by
the Tribal government. Seamless coordination
and communication are necessary for the
most effective use of resources.

Required Documentation

Guidance

1. Documentation demonstrating shared
resources and/or additional capacity

1. The health department must provide documentation that demonstrates how the Tribal, state,
and local health departments are working together to build capacity and share resources.
Departments can provide policies and procedures or MOUs that demonstrate plans to
communicate and collaborate in addressing public health problems and environmental

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Measure 2.3.4 A, continued

Required Documentation

Guidance
public health hazards. Other forms of documentation could include: meeting minutes that
evidence discussion and decisions to work together, as well as After Action Reports that
describe coordination.

2. Joint exercises for rapid detection,
investigation, and containment/mitigation of
public health problems and environmental
public health hazards

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2. The health department must provide records from joint exercises, including AARs,
demonstrating how the Tribal, state, and local levels worked together to test or implement
shared resources and build capacity during the exercise.

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STANDARD 2.4: MAINTAIN A PLAN WITH POLICIES AND
PROCEDURES FOR URGENT AND NON-URGENT
COMMUNICATIONS.
Reliable and timely communications with partners and the public is important to ensure informed and
appropriate responses to public health problems and environmental public health hazards.

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Standard 2.4: Maintain a plan with policies and procedures for
urgent and non-urgent communications.
Measure
2.4.1 A
Maintain written protocols for urgent 24/7
communications

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Purpose

Significance

The purpose of this measure is to assess the
department’s written protocols for
communications during detection,
investigation, and mitigation of urgent public
health problems and environmental public
health hazards that may occur at any time.

Urgent public health problems and
environmental public health hazards require a
community-wide response. Accurate and
timely information is necessary to ensure an
appropriate and effective community response.
Partners and the public need to know how to
contact the health department to both report
and receive information about a public health
emergency or environmental public health risk.

Required Documentation

Guidance

1. Protocols, updated at least annually, for
communication with response partners

1. The health department must provide written communication protocols that provide a means
for the department to contact health care providers, response partners, the media, and
others, 24/7. The protocol must include the contact information, such as phone numbers,
email addresses, and website addresses for relevant partners. The health department must
have duplicative means to get in touch with partners.

2. Documentation of information available to
partners (and/or the public) on how to
contact the health department to report a
public health emergency or environmental/
occupational public health risk 24/7

2. The health department must provide one example of information to partners and the public
about how to contact the health department to report a public health emergency, risk,
problem or environmental or occupational public health hazard. Partners include: law
enforcement, schools, hospitals, and government agencies. A web page with contact
information could demonstrate conformity.

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Required Documentation

Guidance

3. Method for partners and the public to
contact the health department 24/7

3. The health department must provide documentation that demonstrates that partners and the
public can contact the health department 24/7. An after-hour answering service or pager
service could provide this capacity.

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Standard 2.4: Maintain a plan with policies and procedures for
urgent and non-urgent communications.
Measure
2.4.2 A
Implement a system to receive and provide
health alerts and to coordinate an appropriate
public health response

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to receive and
issue health alerts and to communicate and
coordinate the appropriate public health
response with health care providers,
emergency responders, and communities on
a 24/7 basis.

Speedy and accurate communications with
health care providers, emergency
responders, and other partners concerning
health alerts facilitates their understanding of
the scope of the emergency, the steps
necessary to respond to it, and the protection
of the community and responders.
Communication allows the development of
effective and coordinated responses to urgent
public health problems and environmental
public health hazards.

Required Documentation

Guidance

1. Tracking system such as Health Alert
Network (HAN) system

1. The health department must provide documentation that it has established or participates in a
Health Alert Network (HAN) or similar system that receives and issues alerts 24/7. A HAN
usually has the capacity to issue response measures or information related to the risk, hazard
or problem. Since HAN is usually web-based, screen shots from the computer can be printed
as documentation.
The tracking system or health alert network may be a state system in which Tribal or local
health departments participate. The Tribal or local system may establish a smaller system for
providers and responders within the jurisdiction of the health department. Some Tribes have
established a Joint Information Center (JIC) with a public information officer for the Tribal
Health Department; Tribal health departments may provide evidence of this as
documentation.

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Required Documentation

Guidance

2. Reports of testing 24/7 contact and phone
line(s)

2. The health department must provide documentation that the process for 24/7 contact of the
health department has been tested. This testing must include normal work hours and after
hours. Email contact, phone lines, pager, website and other contact points with the
department must be tested where applicable.

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Standard 2.4: Maintain a plan with policies and procedures for
urgent and non-urgent communications.
Measure
2.4.3 A
Provide timely communication to the general
public during public health emergencies

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to provide
information to the public during a public
health emergency in a timely manner.

During a public health emergency, the health
department should function as the expert.
Speedy and accurate communications with
the public during public health emergencies
facilitates their understanding of the
seriousness of the emergency and informs
them of the actions they should and should
not take in response to the public health
emergency. In the absence of accurate
information, false information will be created.
Public information also lets the public know
that the public health department is working to
protect the community. A key mechanism to
reach the public is the media.

Required Documentation

Guidance

1. Communications to the public that provided
accurate, accessible, and actionable
information

1. The department must provide two examples that demonstrate how it has communicated
with and provided information to the public. The information should be accurate, accessible,
and actionable.
The documentation must indicate the timeliness of the information related to the event. A
number of means can be used to communicate information to the public, including posting
on a website, distribution of printed materials (brochures, flyers, factsheets, inserts), fax
broadcast to all providers and other responders, automated call systems, and email

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Measure 2.4.3 A, continued

Required Documentation

Guidance
list-serves. The measure deals with public health emergencies and the documentation must
demonstrate timely communication with the public during an emergency. General public
health educational materials are not relevant.

2. Use of the media to communicate
information during a public health
emergency

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2. The department must provide two examples of using the media to communicate information
to the public during a public health emergency. Examples could include: a press conference,
media packets, press release, public service announcement, or video of a televised interview.
Documents must be dated. The measure deals with public health emergencies and the
documentation must demonstrate timely communication with the media during an
emergency.

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Standard 2.4: Maintain a plan with policies and procedures for
urgent and non-urgent communications.
Measure
2.4.4 S
Provide consultation and technical assistance
to Tribal and local health departments on the
accuracy and clarity of public health
information associated with a public health
emergency

Purpose

Significance

The purpose of the measure is to assess the
state health department’s support to Tribal
and local health departments’ efforts to inform
the public concerning an outbreak or an
environmental or other public health
emergency.

The state health department has a role in
serving as a resource to Tribal and local health
departments for communication associated
with outbreaks and emergencies. An important
element in communication is consistent
messaging from partners.
The state has a role in crafting messages that
are shared to ensure that public health
information is accurate and clear. The measure
specifies the assistance on information that is
associated with an outbreak, an environmental
event, or other emergency.

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Required Documentation

Guidance

1. Consultation, technical assistance, or
guidance provided to Tribal and local
health departments

1. The state health department must provide documentation of consultation, technical
assistance, or guidance provided to Tribal and local health departments. Tribal and local
health departments do not have to use the consultation and technical assistance services from
the state, but it must be available if requested. Minutes of meetings or conference calls could
be provided. Meeting or training agenda or presentations can be provided and must include a
list of Tribal or local health attendees. Assistance could also be documented by emails or listserves sent to Tribal and local health departments.

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Required Documentation

Guidance

2. Guidelines for accurate and clear
communication to the public

2. The state health department must provide communication guidelines, protocols, or written
assistance to Tribal and local departments about developing clear and accurate public health
information during an outbreak, crisis or emergency to prepare Tribes and locals for such an
occurrence.

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Domain 3: Inform and educate about public health issues and functions
Domain 3 focuses on educating the public. This domain assesses the health department’s processes for continuing communication as standard
operating procedures.

The population that a health department serves should have accurate and reliable information about how to protect and promote individual and family
health. They should have information about healthy behaviors, such as good nutrition, hand washing, and seat belt use. The population should have
access to accurate and timely information in the case of particular health risks like H1N1, a food borne disease outbreak, or an anthrax attack. Such
information should be communicated in a language and format that people can understand. Public health departments also have a responsibility to
educate the public about the value, roles, and responsibilities of the health department and the meaning and importance of public health.

These educational responsibilities require a continuing flow of information. To be effective, delivery of information shouldn’t be a one-way street. For the
health department to communicate with the public accurately, reliably, and in a timely manner, it must gather and use information that it receives from
federal, Tribal, state and other local health departments. It also needs input from community partners and the population and sub-groups of the
population that it serves. Communication requires dialogue with the target population to assure that the message is relevant, culturally sensitive, and
linguistically appropriate.

DOMAIN 3 INCLUDES TWO STANDARDS:
Standard 3.1
Standard 3.2

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Provide Health Education and Health Promotion Policies, Programs, Processes, and Interventions to Support
Prevention and Wellness
Provide Information on Public Health Issues and Public Health Functions Through Multiple Methods to a
Variety of Audiences

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STANDARD 3.1: PROVIDE HEALTH EDUCATION AND HEALTH
PROMOTION POLICIES, PROGRAMS, PROCESSES, AND
INTERVENTIONS TO SUPPORT PREVENTION AND WELLNESS.
Health education is an important component of encouraging the adoption of healthy behaviors by the

population served by the health department. Health education provides the information needed by the

population to improve and protect their health. Health education involves gathering knowledge about the
health issue and the target population and sharing that information in a manner and format that can be
used effectively by the population.

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Standard 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support prevention and wellness.
Measure
3.1.1 A
Provide information to the public on protecting
their health

Purpose

Significance

The purpose of this measure is to assess the
health department’s dissemination of accurate
information to the populations that it serves
concerning health risks, healthy behaviors,
disease prevention, and wellness
approaches.

A key activity in promoting population health is
providing public health information that
encourages the adoption of healthy behaviors
and activities. To be effective, information
should be appropriate for the target
population. It must be accurate, timely, and
provided in a manner that can be understood
and used effectively by the target population.
Public health information can address a broad
range of public health promotion messages:
• Health risks, such as high blood
pressure or high cholesterol.
• Health behaviors, such as tobacco
use or unprotected sexual activity.
• Disease, illness, or injury
prevention, such as seat belt use or
immunizations.
• Wellness, such as healthy nutrition
or physical activity.
Health information could address a
combination of these targets. For example,
unprotected sex, needle sharing, and HIV
transmission could combine aspects of health
risks, health behaviors, and prevention.

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Measure 3.1.1 A, continued
Measure
3.1.1 A

Purpose

Significance
For the information to be trusted and
understood, health education messaging should
not be contradictory or confusing. Therefore,
messaging should be coordinated with others
who are providing public health information to
the public.

Required Documentation

Guidance

1. Documentation of the provision of
information on health risks, health
behaviors, prevention, or wellness

1. The health department must provide two examples of information that it has shared with the
public to address the listed message areas (health risks, health behaviors, prevention, or
wellness). Information should be accurate, accessible, and actionable. Health literacy should
be taken into account, and information should be provided in plain language with everyday
examples. The two examples can relate to the same message area, such as two items
addressing prevention issues. The two examples must, however, be from different program
areas, one of which must address a chronic disease program, such as diabetes, obesity, heart
disease or cancer.
Documentation may include a public presentation, press release, media communications,
brochures, flyer, or public service announcement. Documentation should note the target group
or audience, the program area, the date the information was shared or distributed, and the
purpose for the information.

2. Documentation that indicates how
information was gathered from the target
group during the development of the
educational material/message

2. The health department must document one example of steps taken to solicit input from the
target audience during the development of the message and material to help shape the final
content.
This example must come from one of the two program areas from which documentation was
provided in 1, above. Documentation may include: findings from a focus group, key informant
interviews, or pull-aside testing. It could also include minutes from a town meeting with the
target population or a meeting of an advisory group representing the target population.

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Measure 3.1.1 A, continued

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Required Documentation

Guidance

3. Documentation of steps taken with Tribal,
state, and/or local health departments;
and/or community partners to promote
coordinated health education messages

3. The health department must provide documentation of communication with other health
departments (Tribal, state, or other local) or community partners to promote unified
messaging. Examples: a fact sheet, an email or memorandum, meeting minutes where
messaging was discussed, or documented phone conversation discussing the message.

Public Health Accreditation Board • Standards & Measures

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Standard 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support prevention and wellness.
Measure
3.1.2 A
Implement health promotion strategies to
protect the population from preventable health
conditions

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Purpose

Significance

The purpose of this measure is to assess the
health department’s strategies to promote
health and address preventable health
conditions.

Health promotion aims to enable individuals
and communities to protect and improve their
own health. Health promotion is a combination
of health education, community change, and
organizational and social supports that
provide conditions conducive to the good
health of individuals, groups, and
communities. Health education is an
important step towards encouraging healthy
behaviors. It consists of planned learning
activities to convey information to individuals
and communities about behaviors that
encourage wellness and prevent diseases.

Required Documentation

Guidance

1. Documentation of implemented health
promotion strategies

1. The health department must provide two examples of health promotion strategies. The
examples must come from two different program areas, one of which must address a chronic
disease. The documentation must show how the strategies:
• Correspond to public health priorities identified through a health improvement plan.
• Are evidence-based, rooted in sound theory, practice-based evidence, and/or
promising practice.
• Use social marketing methods.

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Measure 3.1.2 A, continued

Required Documentation

Guidance
Documentation could be a portion of a written program plan, a portion of a program strategic
plan, minutes of a program planning meeting, part of a report developed for submission to a
funding agency, or other official description of the strategy.
Due to the limited availability of evidence-based practices or promising practices in Tribal
communities, Tribes may provide examples of practice-based evidence used to adapt
models or create models based on a cultural framework.

2. Documentation that indicates how input
and/or feedback was gathered from the
target audience during the development of
the health promotion strategy

2. The health department must provide one example of steps taken to solicit input and/or
feedback from the target audience during the development of the health promotion strategy.

3. Documentation that strategies have been
implemented in collaboration with
stakeholders and/or partners

3. The health department must provide documentation that the strategies identified in 1 above
were implemented in collaboration with stakeholders and/or partners. The stakeholders and
partners associated with the strategy must be listed. The documentation must define the
stakeholders’ or partners’ relationship and role to the strategy. The role could be to distribute
written information, include information in newsletters, or to reinforce the message in some
way through other programs or services.

The example must be from one of the two program areas from which documentation was
provided in 1, above. Documentation may include: findings from a focus group, key informant
interviews or pull-aside testing. It may also include minutes from a town meeting with the
target population or a meeting of an advisory group representing the target population.

Documentation may be minutes of a program review meeting, a portion of a report developed
for submission to a funding agency, an annual report, or other official description of the
implementation of the strategy.

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STANDARD 3.2: PROVIDE INFORMATION ON PUBLIC HEALTH
ISSUES AND PUBLIC HEALTH FUNCTIONS THROUGH MULTIPLE
METHODS TO A VARIETY OF AUDIENCES.
Health departments must have processes and procedures for communications. Processes and

procedures should address both accessing information from outside sources and communicating to

people outside of the department. Effective public health communication requires a variety of methods

and formats. Health departments should provide information to the public about the mission, processes,

programs, and interventions of the health department so that the public understands the role and value of
public health in its community and the resources available. Also included are plans to communicate with
the public in times of a crisis, disaster, outbreak or other threats to the public’s health.

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Standard 3.2: Provide information on public health issues and public health
functions through multiple methods to a variety of audiences.
Measure
3.2.1 A
Provide information on public health mission,
roles, processes, programs and interventions to
improve the public’s health

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Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to inform the public
about the role and value of public health and
the range of services and programs that the
health department provides.

Public health means different things to
different people at various times. The public’s
understanding of the value, mission, roles,
processes, programs, and interventions of the
health department is a necessary step in
building effective public health programs.

Required Documentation

Guidance

1. Documentation of providing information to
the public about what public health is, its
value, and/or on the health department’s
roles, processes, programs, and
interventions

1. The health department must submit two examples of information it provides to the public
about the role and value of public health and/or the health department’s role, mission, and
scope of processes, programs and interventions. Documentation could include: a copy of a
presentation, advertisements or newspaper inserts, web posting, email or fax list-serve, fax
cover sheet, brochure, services directory, or program flyers. The documentation must
describe how the information was distributed, dates of distribution (or range of dates), and
the purpose of the information.

2. Documentation of branding or
communication of presence of the health
department

2. The health department must provide two examples of methods to communicate the existence
and presence of the health department. Documentation may include a written health
department policy stating that all brochures, flyers, press releases, reports and other
materials bear the department’s name and logo. Documents may also note that department
uniforms or apparel should display the department logo, and a photograph can demonstrate
appropriate signage inside and outside the health department facility.

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Standard 3.2: Provide information on public health issues and public health
functions through multiple methods to a variety of audiences.
Measure
3.2.2 A
Establish and maintain communication
procedures to provide information outside the
health department

Significance

The purpose of this measure is to assess the
health department’s written procedures for
communication and the implementation of the
procedures.

Written procedures and protocols that are put
into practice ensure consistency in the
management of communications on public
health issues. Such measures also ensure that
the information is in an appropriate format to
reach target sectors or audiences. This
includes responding to requests for information
or materials that the health department
distributes in its jurisdiction. Departments
should answer information requests in a timely
and appropriate fashion and should obtain
appropriate reviews and approvals of
information they disseminate.

Required Documentation

Guidance

1. Written procedures for communications,
updated biennially, that include:
a. Disseminating accurate, timely, and
appropriate information for different
audiences

1. The health department must provide a copy of communications procedures. The procedures
must be dated to provide evidence that they were created or have been reviewed within the
last two years. There is no required format for the procedures. The procedures must:
a. Describe the process for disseminating information accurately, timely, and
appropriately. The procedures must define the process for different audiences who
may request or receive information from the health department.
b. Describe the process for informing and/or coordinating with community partners to
promote the dissemination of consistent and unified public health messages that are
accurate and appropriate for the audience.

b. Informing and/or coordinating with
community partners for the
communication of targeted and
unified public health messages
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Purpose

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Measure 3.2.2 A, continued

Required Documentation

Guidance

c. Maintaining a current contact list of
media and key stakeholders

c. Include a current contact list of media and key stakeholders related to the protocol;
set forth when the contact list is to be used; and include the process for maintaining
the contact list.
d. Designate a department staff position as public information officer. The protocol must
define this officer’s responsibilities, which must include: maintaining media
relationships; creating appropriate, effective public health messages; and managing
other communications activities.
e. Describe the responsibilities for all staff positions that may interact with the news
media and the public. This may include guidance for specific staff, such as the
director and public information officer, as well as guidance for others, including any
governing entity members who may speak on behalf of the health department or any
department staff member who may be contacted by the public or press.

d. Designating a staff position as the
public information officer

e. Describing responsibilities and
expectations for positions
interacting with the news media
and the public, including, as
appropriate, any governing entity
members and any department staff
member

2. Dissemination of public health messages
outside the health department

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The Tribal attorney may need to be included when crafting messages for the public and
the public health partners, especially for situations involving Tribal sovereignty, land and
mineral disputes, or interactions with other local and federal government entities.
Evidence of Tribal attorney use is acceptable documentation for items listed above, as
appropriate.
2. The health department must submit two examples of the department following their
communications procedures listed in 1, above. The two examples must come from two
different program areas, one of which is a chronic disease program. Documentation could be
a press release, email between the public information officer and the media, or other written
communication to the media.

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Standard 3.2: Provide information on public health issues and public health
functions through multiple methods to a variety of audiences.
Measure
3.2.3 A
Maintain written risk communication plan

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Purpose

Significance

The purpose of this measure is to assess the
health department’s plans for risk
communication during a crisis, disaster,
outbreak, or other threat. The goal: Ensure an
accurate understanding of the actual and
perceived public health risks, the possible
solutions, and related issues and concerns
voiced by experts and non-experts.

The purpose of the risk communication plan is
to detail the communications and media
protocols the health department will follow
during a public health crisis or emergency.
The risk communication plan outlines the
decisions and activities that will be taken for a
timely and effective response. The plan will
detail public relations processes and give
guidance on anticipating a crisis and
responding effectively. It should even address
how to prevent public alarm by dealing
appropriately with rumor or misinformation. A
risk communication plan may be called an
emergency communication, crisis
communication or media communication plan.

Required Documentation

Guidance

1. Written risk communication plan

1. The health department must provide a copy of the risk communication plan, protocol, or
procedures. The plan must provide protocols for how information is provided for a given
situation, delineate roles and responsibilities, and describe how the health department will
work with the media. There is no required format for the plan; it may be a part of a larger
communications plan or part of an overall department emergency operations plan.

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Measure 3.2.3 A, continued

Required Documentation

Guidance
For Tribal health departments, documentation may include referencing an existing, approved
Tribal policy that identifies another Tribal employee or program (such as the Tribal emergency
management planner) as being responsible for the risk communication plan and its
implementation. For smaller Tribal health departments and programs, this measure could also
be met with a written MOU or MOA with an external agency, such as a local health
department, with clearly delineated roles for Tribal and non-Tribal staff and elected officials
involved in the plan.

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Standard 3.2: Provide information on public health issues and public health
functions through multiple methods to a variety of audiences.
Measure
3.2.4 A
Make information available through a variety
of methods

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Purpose

Significance

The purpose of this measure is to assess the
health department’s use of a variety of
methods and formats to keep the public
informed about public health and
environmental public health issues, health
status, public health laws, health programs,
and other public health information.

Health departments should present information
to different audiences through a variety of
methods, including information technology.

Required Documentation

Guidance

1. Website or web page that contains current
information on the following issues:
a. 24/7 contact number for reporting
health emergencies
b. Notifiable/reportable conditions
line or contact number
c. Health data
d. Links to public health related laws

1. The health department must provide documentation of a website that provides:

Public Health Accreditation Board • Standards & Measures

a. A 24/7 contact number for reporting health emergencies
b. Notifiable/reportable conditions line or contact number
c. Health data, such as morbidity and mortality data
d. Links to public health related laws

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Measure 3.2.4 A, continued

Required Documentation

Guidance

e. Information and materials from
program activities
f. Links to CDC and other public
health related federal, state, or local
agencies, as appropriate

e. Information and materials from program activities, such as communicable disease,
chronic diseases, environmental public health, and prevention
f. Links to CDC and other public health related federal, state, or local agencies, as
appropriate
The health department may have its own website or be part of another government
website or internet domain. Documentation may be submitted by providing links to web
pages that have the information requested in each of the elements listed.

2. Two examples of other communication
strategies for informing the public about
public health issues or functions

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2. The health department must provide two examples of other methods used to make
information available to the general public about public health issues and/or functions.
Methods could include: radio or television programs or interviews, brochures, flyers,
newsletters, or other information technologies, such as Facebook or Twitter. Methods that
target low-literacy individuals could include audio-visual formats and/or written materials that
include images to support text.

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Standard 3.2: Provide information on public health issues and public health
functions through multiple methods to a variety of audiences.
Measure
3.2.5 A
Provide accessible, accurate, actionable, and
current information in culturally sensitive and
linguistically appropriate formats for
populations served by the health department

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to convey public
health information to the population it serves,
including those who are hard to reach or who
present language or cultural challenges.

Public health information, for whatever purpose
or audience, must be understandable and
usable by the recipient audience. Information
should be accessible to all audiences in the
jurisdiction served, whether they speak another
language, are hearing impaired, or have low
literacy.

Required Documentation

Guidance

1. Demographic data regarding ethnicity and
languages spoken in the community

1. The health department must provide demographic data defining the ethnic distribution and
languages spoken in the jurisdiction served.

2. List of staff or contractors providing
interpretation, translation, or other specific
communication services

2. The health department must provide a list of staff or contractor(s) who provide interpretation,
translation, or specific communication services. Specific communication services may mean
low literacy or hearing impaired communications. These services are provided as needed,
based on demographic data. The services do not have to be provided directly by the health
department, but must be available when needed.
Tribal health departments may have “Indian preference” policies that demonstrate the
promotion of culturally appropriate interactions between staff and community members.
CHRs or “Cultural Interpreters” may also be available to provide both translation and
feedback from community members on program materials or services provided.

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Measure 3.2.5 A, continued

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Required Documentation

Guidance

3. Availability of assistive staff or technology
devices to meet ADA requirements

3. The health department must provide evidence of TTY for the hearing impaired, assistance for
the visually impaired, and/or other assistive staff or technology devices available to meet ADA
requirements. Other examples may be emails, texting, and social networking online.

4. Materials that are culturally appropriate, in
other languages, at low reading level,
and/or address a specific population that
may have difficulty with the receipt or
understanding of public health
communications

4. The health department must provide two examples of materials, currently in use, which are
appropriate for a population who may have difficulty with the receipt or understanding of
public health communications. Examples are materials that are in a language other than
English, written for individuals with low English literacy, communicated for the hearing
impaired, or unique to address cultural differences in a population. The two examples must
be from different program areas.

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Domain 4: Engage with the community to identify and address health problems
Domain 4 focuses on community engagement. Community members are important partners in identifying and defining public health issues, developing
solutions or improvements, developing policies, communicating important information, and implementing public health initiatives. Members of the
community offer a unique perspective on how issues are manifested in the community, what community assets can be mobilized, and what
interventions will be effective. Public health can broaden its leverage and impact by doing things with the community rather than doing things to the
community. This domain addresses health departments’ establishment and maintenance of community relationships that will facilitate public health
goals being accomplished.

DOMAIN 4 INCLUDES TWO STANDARDS:
Standard 4.1
Standard 4.2

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Engage with the Public Health System and the Community in Identifying and Addressing Health Problems
Through Collaborative Processes
Promote the Community’s Understanding of and Support for Policies and Strategies That will Improve the
Public’s Health

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STANDARD 4.1: ENGAGE WITH THE PUBLIC HEALTH SYSTEM AND
THE COMMUNITY IN IDENTIFYING AND ADDRESSING HEALTH
PROBLEMS THROUGH COLLABORATIVE PROCESSES.
Health improvement efforts will be most effective if the community has contributed to the dialogue,

deliberated on the options and alternatives, and taken ownership of the decisions. Collaboration with other
members of the public health system and with representatives of the community develops a sense of

shared responsibility and leads to better coordination of the use of resources. Collaboration provides the

health department with various perspectives and additional expertise. Collaboration allows the community’s
assets to be mobilized and coordinated for increased community efficacy in dealing with public health
issues and concerns.

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Standard 4.1: Engage with the public health system and the community in
identifying and addressing public health problems through collaborative
processes.

Measure

4.1.1 A
Establish and/or actively participate in
partnerships and/or coalitions to address
specific public health issues or populations

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Purpose

Significance

The purpose of this measure is to assess the
health department’s engagement with
representatives of sectors of the community
and partners in the public health system to
address public health issues and concerns.

Collaboration to address particular public
health issues and concerns or populations
provides various perspectives and additional
expertise. Collaboration provides the
opportunity to leverage resources, coordinate
activities, and employ community assets in new
and effective ways. Collaboration includes
engagement with community members so that
they are participants in the process and feel
connected to the decisions made and
actions taken.

Required Documentation

Guidance

1. Documentation of current collaborations
that address specific public health issues
or populations

1. The health department must provide two examples of current collaborations in which it is an
active member. Each collaboration must address a particular public health issue or population.
Examples include: an anti-tobacco coalition, a maternal and child health coalition, an HIV/AIDS
coalition, a childhood injury prevention partnership, child labor coalition, immigrant
worker/community coalition, newborn screening advisory group, and a partnership to decrease
childhood obesity. Tribal public health departments may partner with other Tribal or local
partners, such as Headstart, emergency management, and social services to address specific
Tribal health issues.

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Measure 4.1.1 A, continued

Required Documentation

Guidance
The collaboration must focus on public health issues. These include: an already established
program area; a newly identified issue; an issue identified by the health assessment; a
strategy or action included in a health improvement plan; a potential public health threat or
hazard; a population with particular health needs; and/or goals of the health department,
community, region, or state.
These collaborations may be convened by the health department, by another organization, or
by community members. The health department must actively participate. Examples must be
from current productive partnerships, and not partnerships that have completed their tasks
and disbanded.
Documentation could include a summary or report of the coalition, indicating on-going
activities, meeting minutes, agendas, etc.

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2. List of partner organizations or
representation in each collaboration

2. The health department must provide a list of the participating partner organizations in the two
collaborations referenced in 1 above. Individuals’ names are not required. Organizational and
representational membership must be listed. For example: the community hospital; the school
system; and specific businesses, social service organizations, non-profit organizations, faith
institutions, private citizen, or member of a particular population group. The membership
should be appropriate for the topic being addressed by the coalition.

3. Description of process used to mobilize the
Tribal/state/local community

3. The health department must provide a description of the process, protocol, steps taken, or
strategies employed to engage with and mobilize the community. Examples include:
community member representation on the collaborative, a community deliberative process,
town meetings, and open forums.

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Standard 4.1: Engage with the public health system and the community in
identifying and addressing public health problems through collaborative
processes.

Measure

4.1.2 T/L
Link stakeholders and partners to technical
assistance regarding models of engaging with
the community

Purpose

Significance

The purpose of this measure is to assess the
Tribal and local health department’s provision
of recommendations concerning sources of
information about principles, processes, and
models of community engagement.

Tribal and local health departments are a
community resource for partners and
stakeholders who are seeking information
about engaging with the community. Local
health departments should be able to assist
and link partners and stakeholders to
resources for information on the principles,
processes, and models for engaging with
the community.

Required Documentation

Guidance

1. Documentation of consultation, technical
assistance, or information provided on
models of community engagement

1. Tribal health departments and local health departments must provide two examples of
consultation, technical assistance, or information provided to a community partner or
stakeholder concerning an established model for collaborative community engagement.
Tribal health departments must provide supporting documentation that they forward technical
assistance requests to the state or a federal agency, such as IHS, BIA, CDC or EPA, or that
they work in partnership with state or local health departments, or other organizations/entities,
such as an academic institution or consultant.

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Measure 4.1.2 T/L, continued
Required Documentation

Guidance
Examples of documentation may include: emails, newsletters, meeting minutes, web based
assistance, agenda of meetings, documented phone calls, presentations, or training sessions
that provide information about community engagement principles, processes, and/or models.
Established models of community engagement include: Healthy Cities/Communities;
adoption of community indicators; Community Asset Mapping; and deliberative processes,
such as regular town forums, community advisory groups, and participatory decision
processes. Public health specific tools include: the National Public Health Performance
Standards Program (NPHPSP) and Mobilizing for Action Through Planning and Partnership
(MAPP).

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Standard 4.1: Engage with the public health system and the community in
identifying and addressing public health problems through collaborative
processes.

Measure

4.1.2 S
Provide technical assistance to Tribal and
local health departments and/or public health
system partners regarding models for
engaging with the community

Purpose

Significance

The purpose of this measure is to assess the
state health department’s provision of
technical assistance to Tribal and local health
departments and/or to public health system
partners concerning models of community
engagement.

State health departments are a resource to
Tribal and local health departments in the state
and to public health system partners for
information about engaging with the
community.

Required Documentation

Guidance

1. Documentation of consultation, technical
assistance, and/or information provided
concerning the use of an established model
of community planning

1. The state health department must provide two examples of consultation, technical assistance,
and/or information provided to Tribal and local health departments or to public health system
partners on use of an established model for collaborative community engagement. The state
health department can provide this technical assistance directly, or through an established
partner or contractor, such as a consultant or academic institution.
Examples of documentation may include: emails, newsletters, meeting minutes, web based
assistance, agenda of meetings, documented phone calls, presentations, and training sessions.
Established models of community engagement include: Healthy Cities/Communities;
adoption of community indicators; Community Asset Mapping; and deliberative processes,
such as regular town forums, community advisory groups, and participatory decision
processes. Tools include the National Public Health Performance Standards Program
(NPHPSP) and Mobilizing for Action Through Planning and Partnership (MAPP).

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STANDARD 4.2: PROMOTE THE COMMUNITY’S UNDERSTANDING
OF AND SUPPORT FOR POLICIES AND STRATEGIES THAT WILL
IMPROVE THE PUBLIC’S HEALTH.
Community understanding and support is critical to the implementation of public health policies and

strategies. Community input and support is an important public health tool in developing and implementing
policies and strategies. It is important to gain community input to ensure that a policy or strategy is
appropriate, feasible and effective.

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Standard 4.2: Promote the community’s understanding of and support
for policies and strategies that will improve the public’s health.
Measure
4.2.1 A
Engage with the community about policies
and/or strategies that will promote the
public’s health

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to engage with the
community on public health policies and
strategies to promote the health of the
population.

A health policy or strategy will more likely be
strongly supported by the community if the
community has engaged in a dialogue,
deliberated on the options and alternatives,
and taken ownership of the issue and the
policy or strategy. Community engagement will
encourage a sense of shared responsibility for
the support and implementation of the policy
or strategy.

Required Documentation

Guidance

1. Engagement with members of the
community that will be affected by a policy
and/or strategy to promote the public’s
health

1. The health department must provide two examples of engagement with a particular
population that will be affected by a policy or strategy. The efforts can target the community
as a whole, if the policy or strategy is community-wide, or a specified audience, such as
those who will be most affected by a policy or strategy. Examples must have occurred in the
previous two years.
Documentation may be an announcement or minutes of a town meeting or public hearing, or a
call for review and input posted in the local newspaper. Other examples: meetings with a
particular geographic community served by the health department or a particular group of
people, such as adolescents, single mothers, or seniors.

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Standard 4.2: Promote the community’s understanding of and support
for policies and strategies that will improve the public’s health.
Measure
4.2.2 A
Engage with governing entities, advisory
boards, and elected officials about policies
and/or strategies that will promote the
public’s health

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to engage with
governing entities, advisory boards, and
elected officials whose policy decisions,
advice, or strategies affect public health
actions.

Health department policies and strategies will
more likely be endorsed and supported by
governing entities, advisory boards, and
elected officials if they have been informed,
engaged, and consulted during the decisionmaking process.

Required Documentation

Guidance

1. Engagement of the governing entity,
advisory boards, and/or elected officials
about policies and/or strategies that will
promote the public’s health

1. The health department must provide two examples of educating and/or working with the
governing entity, an advisory board, and/or elected officials on public health policy or
strategy. The two examples must be policies or strategies that address two separate public
health issues. The examples must have occurred in the previous two years.
Documentation may be a copy of a presentation, meeting packet, meeting agenda, meeting
minutes, press story, event summary, briefing paper, or written public comments. Tribal
documentation may include reports and/or meeting minutes from Health Oversight
Committees and Tribal Council meetings, and Tribal and non-Tribal media coverage,
including Tribal radio, newspapers, or newsletters.

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Domain 5: Develop public health policies and plans
Domain 5 focuses on the development of public health policies and plans. Written policies and plans serve as tools to guide the health department’s
work and bring structure and organization to the department. Written policies and plans provide a resource to health department staff as well as the
public. Policies and plans help to orient and train staff, inform the public and partners, and serve as a key component of developing consistency in
operations and noting areas for improvement. Policies and plans can be a vehicle for community engagement and shared responsibility for addressing
population health improvement.

Policies that are not public health specific may also impact the public’s health. Policy makers should be informed of the potential public health impact of
policies that they are considering or that are already in place. Policy makers and the public should have sound, science-based, current public health
information when policies are being considered or adopted.

DOMAIN 5 INCLUDES FOUR STANDARDS:
Standard 5.1

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Serve As a Primary and Expert Resource for Establishing and Maintaining Public Health Policies, Practices,
and Capacity

Standard 5.2

Conduct a Comprehensive Planning Process Resulting in a Tribal/State/Community Health Improvement Plan

Standard 5.3

Develop and Implement a Health Department Organizational Strategic Plan

Standard 5.4

Maintain an All Hazards Emergency Operations Plan

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STANDARD 5.1: SERVE AS A PRIMARY AND EXPERT RESOURCE
FOR ESTABLISHING AND MAINTAINING PUBLIC HEALTH
POLICIES, PRACTICES, AND CAPACITY.
Health departments possess knowledge and expertise on current public health science, evidence-based

interventions, and promising practices that are required to develop sound public health policies, practices,
and capacities. Health departments should play a central and active role in establishing policies and

practices, whenever governing entities, elected officials, and others set policies and practices with public
health implications.

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Standard 5.1: Serve as a primary and expert resource for establishing
and maintaining public health policies, practices, and capacity.
Measure
5.1.1 A
Monitor and track public health issues that are
being discussed by individuals and entities
that set public health policies and practices

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to maintain
knowledge about what public health policies
are being considered in order to be in a
position to influence development of
those policies.

Health departments must be constantly aware
of what public health issues are being
discussed by those who set public health
policies and practices so that they can be a
resource for science-based information,
thereby influencing the adoption of effective
policies and practices.

Required Documentation

Guidance

1. Documentation of monitoring/tracking
public health policies under consideration
by the governing entity, individuals, and/or
other entities that set public health policies
and practices

1. The health department must provide two separate examples that demonstrate that the
department stays informed of the public health issues that are being discussed by the health
department’s governing entity, or by elected officials, individuals, and/or other entities that set
public health policies and practices for the health department.
Local elected officials include: county (county manager, board of commissioners or supervisors)
or city officials (mayor, board of commissioners or supervisors). State elected officials include:
the governor, council of state, and state legislators. Tribal elected or appointed officials vary
depending on the Tribal Nation’s governance. Some examples include: Principal Chief, Chief,

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Measure 5.1.1 A, continued

Required Documentation

Guidance
President, Chairman/woman/person, Governor, Council Member, Legislator, and Business
Committee Member.
Documentation could include meeting minutes and agendas. Conformity could be
demonstrated by a health department log of health and environmental public health
legislation. Health department membership on a list-serve that discusses public health issues
could demonstrate this measure. Newsletters, reports, or summaries showing health
department review and tracking of public health issues by elected officials or governing
entities could also be acceptable.

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Standard 5.1: Serve as a primary and expert resource for establishing
and maintaining public health policies, practices, and capacity.
Measure
5.1.2 A
Engage in activities that contribute to the
development and/or modification of public
health policy

Purpose

Significance

The purpose of this measure is to assess the
Tribal, state, or local health department efforts
to contribute to and influence the
development and/or modification of Tribal,
state, or local public health policies.

To ensure that public health policies and
practices are effective, health departments
must be actively engaged in development
and/or modification of policies. The health
department can provide policy makers with
sound, science-based, current public health
information that should be considered in setting
policies and practice.

Required Documentation

Guidance

1. Documentation of the health department’s
contributions to deliberations concerning
public health policy

1. The health department must provide current (within the last 24 months) documentation that it
has contributed to deliberations concerning public health policy and practice. The health
department must engage with those who set policies, as well as with other stakeholders who
can influence those who set policies. The health department can also contribute to and
encourage stakeholder or community involvement in development and/or modification of
public health policy.
Documentation must address two of the three items listed below:
• Informational materials, such as issue briefs, media statements, talking points, fact
sheets, white papers, and other official written documents.

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Measure 5.1.2 A, continued

Required Documentation

Guidance
• Health department staff providing official department public testimony.
• Health department staff participation in an advisory or work group appointed by the
governing entity, elected officials, or the health department director. The group must
have community or stakeholder representation and have a stated purpose or intent of
providing advice or influencing health policy. This does not have to be the only role of
the group, but may be one among many responsibilities assigned.
The health department can define its stakeholders, but may include: health department staff;
elected/appointed officials; Tribal, state, or local representatives; community based
organizations; professional organizations; and community members or consumers.

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Standard 5.1: Serve as a primary and expert resource for establishing
and maintaining public health policies, practices, and capacity.
Measure
5.1.3 A
Inform governing entities, elected officials,
and/or the public of potential public health
impacts, both intended and unintended, from
current and/or proposed policies

Purpose

Significance

The purpose of this measure is to assess the
health department’s activities to provide
information about the intended or unintended
public health impacts of proposed or current
public policies.

The health department is responsible for
informing others of the potential public health
impact of policies that they are considering or
that are in place. Policies that are not health
specific may impact the public’s health. Health
departments should provide policy makers and
the public with sound, science-based, current
public health information that should be
considered in setting or supporting policies.

Required Documentation

Guidance

1. Documentation of the health department
informing policy makers and/or the public
about potential public health impacts of
policies that are being considered or are
in place

1. The health department must provide current (within the last 24 months) documentation that it
has informed policy makers and the public about potential public health impacts of policies that
are being considered or are in place. Included may be policies that impact public health but are
developed by other public sectors, such as land use, housing, employment, transportation, and
education. The measure requires the health department to address both intended and
unintended impact. Documentation can address policies either in effect or proposed.
Documentation must address two of the three items listed:
• Impact statement or fact sheet that addresses current or proposed policies. The impact
statements must be science-based. The health department must show to whom the
statement or fact sheet was distributed.

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Measure 5.1.3 A, continued

Required Documentation

Guidance
• The distribution of correspondence, emails, briefing statements, or reports on policy
impacts. If there is a discussion of policy issues and impacts, the documentation must
include who in the health department participated, who was invited to participate,
participant listing, what was discussed, meeting materials or agenda, and any followup to be completed.
• A presentation of evaluations or assessments of current and/or proposed policies. The
presentation or the evaluation/assessment report and an agenda for the presentation
must be provided as evidence.

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STANDARD 5.2: CONDUCT A COMPREHENSIVE PLANNING
PROCESS RESULTING IN A TRIBAL/STATE/COMMUNITY HEALTH
IMPROVEMENT PLAN.
The Tribal, state or community health improvement plan is a long-term, systematic plan to address issues
identified in the Tribal, state, or community health assessment. The purpose of the community health

improvement plan is to describe how the health department and the community it serves will work together
to improve the health of the population of the jurisdiction that the health department serves. The plan is
more comprehensive than the roles and responsibilities of the health department alone, and the plan’s
development must include participation of a broad set of stakeholders and partners. The planning and
implementation process is community-driven. The plan reflects the results of a participatory planning

process that includes significant involvement by a variety of community sectors. Stakeholders and partners
can use a solid community health improvement plan to set priorities, direct the use of resources, and
develop and implement projects and programs.

The state health department’s state health improvement plan addresses the needs of all citizens in the
state. The local health department’s community health improvement plan addresses the needs of the

citizens within the jurisdiction it serves. The Tribal health department’s Tribal health improvement plan
addresses the needs of the Tribal population residing within the Tribe’s jurisdictional area.

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Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure

5.2.1 S
Conduct a process to develop a state health
improvement plan

119

Purpose

Significance

The purpose of this measure is to assess the
state health department’s community health
improvement process and the participation of
stakeholders.

While the state health department is
responsible for protecting and promoting the
health of the population, it cannot be effective
acting unilaterally. The health department must
partner with other agencies and organizations
to plan and share responsibility for health
improvement. Stakeholders have access to
additional data and bring different perspectives
that will enhance planning. A collaborative
planning process fosters a shared sense of
ownership and responsibility for the plan’s
implementation. The state health improvement
process is a vehicle for developing
partnerships and for understanding roles
and responsibilities.

Required Documentation

Guidance

1. Description of a completed state
health improvement planning process
that included:

1. The state health department must provide documentation of a completed state health
improvement planning process. The process may be an accepted state or national model; a
model from the public, private, or business sector; or other participatory process model.
Examples of models include: Healthy Cities/Communities or Community Indicators Project.
Examples of tools and processes that may be adapted as a planning process or used for
particular components of the planning process include: community asset mapping, National
Public Health Performance Standards Program (NPHPSP), Assessment Protocol for Excellence
in Public Health (APEXPH), Healthy People 2020, and Protocol for Assessing Community
Excellence in Environmental Health (PACE-EH).

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Measure 5.2.1 S, continued

Required Documentation

a. Broad participation of public health
system partners

b. Information from the state health
assessment
c. Issues and themes identified by the
stakeholders
d. Identification of state assets and
resources
e. A process to set state health issues
priorities

120

Guidance
The state health department must provide documentation that the state health improvement
process included all of the following:
a. Participation by public health system partners. This can be documented through
participant lists, attendance rosters, minutes, or work groups or subcommittees.
Partners are organizations that work with the state health department on health issues
and may include other governmental agencies, statewide non-profit groups,
statewide associations, and others.
b. Data and information provided to participants in the state health improvement
planning process to use in their deliberations. This could include a list of data sets or
evidence that participants used the state health assessment.
c. Evidence that stakeholder discussions were held and that they identified issues and
themes. The list of issues must be provided as documentation.
d. Assets and resources identified and considered in the state health improvement
planning process.
e. Evidence that participants developed a set of priority state health issues.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.1 L
Conduct a process to develop community
health improvement plan

121

Purpose

Significance

The purpose of this measure is to assess the
local health department’s community health
improvement process and the participation
of stakeholders.

While the local health department is
responsible for protecting and promoting the
health of the population, it cannot be effective
acting unilaterally. The health department
must partner with other sectors and
organizations to plan and share responsibility
for community health improvement. Other
sectors of the community and stakeholders
have access to additional data and bring
different perspectives that will enhance
planning. A collaborative planning process
fosters a shared sense of ownership and
responsibility for the plan’s implementation.
The community health improvement process
is a vehicle for developing partnerships and
for understanding roles and responsibilities.

Required Documentation

Guidance

1. Completed community health improvement
planning process that included:

1. The local health department must provide documentation of a completed community health
improvement planning process. The process may be an accepted state or national model; a
model from the public, private, or business sector; or other participatory process model.
Examples of models include: Mobilizing for Action through Planning and Partnership (MAPP),
Healthy Cities/Communities, or Community Indicators Project. Examples of tools and
processes that may be adapted as a planning process or used for particular components of
the planning process include: community asset mapping, National Public Health
Performance Standards Program (NPHPSP), Assessment Protocol for Excellence in Public

Public Health Accreditation Board • Standards & Measures

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Measure 5.2.1 L, continued

Required Documentation

Guidance
(APEXPH), Healthy People 2020, and Protocol for Assessing Community Excellence in
Environmental Health (PACE-EH).

a. Broad participation of community partners

b. Information from community health
assessments

c. Issues and themes identified by
stakeholders in the community
d. Identification of community assets and
resources
e. A process to set community health priorities

122

The local health department must provide documentation of a completed community health
improvement process framework. The local health department must provide documentation
of the community health improvement process that includes all of the following:
a. Participation by community partners. This can be documented through participant
lists, attendance rosters, minutes, or work groups or subcommittees. Partners are
community members, organizations, businesses, other governmental agencies, nonprofit groups, associations, and others that work with the health department on health
issues. Members of this group may or may not be the same as members of the
community health assessment partnership.
b. Data and information from the community health assessment that were provided to
participants in the community health improvement planning process for use in their
deliberations. This may include a list of data sets or evidence that participants used
the community health assessment.
c. Evidence that stakeholder discussions were held and that they identified issues and
themes. The list of issues must be provided as documentation.
d. Assets and resources identified and used in the community health
improvement process.
e. Evidence that participants developed a set of priority community health issues.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.1 T
Conduct a process to develop a Tribal
community health improvement plan

123

Purpose

Significance

The purpose of this measure is to assess the
Tribal health department’s community health
improvement process and the participation
of stakeholders.

While the Tribal health department is
responsible for protecting and promoting the
health of the population, it cannot be effective
acting unilaterally. The health department must
partner with other sectors and organizations to
plan and share the responsibility for health
improvement. Other sectors of the community
and stakeholders have access to additional
data and bring different perspectives that will
enhance planning. A collaborative planning
process fosters a shared sense of ownership
and responsibility for the plan’s implementation.
The community health improvement process is
a vehicle for developing partnerships and for
understanding roles and responsibilities.

Required Documentation

Guidance

1. Completed community health improvement
planning process that included:

1. The Tribal health department must provide documentation of a completed community health
improvement planning process. The process may be an accepted state or national model; a
model from the public, private, or business sector; or other participatory process model.
Examples of models include: Mobilizing for Action through Planning and Partnership (MAPP),
Healthy Cities/Communities, or a Community Indicators Project. Examples of other tools and
processes that may be adapted as a planning process or used for particular components of
the planning process include: community asset mapping, National Public Health
Performance Standards Program (NPHPSP), Assessment Protocol for Excellence in Public
Health (APEXPH), Healthy People 2020, Protocol for Assessing Community Excellence in

Public Health Accreditation Board • Standards & Measures

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Measure 5.2.1 T, continued

Required Documentation

Guidance
Environmental Health (PACE-EH), and the Indian Community Health Profile.

a. Broad participation of public health
system partners

b. Information from Tribal or
community health assessments

c. Issues and themes identified by
the stakeholders
d. Identification of Tribal assets
and resources
e. A process to set Tribal health
priorities

124

The Tribal health department must provide documentation of the Tribal community health
improvement process that includes all of the following:
a. Participation by public health system partners. This can be documented through
participant lists, attendance rosters, minutes, or work groups or subcommittees.
Partners are organizations that work with the Tribal health department to address
health issues and may include other governmental agencies, statewide non-profit
groups, statewide associations, and others. Members of this group may or not be the
same as members of the community health assessment partnership.
b. Data and information from the Tribal community health assessment that were
provided to participants in the Tribal health improvement planning process to use in
their deliberations. National data sources on American Indian/Alaska Native
populations include Indian Health Service data and other sources.
c. Evidence that stakeholder discussions were held and that they identified issues and
themes. The list of issues must be provided as documentation.
d. Assets and resources identified and used in Tribal community health improvement
planning process.
e. Evidence that participants developed a set of priority Tribal health issues.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.2 S
Produce a state health improvement plan
as a result of the health improvement
planning process

125

Purpose

Significance

The purpose of this measure is to assess the
state health department’s completion of a
state health improvement plan. While some or
many programs in the state health department
may have program specific plans, they do not
fulfill the purpose of the state health
improvement plan, which looks at population
health across programs.

The state health improvement plan provides
guidance to the health department, its partners,
and stakeholders for improving health of the
population within the health department’s
jurisdiction. The plan reflects the results of a
participatory planning process that includes
significant involvement by key sectors. Partners
can use a solid state health improvement plan
to prioritize existing activities and set new
priorities. The plan can serve as the basis for
partnership development and can facilitate
collaborations.

Required Documentation

Guidance

1. State health improvement plan dated within
the last five years that includes:
a. Statewide health priorities,
measurable objectives,
improvement strategies, and
performance measures with
measurable and time-framed
targets

1. The state health department must provide a state health improvement plan dated within the
last five years that includes all of the following:
a. Statewide health priorities, measurable objectives, improvement strategies, and
performance measures with measurable and time-framed targets that were
determined in the planning process. Measurable and time-framed targets may be
contained in another document, such as an annual work plan. If this is the case, the
companion document must be provided with the state health improvement plan for
this measure. Strategies should be evidenced based or promising practices. National
state-of-the-art guidance, such as the National Prevention Strategy, Guide to
Community Preventive Services, and Healthy People 2020, should be referenced.

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Measure 5.2.2 S, continued

Required Documentation

Guidance

b. Policy changes needed to
accomplish health objectives
c. Individuals and organizations that
have accepted responsibility for
implementing strategies

d. Measurable health outcomes or
indicators to monitor progress

e. Alignment between the state health
improvement plan and Tribal, local
and national priorities

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b. Policy changes needed to accomplish the identified health objectives must be
included in the plan.
c. Designation of individuals and organizations that have accepted responsibility for
implementing strategies outlined in the state health improvement plan. This may
include assignments to staff or agreements between planning participants,
stakeholders, other state governmental agencies, or other statewide organizations.
For this measure, agreements do not need to be formal, such as an MOA/MOU.
d. Measurable health outcomes or indicators to monitor progress. These may be
compiled with the objectives and measures, as stated in section b above, and may
also be in a companion document. If this is the case, the companion document must
be provided with the health improvement plan for this measure.
e. Alignment between state priorities described in the state health improvement plan
and both local priorities in the community and national priorities. States must
demonstrate alignment with both Tribal and local health department health
improvement priorities, where appropriate. National priority alignment could include
using the National Prevention Strategy and Healthy People 2020.

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.2 L
Produce a community health improvement
plan as a result of the community health
improvement process

127

Purpose

Significance

The purpose of this measure is to assess the
local health department’s completion of a
community health improvement plan. While
some or many programs in the local health
department may have program specific plans,
they do not fulfill the purpose of the
community health improvement plan, which
looks at population health of the community
across programs.

The community health improvement plan
provides guidance to the health department,
its partners, and stakeholders for improving
the health of the population within the health
department’s jurisdiction. The plan reflects the
results of a participatory planning process that
includes significant involvement by key
sectors. Partners can use a solid community
health improvement plan to prioritize existing
activities and set new priorities. The plan can
serve as the basis for partnership
development and can facilitate collaboration.

Required Documentation

Guidance

1. Community health improvement plan dated
within the last five years that includes:
a. Community health priorities,
measurable objectives,
improvement strategies and
performance measures with
measurable and time-framed
targets

1. The local health department must provide a community health improvement plan dated within
the last five years that includes all of the following:
a. Community health priorities, measurable objectives, improvement strategies and
performance measures with measurable and time-framed targets that were
determined in the planning process. Measurable and time-framed targets may be
contained in another document, such as an annual work plan. If this is the case, the
companion document must be provided with the health improvement plan for this
measure. Strategies should be evidence-based or promising practices. National
state-of-the-art guidance, such as the National Prevention Strategy, Guide to
Community Preventive Services, and Healthy People 2020, should be referenced.

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Measure 5.2.2 L, continued

Required Documentation

Guidance

b. Policy changes needed to
accomplish health objectives
c. Individuals and organizations that
have accepted responsibility for
implementing strategies

d. Measurable health outcomes or
indicators to monitor progress

e. Alignment between the community
health improvement plan and the
state and national priorities

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Public Health Accreditation Board • Standards & Measures

b. Policy changes needed to accomplish the identified health objectives must be
included in the plan.
c. Designation of individuals and organizations that have accepted responsibility for
implementing strategies outlined in the community health improvement plan. This
may include assignments to staff or agreements between planning participants,
stakeholders, other local governmental agencies, or other community organizations.
For this measure, agreements do not need to be formal, such as an MOA/MOU.
d. Measurable health outcomes or indicators to monitor progress. These may be
compiled with the objectives and measures as stated in section b above and may
also be in a companion document. If this is the case, the companion document must
be provided with the health improvement plan for this measure.
e. Alignment between community priorities described in the community health
improvement plan and both state and national priorities. Local health departments
must demonstrate alignment with both Tribal and state health improvement priorities,
where appropriate. National and state priority alignment would include the National
Prevention Strategy and Healthy People 2020.

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.2 T
Produce a Tribal community health
improvement plan as a result of the health
improvement process

129

Purpose

Significance

The purpose of this measure is to assess the
Tribal health department’s completion of a
Tribal community health improvement plan.
While some or many programs in the Tribal
health department may have program specific
plans, they do not fulfill the purpose of the
Tribal community health improvement plan,
which looks at population health across
programs.

The Tribal community health improvement plan
provides guidance to the health department,
its partners, and stakeholders for health
improvement. The plan reflects the results of a
participatory planning process that includes
significant involvement by key sectors.
Partners can use a solid health improvement
plan to prioritize existing activities and set new
priorities. The plan can serve as the basis for
partnership development and facilitate
collaboration.

Required Documentation

Guidance

1. Tribal health community improvement plan
dated within the last five years that includes:
a. Tribal health priorities, measurable
objectives, improvement strategies
and performance measures with
measurable and time-framed
targets

1. The Tribal health department must provide a Tribal health improvement plan dated within the
last five years that includes all of the following:
a. Tribal health priorities, measurable objectives, improvement strategies, and
performance measures with measurable and time-framed targets that were
determined in the planning process. Measurable and time-framed targets may be
contained in another document, such as an annual work plan. If this is the case, the
companion document must be provided with the health improvement plan for
this measure.

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Measure 5.2.2 T, continued

Required Documentation

Guidance

b. Policy changes needed to
accomplish health objectives
c. Individuals and organizations that
have accepted responsibility for
implementing strategies

d. Measurable health outcomes or
indicators to monitor progress

e. Documentation of alignment
between the health improvement
plan and state and national
priorities

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Public Health Accreditation Board • Standards & Measures

b. Policy changes needed to accomplish the identified health objectives must be
included in the plan.
c. Designation of individuals and organizations that have accepted responsibility for
implementing strategies outlined in the Tribal health improvement plan. This may
include assignments to staff or agreements between planning participants,
stakeholders, other state governmental agencies, or other Tribal or statewide
organizations. For this measure, agreements do not need to be formal and do not
require compacts, contracts or an MOA/MOU.
d. Measurable health outcomes or indicators to monitor progress. These may be
compiled with the objectives and measures as stated in section b above and may
also be in a companion document. If this is the case, the companion document must
be provided with the health improvement plan for this measure.
e. Alignment between Tribal priorities described in the Tribal community health
improvement plan and both State and national priorities. Tribes must demonstrate
alignment with both State and local health department health improvement priorities,
where appropriate. This could include the National Prevention Strategy and Healthy
People 2020.

Version 1.0 • Approved May 2011

Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.3 A
Implement elements and strategies of the
health improvement plan, in partnership
with others

131

Purpose

Significance

The purpose of this measure is to assess the
Tribal, state, or local health department’s
implementation of its community health
improvement plan in partnership with others.

Any plan is useful only when it is implemented
and provides guidance for priorities, activities,
and resource allocation.

Required Documentation

Guidance

1. Reports of actions taken related to
implementing strategies to improve health

1. The health department must provide reports showing implementation of the plan.
Documentation must specify the strategies being used, the partners involved, and the status or
results of the actions taken. The report could be a work plan for the community health
improvement plan showing timelines and progress. This could be in narrative or a table format.

2. Examples of how the plan was
implemented

2. The health department must provide two examples of how the plan was implemented by the
health department and/or its partners.

Public Health Accreditation Board • Standards & Measures

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Standard 5.2: Conduct a comprehensive planning process resulting
in a Tribal/state/community health improvement plan.
Measure
5.2.4 A
Monitor progress on implementation of
strategies in the community health
improvement plan in collaboration with broad
participation from stakeholders and partners

132

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to ensure that the
implementation of the community health
improvement plan is evaluated and that the
plan is revised as indicated by those
evaluations.

Effective, implemented plans are dynamic. The
plan may need revision based on a completed
objective, a newly identified priority, a change
in responsibilities, or a change in resources
and assets. All aspects of the plan, and the
identified tasks and timelines, should be
monitored for progress, and adjustments
should be made when indicated to ensure that
the plan remains relevant. Changes should be
developed in collaboration with partners and
stakeholders involved in the planning process.

Required Documentation

Guidance

1. Evaluation reports on progress made in
implementing strategies in the community
health improvement plan including:
a. Monitoring of performance
measures
b. Progress related to health
improvement indicators

1. The health department must provide annual evaluation reports on progress in implementing
the community health improvement plan. Documentation must include:

Public Health Accreditation Board • Standards & Measures

a. Monitoring progress in meeting performance measures
b. Description of the progress made on health indicators as defined in the plan. It may
take several years to show measurable progress in health indicators. If there has
been no progress, the health department should explain that no progress has been
evidenced to date.
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Measure 5.2.4 A, continued

133

Required Documentation

Guidance

2. Revised health improvement plan based on
evaluation results

2. The health department must show that the health improvement plan has been revised based
on the evaluation listed in 1 above. The revisions can be in the health priorities, objectives,
improvement strategies, performance measures, time-frames, targets, or health outcome
indicators listed in the plan. Revisions may be based on achieved performance measures,
implemented strategies, changing health status indicators, newly developing or identified
health issues, and changing level of resources.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

STANDARD 5.3: DEVELOP AND IMPLEMENT A HEALTH
DEPARTMENT ORGANIZATIONAL STRATEGIC PLAN.

Strategic planning is a process for defining and determining an organization’s roles, priorities, and direction

over three to five years. A strategic plan sets forth what an organization plans to achieve, how it will achieve
it, and how it will know if it has achieved it. The strategic plan provides a guide for making decisions on

allocating resources and on taking action to pursue strategies and priorities. A health department’s strategic
plan focuses on the entire health department. Health department programs may have program-specific
strategic plans that complement and support the health department’s organizational strategic plan.

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Standard 5.3: Develop and implement a health
department organizational strategic plan.
Measure
5.3.1 A
Conduct a department strategic planning
process

Significance

The purpose of this measure is to assess the
health department’s strategic planning
process.

A functional and useful strategic plan requires
that it be understood by staff and implemented
by the health department. The development of
such a plan requires a planning process that
considers opinions and knowledge from
across the health department, assesses the
larger environment in which the health
department operates, uses its organizational
strengths and addresses its weaknesses, links
to the health improvement plan that has been
adopted by the community, and links to the
health department’s quality improvement plan.

Required Documentation

Guidance

1. Description of elements of the planning
process used to develop the organization’s
strategic plan:

1. The health department must document the process that it used to develop its organizational
strategic plan. The planning process may have been facilitated by staff of the health
department or by an outside consulting organization or individual. If the health department is
part of a super health agency or umbrella agency, the department’s process may have been
part of a larger organizational planning process. If that is the case, the health department
must have been actively engaged in the process and must provide evidence that public
health was an integral component in the process.
a. A list of the individuals who participated in the strategic planning process and their
titles must be provided. Participants should include the health department’s

a. Membership of the strategic
planning group
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Purpose

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Measure 5.3.1 A, continued

Required Documentation

Guidance

b. Strategic planning process steps

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governing entity members or representatives. Documentation could be meeting
minutes, a report that presents the members of a strategic planning committee, or
other formal listing of participants.
b. Documentation must include a summary or overview of the strategic planning
process, including the number of meetings, duration of the planning process, and
the methods used for the review of major elements by stakeholders. Steps in the
planning process must be described, such as opportunities and threats analysis or
environmental scanning process, stakeholder analysis, story-boarding, strengths and
weaknesses analysis, or scenario development.

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Standard 5.3: Develop and implement a health
department organizational strategic plan.
Measure
5.3.2 A
Adopt a department strategic plan

Required Documentation

Purpose

Significance

The purpose of this measure is to assess the
health department’s completion and adoption
of a department strategic plan.

A strategic plan defines and determines the
health department’s roles, priorities, and
direction over three to five years. A strategic
plan sets forth what the department plans to
achieve as an organization, how it will achieve
it, and how it will know if it has achieved it. The
strategic plan provides a guide for making
decisions and allocating resources to pursue
its strategies and priorities.

Guidance
If the health department is part of a super health agency or umbrella agency, the health
department’s strategic plan may be part of a larger organizational plan. If that is the case, the
plan must include a section that addresses the health department and includes the required
elements of the plan specific to the health department. Submitted documentation should include
only the section(s) of the larger plan that addresses the health department and not the entire
plan. If the plan of the super health agency or umbrella agency does not include the required
elements for the health department, then the health department must conduct an internal
planning process and adopt a health department specific strategic plan.

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Measure 5.3.2 A, continued

Required Documentation

Guidance

1. Health department strategic plan dated
within the last five years that includes:

1. The health department must provide a strategic plan that is dated within the last five years.
Some health departments may have shorter planning timeframes and, for example, may
produce a strategic plan every three years. Some of the goals in the plan may be for a longer
time period than five years, but the plan must have been produced or revised within the last
five years. The health department may not officially call the plan a “strategic plan,” but it must
include the items listed in a through f.
There is no required or suggested format for the strategic plan. There is no required or
suggested length of the strategic plan.

a. Mission, vision, guiding
principles/values
b. Strategic priorities
c. Goals and objectives with
measurable and time-framed
targets
d. Identification of external trends,
events, or factors that may impact
community health or the health
department
e. Assessment of health department
strengths and weaknesses
f. Link to the health improvement plan
and quality improvement plan

138

The strategic plan must include all of the following:
a. The health department’s mission, vision, and guiding principles/values for the health
department
b. The health department’s strategic priorities
c. The health department’s goals and objectives with measurable and time-framed
targets (expected products or results). Measurable and time-framed targets may be
contained in another document, such as an annual work plan. If this is the case, the
companion document must be provided with the strategic plan for this measure.
d. The identification of external trends, events, or other factors that may impact
community health or the health department

Public Health Accreditation Board • Standards & Measures

e. The analysis of the department’s strengths and weaknesses
f. Linkages with the health improvement plan and details on the health department’s
roles and responsibilities for implementing the health improvement plan. It must also
link with the health department’s quality improvement plan. The strategic plan need
not link to all elements of the health improvement plan or quality improvement plan,
but it must show where linkages are appropriate for effective planning and
implementation.
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Standard 5.3: Develop and implement a health
department organizational strategic plan.
Measure
5.3.3 A
Implement the department strategic plan

139

Purpose

Significance

The purpose of this measure is to assess the
health department’s implementation of its
strategic plan.

A plan is useful only when it is implemented
and provides guidance for priorities, activities,
and resource allocation. A strategic plan sets
forth what the department plans to achieve as
an organization, how it will achieve it, and how
it will know if it has achieved it. It is important
to regularly review the implementation of the
plan to ensure that the department is on track
to meet its targets.

Required Documentation

Guidance

1. Annual reports of progress towards goals
and objectives contained in the plan,
including monitoring and conclusions on
progress toward meeting targets

1. The health department must provide annual reports since the plan’s adoption showing that it
has reviewed the strategic plan and has assessed progress towards reaching the goals and
objectives. The reports must include how the targets are monitored. Progress is evidenced by
completing defined steps to reach a target, by completing objectives, or by addressing
priorities and implementing activities. The plan may be revised based on work completed,
adjustments to timelines, or changes in available resources.

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STANDARD 5.4: MAINTAIN AN ALL HAZARDS EMERGENCY
OPERATIONS PLAN.

Health departments play important roles in preparing for and responding to disasters, including preventing

the spread of disease, protecting against environmental public health hazards, preventing injuries, assisting
communities in recovery, and assuring the quality and accessibility of health and health care services

following a disaster. Disasters include: natural disasters (such as floods, earthquakes, and tornadoes),

manmade or technological disasters (such as bridge or building collapses, nuclear accidents, and chemical
releases), and terrorism (such as anthrax or other biological or chemical terrorism, or bombings). Plans for
responding to emergencies are critical to being prepared for effective action during disasters and similar
emergency events.

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Standard 5.4: Maintain an all hazards emergency operations plan.
Measure
5.4.1 A
Participate in the process for the development
and maintenance of an All Hazards
Emergency Operations Plan (EOP)

141

Purpose

Significance

The purpose of this measure is to assess the
health department’s collaborative activities to
organize coordinated responses to
emergencies.

Health departments play a central but not
exclusive role in response to emergencies. It
is critical to ensure effective coordination of
many agencies and organizations involved in
responding to emergencies and in managing
the many response activities.

Required Documentation

Guidance

1. Collaborative planning through
preparedness meetings with other
government agencies

1. The health department must document that it participates in preparedness meetings with
other government agencies. This documentation could be meeting agendas and minutes,
meeting rosters, calendar of meetings, email exchanges, and phone calls, as shown on a log
or other record.

2. Collaborative testing of the All Hazards
EOP, through drills and exercises
a. Description of a real emergency or
exercise, including documented
coordination with emergency
response partners

2. The health department must document its participation in a test that implements the All
Hazards Emergency Operations Plan.
a. The documentation can be of either an actual or a simulated emergency (drill or
exercise). This description must include documentation of how the health department
coordinated with emergency response partners during the emergency or
drill/exercise. Emergency response partners may be Tribal, state or local emergency

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Measure 5.4.1 A, continued

Required Documentation

Guidance
services agencies, including law enforcement, or community partners, such as a
hospital. Partners may also come from the Tribal, state or local planning committee.
b. Documentation must include debriefing or evaluation reports from the emergency or
drill/exercise. Examples could include an evaluation report, minutes from a debriefing
session, or the AAR produced by the health department or a partner health
department.

b. Debriefing or After-Action
Report (AAR)

3. Collaborative revision of the All Hazards EOP
a. Documentation of a collaborative
review meeting within the last two
years
b. Documentation of updated contact
information
c. Documentation of coordination with
emergency response partners
d. Revised All Hazards/EOP

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3. The health department must document its collaboration in revising emergency plans.
a. Documentation must include a collaborative review within the last two years of the All
Hazards Emergency Operations Plan by those responsible for its implementation.
This can be demonstrated by meeting agendas and minutes or attendance rosters.
b. A contact list of respondents that has been updated within the last two years must be
provided. This could be shown by presenting the most current contact list and
demonstrating through minutes or previous listings that it has been updated.
c. Coordination with emergency response partners includes the delineation of roles and
responsibilities in the Emergency EOP and the various roles that partners play in
responding to a public health emergency or hazard.
d. A copy of the revised emergency operations plan must be provided to document the
result of the work to maintain the plan and ensure that it is up-to-date and reflects
current practice and information.

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Standard 5.4: Maintain an all hazards emergency operations plan.
Measure
5.4.2 A
Adopt and maintain a public health
emergency operations plan (EOP)

143

Purpose

Significance

The purpose of this measure is to assess the
health department’s EOP and the
maintenance of the plan for the public health
response in an emergency.

An emergency operations plan outlines core
roles and responsibilities for all-hazard
responses, as well as plans for scenariospecific events, such as hurricanes. Health
departments must engage in basic activities to
prepare for and respond to emergencies. In
addition to coordination and communication
with other agencies and organizations, the
health department should have a public health
specific emergency operations plan that it is
responsible for implementing in an emergency.

Required Documentation

Guidance

1. EOP, as defined by Tribal, state, or national
guidelines that includes:

1. The health department must submit its public health emergency operations plan. The plan
must be written as defined by national, Tribal, or state guidelines. The guidelines may be
defined for locals by the state health department or may be defined for both state and locals
by another Federal or state agency, such as an office of emergency management. Tribes may
use guidelines that are most appropriate for their unique emergency management needs.
The plan may be a standalone document that delineates the health department’s roles and
responsibilities, or it may be a section within a larger plan. Project Public Health Ready
(PPHR) is a national model that could be used.

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Measure 5.4.2 A, continued

Required Documentation
a. Designation of the health
department position that is
assigned the emergency
operations coordinator
responsibilities
b. Roles and responsibilities of the
health department and its partners
c. Communication networks and/or
communication plan

Guidance
The health department’s public health EOP must include all of the following:
a. The health department staff position responsible for coordinating a response within
the department in an emergency. This person may have various job titles.

b. The roles and responsibilities of the health department and its partners.
c. A health department communication plan that includes emergency communication
networks. The emergency communication plan may be a separate plan, a defined
section within the emergency operations plan, or it may be incorporated within the
emergency operations plan.
d. Description of how the health department will manage continuity of operations during
an emergency.

d. Continuity of operations

2. Documentation of testing the public health
EOP, through the use of drills and exercises
a. Process for exercising and
evaluating the public health EOP
b. After-Action Report (AAR)
3. Documentation of revision of the public
health EOP within the last two years
a. Documentation of review meeting
b. Revised public health EOP, as
needed

144

2. The health department must provide documentation to show that the plan has been reviewed
or tested through the use of exercises and drills, and revised as needed and must include:
a. Documentation of the process for testing and evaluating the Emergency Operations
Plan. This can be a written procedure, a memo stating the process, or meeting
minutes that document the procedure.
b. An After-Action Report (ARR) after an emergency or exercise/drill must be provided.
3. The health department must provide documentation that the public health emergency
operations plan has been revised within the last two years as indicated by review of the AAR.
Documentation must include:
a. Meeting minutes, a list of items discussed, or a memo documenting review
and decisions.
b. A public health EOP that has been revised as indicated through review,
evaluation and/or drills.

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Standard 5.4: Maintain an all hazards emergency operations plan.
Measure
5.4.3 S
Provide consultation and/or technical
assistance to Tribal and local health
departments in the state regarding evidencebased and/or promising practices/templates
in EOP development and testing

145

Purpose

Significance

The purpose of this measure is to assess the
state health department’s support of Tribal
and local health departments in the state in
preparing for response to emergency
situations and the development of an EOP.

State health departments are ultimately
responsible for ensuring adequate response to
public health emergencies. Tribal and local
health departments are partners in providing a
public health response to an emergency. State
health departments are in a position to share
communications and information received
from the federal level and to share information
concerning the state’s EOP to ensure optimal
coordination.

Required Documentation

Guidance

1. Documentation of consultation and/or
technical assistance communications

1. The state health department must submit two examples of expert consultation, advice,
and /or information provided to Tribal or local health departments concerning development
and testing of emergency operations plans. Examples of documentation include: blast faxes,
webinars, emails, briefing papers, meeting minutes, distributed sample protocols,
newsletters, trainings, conference calls, and documented phone calls.

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Domain 6: Enforce public health laws
Domain 6 focuses on the role of public health departments in the enforcement of public health related regulations, executive orders, statutes, and other
types of public health laws. Public health laws are key tools for health departments as they work to promote and protect the health of the population. Health
department responsibilities related to public health laws do not start or stop with enforcement. Health departments also have a role in promoting new laws
or revising existing laws. Public health related laws should be science-based and protect the rights of the individual, as they also protect and promote the
health of the population. Health departments have a role in educating regulated entities about the meaning, purpose, compliance requirements, and benefit
of public health laws. Health departments also have a role in educating the public about laws and the importance of complying with them.

The term “laws” as used in these standards and measures refers to ALL types of statutes, regulations, rules, executive orders, ordinances, case law, and
codes that are applicable to the jurisdiction of the health department. For state health departments, not all ordinances are applicable, and therefore
ordinances may not need to be addressed by state health departments. Similarly, some statutes are not applicable to local health departments, and
therefore some statutes may not need to be addressed by local health departments. For Tribal health departments, applicable “laws” will depend on several
factors, including governance framework and interaction with external governmental entities (federal, state, and local).
Public health laws include such areas as environmental public health (food sanitation, lead inspection, drinking water treatment, clean air, waste-water
disposal, and animal and vector control), communicable disease (outbreak investigation, required newborn screenings, immunizations, communicable
disease reporting requirements, quarantine, tuberculosis enforcement, and STD contact tracing), chronic disease (sales of tobacco products to youth,
smoke-free ordinances, and adoption of bike lanes), and injury prevention (seat belt laws, helmet laws, and speeding limits). Clearly, health departments
are not responsible for the enforcement of many or most of these laws. The adoption and implementation of such laws, however, have enormous public
health implications. It is important for the health department to be involved in their adoption, monitoring their enforcement, providing follow-up services
and/or education, and educating the policy makers and the public about their importance and impact.

Domain 6 incluDEs ThrEE sTanDarDs:
Standard 6.1
Standard 6.2
Standard 6.3
146

Review Existing Laws and Work with Governing Entities and Elected/Appointed Officials to Update as Needed

Educate Individuals and Organizations On the Meaning, Purpose, and Benefit of Public Health Laws and
How to Comply

Conduct and Monitor Public Health Enforcement Activities and Coordinate Notification of Violations among
Appropriate Agencies

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sTanDarD 6.1: rEViEW EXisTinG laWs anD WorK WiTh
GoVErninG EnTiTiEs anD ElEcTED/aPPoinTED oFFicials To
uPDaTE as nEEDED.
Public health laws should be current with public health knowledge, practices and emerging issues in public
health. Laws may also need to be revised to be current with societal actions and behaviors that place

individuals or groups at health risk. Health departments must have the legal capacity to review laws, as well
as the ability to assess them for changes. Health departments should collaborate and work with the
appropriate entities to effect changes to a law, when needed.

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standard 6.1: review existing laws and work with governing
entities and elected/appointed officials to update as needed.
Measure
6.1.1 A
Review laws to determine the need
for revisions

148

Purpose

Significance

The purpose of this measure is to assess the
health department’s analysis of public health
laws and other laws that have public health
implications to ensure that they are consistent
with evidence-based public health and newly
emerging public health issues and
information. The assessment of laws should
consider individual or community cost,
inconvenience, and regulatory alternatives
and sanctions, in addition to the public health
benefits of the law.

Health departments should be aware of
current public health laws and of laws that are
not specific to public health but have public
health implications, such as zoning, recreation
related, or transportation laws. The laws that
the health department evaluates need not be
only laws that the health department enforces.
They may also be laws that others enforce but
that impact public health, such as helmet use
laws, school nutrition requirements, sale of
tobacco products to minors, or school
requirements for proof of childhood
vaccinations. Program staff of the health
department should be reviewing these laws to
ensure that they are consistent with evidencebased public health practices and emerging
public health issues.

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measure 6.1.1 a, continued

Required Documentation

Guidance

1. Reviews of public health laws or laws with
public health implications within last three
years that include the following:

1. The health department must document its evaluation of two laws within the last three years.
The reviews may be documented by meeting minutes, reports, presentations, memos, or
some other record of the discussion of the review and findings. They may also be in the form
of policy agendas, position papers, white papers, and legislative briefs, including
recommendations for amendments.
Reviews may be of a law that the health department enforces or of a law that the health
department has no legal authority to enforce, but that has implications for the health of the
public in the jurisdiction of the health department. The documentation may address the
review of enforcement protocols and/or adherence to protocols and not of a law itself.

a. Evaluations of laws for consistency
with public health evidence-based
and/or promising practices
b. Documented use of model public
health laws, checklists, templates
and/or exercises in reviewing laws
c. Documentation of input solicited
from key stakeholders on proposed
and/or reviewed laws

Health departments must provide documentation that:
a. Demonstrates that evidence-based practices, promising practices, or practicebased evidence was considered in reviewing the law.
b. Demonstrates how model public laws, check lists, templates, or some other standard
outline or guide was used to review the law or enforcement activity.
c. Demonstrates evidence that input was sought from key partners and stakeholders
through, for example, public notice, town forums, meetings, hearings, or request for
input on the health department’s web page.
State health departments must provide examples that show it has collaborated with
Tribal or local health departments in reviewing or developing laws that may impact
those Tribal or local health departments. This collaboration may involve providing
assistance to Tribal or local health departments as they review and revise laws, or it
may involve obtaining Tribal or local input on new state laws or revisions of state
laws. Specifically, states must consult with Tribal governments on laws that may
impact them or for which they are requesting assistance for implementing within
Tribal jurisdictions.

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measure 6.1.1 a, continued

Required Documentation

Guidance
Documentation examples include: minutes or summaries of meetings between Tribal,
state and/or local public health officials or joint local meetings facilitated by the state;
agenda, minutes and any resulting documents from meetings with stakeholders;
summaries of comments from town meetings, hearings, or comments received
through a website.
Local health departments must document how they consult with Tribes when
reviewing laws that impact multiple jurisdictions, such as disease reporting, isolation
and quarantine, and immunizations.
Tribal health departments must work together with its local Tribal units (i.e. Chapter
Houses, Pueblos, or Districts), in addition to other partners, when reviewing existing
laws and revising or creating new laws. Documentation may include: working with
local Tribal community stakeholders, such as elected Tribal District Chairpersons,
elected Tribal council committees, Tribal Community Colleges, Tribal school districts,
and boards. Tribal health department examples may also include work completed
with Tribal Legislative Counsel or Tribal Elected/Appointed officials, such as District
Chairpersons, Tribal Oversight Committees, and governing entities.
Due to the limited availability of evidenced-based practices or promising practices in Tribal
communities, Tribes may provide examples of practice-based evidence used to adapt
models or create models based on a cultural framework or traditional forms of governance.

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standard 6.1: review existing laws and work with governing
entities and elected/appointed officials to update as needed.
Measure
6.1.2 A
Inform governing entity and/or
elected/appointed officials of needed
updates/amendments to current laws and/or
proposed new laws

151

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to provide advice
to governing entities and/or elected/appointed
officials on the public health impact of the
content of new laws and changes to
current laws.

The health department can be a strong
advocate for new laws or changes to laws that
impact the public’s health. As the public
health expert for the jurisdiction, the health
department should share its findings and
make recommendations for amendments –
revision, creation, deletion – to the body of
public health law. The laws need not be laws
that the health department enforces but may
be laws that others enforce that impact public
health, such as helmet use laws, school
nutrition requirements, sale of tobacco
products to minors, or public school
requirements for proof of childhood
vaccinations. Not all legal reviews or policy
recommendations will result in a change, but
health departments have a responsibility to
provide the information for consideration by
elected/appointed officials.

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measure 6.1.2 a, continued

Required Documentation

Guidance

1. Documentation of distribution of two written
recommendations to governing entity
and/or elected/appointed officials
concerning amendments or updates to
current laws and/or proposed new laws

1. The health department must provide documentation that it has submitted written reviews of
current laws or position statements proposing new laws to the governing entity and/or
elected/appointed officials. These reviews and recommendations may be in the form of a
policy agenda, position paper, white paper, legislative brief, or other written policy document.
Documentation that governing entities and/or elected/appointed officials have been informed
could be in the form of a governing entity meeting agenda, email, or mailed cover memo to
governing entity members and elected/appointed officials. For this measure, a public posting,
such as a notice on the health department website, would not be sufficient. The
documentation must show distribution to the targeted audiences of governing entities and/or
elected/appointed officials.
Two examples are required for this measure. Examples may be: two needed
updates/amendments to current laws, or two proposed new laws. The examples can be, but
do not have to be, related to the two examples provided for measure 6.1.1.
Examples for Tribal health departments could include work completed with Tribal Legislative
Counsel or Tribal Elected/Appointed official, such as District Chairpersons, Tribal Oversight
Committees, and governing entities.

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sTanDarD 6.2: EDucaTE inDiViDuals anD orGaniZaTions on
ThE mEaninG, PurPosE, anD BEnEFiT oF PuBlic hEalTh
laWs anD hoW To comPlY.
Public health laws impact all members of the community. Health departments have the responsibility to

educate the public about public health laws and to inform members of the community about the meaning

behind the law, the purpose for the law, the benefits of the law, and compliance requirements. Educational
efforts should be aimed at individuals and organizations that are a part of the jurisdiction served, including
schools, civic organizations, human service organizations, other government units and agencies, and the
medical community.

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standard 6.2: Educate individuals and organizations on the meaning,
purpose, and benefit of public health laws and how to comply.
Measure
6.2.1 A
Maintain agency knowledge and apply public
health laws in a consistent manner

Purpose

Significance

The purpose of this measure is to assess the
health department’s knowledge of how laws
support public health practice and their efforts
to ensure that these measures are applied
consistently.

Health departments with the responsibility to
enforce laws must maintain assurance that the
laws are clearly understood by health
department staff and that the laws are being
applied in a consistent manner.
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 tobacco
products to minors is enforced consistently.

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measure 6.2.1 a, continued

Required Documentation

Guidance
Public health law enforcement, such as environmental public health, animal control, solid waste
and food codes, may be handled by multiple departments within the Tribal, state, or local
government. For this measure, the health department should provide documentation of how it
maintains knowledge of the laws and their consistent application.

155

1. Documentation of staff training in laws to
support public health interventions and
practice within the last two years

1. The health department must document that the staff are trained in laws that support public
health interventions and practice. The training agenda is not specified and can include both
general and specific aspects of public health law. Staff must be trained on the specific
aspects of the law for which they are programmatically responsible. For example, a
communicable disease nurse should be trained on the law that addresses communicable
disease reporting; he or she would not be required to know specific elements on public water
laws. The training must have been provided to staff within the prior two years. Documentation
could be training agendas, minutes of training meetings, HR lists of personnel trained and the
date of the training, or links to online training required for staff completion and documentation
that it was completed.

2. Documentation of efforts to ensure
consistent application of public health laws

2. The health department must document its efforts to ensure consistent application of public
health laws. Documentation might include: internal audits, enforcement documents or logs,
written review of case reports, reports or minutes of meetings with other agencies or entities
that enforce laws, communications with other agencies or entities on the importance of
consistent application of laws.

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standard 6.2: Educate individuals and organizations on the meaning,
purpose, and benefit of public health laws and how to comply.
Measure
6.2.2 A
Ensure that laws and permit/license
application requirements are accessible
to the public

156

Purpose

Significance

The purpose of this measure is to assess the
health department’s provision of information to
the public concerning public health related
permits and license applications.

Members of the public will seek information
from the health department about laws,
permits and license requirements and
applications. In some cases, the health
department may not be responsible for
administration of the requirements of the laws,
but it should be sufficiently informed to
correctly advise the public and direct them
to the responsible agency.

Required Documentation

Guidance

1. Public access to information about laws
and permit/license application processes

1. The health department must document that it makes information concerning public health
related laws and permits/license applications available to those who request it. This
information can be made available through the health department’s website or provided in
hard copy. The website can post laws, or provide a link to the laws, along with forms,
protocols or other components of the permit or licensing process. The website may also
direct the public to the appropriate agency, if the responsibility does not legally reside with the
health department.

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standard 6.2: Educate individuals and organizations on the meaning,
purpose, and benefit of public health laws and how to comply.
Measure
6.2.3 A
Provide information or education to regulated
entities regarding their responsibilities and
methods to achieve full compliance with
public health related laws

Purpose

Significance

The purpose of this measure is to assess the
health department’s education of entities that
are responsible for complying with laws that
have public health impact. Enforcement of
compliance with these laws may or may not
be the responsibility of the health department.

A primary role of health departments is to
educate the population and regulated entities
and organizations about the meaning,
purpose, benefits, and compliance
requirements of public health related laws.

Required Documentation

Guidance

1. Written record of the provision of
information or education to regulated
entities concerning their responsibilities for
compliance with public health laws

1. The health department must submit a written record that it has provided information to regulated
individuals or entities about their responsibilities related to public health laws. This may be a
targeted group, such as public schools that are responsible for enforcing immunization
requirements of their students, tracking immunization records, and reporting the vaccination
records or lack of records; or, it may be the entire population, who are a regulated entity in
regard to the immunization law and their responsibility for having their children vaccinated.
Documentation could be a set of FAQs on the health department’s website, newsletters (with
distribution list), training sessions (with attendance list and materials), public meetings (with
minutes, agendas, and attendance list), documentation of technical assistance and
information (provided through email, phone logs, etc.), pamphlets, posters, or press releases.

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sTanDarD 6.3: conDucT anD moniTor PuBlic hEalTh
EnForcEmEnT acTiViTiEs anD coorDinaTE noTiFicaTion
oF ViolaTions amonG aPProPriaTE aGEnciEs.
Health departments have a role in ensuring that public health laws are enforced. In some cases, the health
department has the enforcement authority. In other cases, the health department works with those who
have the legal authority to enforce the laws. When other state agencies, local departments, or levels of

government have enforcement authority, the role of the health department is to collaborate, assist, and

share information. In either case, the health department needs to know about enforcement activities and
violations in their jurisdiction, since violations and enforcement can impact the public’s health. The

department should be coordinating and sharing information with agencies that have public health related

enforcement authority. The health department is responsible for follow-up communication and education on
public health impacts and protection.

As with all of the standards and measures, accountability for meeting the measures rests with the health
department being reviewed for accreditation. Documentation that provides evidence of meeting the

measure must be provided, even if the documentation is produced by a partner organization, another
governmental agency, or another level of government, and not by the health department seeking

accreditation. The health department must partner with enforcement agencies to ensure that the laws and
their enforcement protect and promote the public’s health.

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standard 6.3: conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
Measure
6.3.1 A
Maintain current written procedures and
protocols for conducting enforcement actions

159

Purpose

Significance

The purpose of this measure is to assess the
health department’s standard and consistent
enforcement actions.

Enforcement actions should be conducted
using standard steps, criteria, and actions.
When public health enforcement is conducted
by other agencies or entities, the health
department should have working relationships
with those entities to share information. The
health department may be able to provide
advice concerning enforcement. Additionally,
the health department should be informed of
noncompliance. For example, if a toxic
substance is being emitted by a plant or a
restaurant inspection identifies a risk of a food
borne illness, the health department should be
involved to provide public health follow-up on
any related illnesses or to deliver community
information and education.

Required Documentation

Guidance

1. Documentation of authority to conduct
enforcement activities

1. The health department must provide the documentation of authority to conduct enforcement
activities. Two examples are required. The health department may select the areas or
programs. This authority may be located in a state or local code, MOU, letter of agreement,
contract, legislative action, executive order, ordinance, or rules/regulations. In some cases,
the health department may have little or no authority to conduct enforcement actions. In those
cases, the department should be coordinating and sharing information with agencies that do
have public health related enforcement authority. In those cases, the health department must
provide documentation of the authority of the other entity that conducts enforcement.

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measure 6.3.1 a, continued

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Required Documentation

Guidance

2. Procedures and protocols for laws or
enforcement actions for achieving
compliance

2. The health department must provide copies of two procedures, protocols or processes, such as
decision trees, for two enforcement program areas. One of the examples should address
communicable disease. Where the health department does not conduct public health
enforcement actions, the protocols used by the enforcement agency should be provided and
should demonstrate cooperation between the enforcement agency and the health department.

Public Health Accreditation Board • Standards & Measures

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standard 6.3: conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
Measure
6.3.2 A
Conduct and monitor inspection activities of
regulated entities according to mandated
frequency and/or a risk analysis method that
guides the frequency and scheduling of
inspections of regulated entities

Purpose

Significance

The purpose of this measure is to assess the
health department’s adherence to guidelines
on the frequency of inspection activities.
Where the inspections are conducted by other
agencies, the health department should be
notified of inspections, protocols, and status.
This enables the health department to provide
follow-up education and communication,
where appropriate, to safeguard the public’s
health.

When the law specifies inspection frequency,
the health department should be following the
defined schedule. When there is no mandated
schedule, the health department should have
a method to define an appropriate schedule
and should adhere to the schedule.

Required Documentation

Guidance

1. Protocol/algorithm for scheduling
inspections of regulated entities

1. The health department must provide the schedule for inspections for two programs. The
health department may select the areas or programs. The selected schedules should be, but
may not be, in programs where the health department has authority to conduct an inspection
of the regulated entity.
In some cases, these schedules are mandated. In other cases, the department may provide
a protocol or an algorithm for scheduling inspections. For example, rules requiring restaurant
inspections on a specified schedule or a schedule for return inspections after a violation may
be submitted. These may be documents provided by another agency that has enforcement
responsibilities.

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measure 6.3.2 a, continued

Required Documentation

Guidance

2. Database or log of inspection reports with
actions, status, follow-up, re-inspections,
and final disposition

2. To show that inspections have met defined frequencies, the health department must provide a
database or log of inspection reports with actions taken, current status, follow-up, return
inspections and final disposition. This documentation of inspections must relate to the same
programs for which schedules were provided in 1 above.
In some cases, the health department may have little or no authority to conduct enforcement
actions. In those cases, the department should be coordinating and sharing information with
agencies that do have public health related enforcement authority. In those cases the health
department must provide documentation of the authority of the other entity that conducts
enforcement. The health department must provide documentation that it is informed of
inspection protocols and reports showing the results of inspection.

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standard 6.3: conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
Measure
6.3.3 A
Follow procedures and protocols for both
routine and emergency situations requiring
enforcement activities and complaint followup

163

Purpose

Significance

The purpose of this measure is to assess the
health department’s implementation of
procedures and protocols for routine and
emergency enforcement activities and for
follow up of complaints.

Scheduled investigations, emergency
situations, complaint follow-up should be
conducted according to standard procedures
and protocols to ensure that they are
conducted appropriately.

Required Documentation

Guidance

1. Data base or log of actions with analysis
and standards for follow-up at each level

1. The health department must document actions taken through investigations or follow-up of
complaints, as well as analysis of the situation and standards for follow-up. Documentation
must be provided for two programs. The health department may select the areas or
programs. The standards for follow-up may be within the procedure and protocols and do not
have to be a part of the log. If separate, the standards must be included with the database or
log for the documentation.

2. Communications with regulated entities
regarding a complaint or compliance plan

2. The health department must provide documentation of hearings, meetings or other official
communications with regulated entities regarding a complaint and any resulting compliance

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measure 6.3.3 a, continued

Required Documentation

Guidance
plans. The compliance plan has no specific format and will be determined by law or agency
protocol. The regulated entity, based on the law, could be an organization, business, or
individual.
In some cases, the health department may have little or no authority to conduct enforcement
actions. In those cases, the department should be coordinating and sharing information with
agencies that do have public health related enforcement authority. In those cases, the health
department must provide documentation of the authority of the other entity to conduct
enforcement. The health department must provide documentation that it is informed of
inspection protocols and reports showing the results of inspection.

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standard 6.3: conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
Measure
6.3.4 A
Determine patterns or trends in compliance
from enforcement activities, and complaints

165

Purpose

Significance

The purpose of this measure is to assess the
health department’s analysis of patterns,
trends, and compliance from enforcement
activities and complaint investigations.

It is important for the health department to
determine patterns or trends in noncompliance, complaints, or enforcement
activities. This will help in understanding the
prevalence of issues, in employing preventive
measures, in pursuing opportunities for
improvement in enforcement activities, and in
providing follow-up education.

Required Documentation

Guidance

1. Annual report summarizing complaints,
enforcement activities, and compliance

1. The health department must provide annual reports from two enforcement programs that
summarize complaints, enforcement activities, and compliance. The health department may
select the enforcement programs. Reports must include patterns, trends, and compliance.

2. Debriefings or other evaluations of specific
enforcement for process improvements

2. The health department must provide documentation of debriefings or other methods to
evaluate what worked well, problems that arose, issues and recommended changes in
investigation/response procedures, and other process improvements to enforcement
protocols or procedures. All other process improvements discussed must be noted in the
documentation.

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measure 6.3.4 a, continued

Required Documentation

Guidance
In some cases, the health department may have little or no authority to conduct enforcement
actions. In those cases, the department should be coordinating and sharing information with
agencies that do have public health related enforcement authority. In those cases, the health
department must provide documentation of the authority of the other entity to conduct
enforcement. The health department must document that it is informed of patterns, trends,
and compliance.

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standard 6.3: conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
Measure
6.3.5 A
Coordinate notification of violations to the
public, when required, and coordinate the
sharing of information among appropriate
agencies about enforcement activities, followup activities, and trends or patterns

Purpose

Significance

The purpose of this measure is to assess the
health department’s communication with the
public concerning enforcement violations and
with appropriate agencies concerning
enforcement activities, follow-up activities,
and trends or patterns.

It is important that the health department share
enforcement information with the public when
the public may make decisions or alter their
behavior, based on this information. For
example, many members of the public want to
know what local restaurants have failed
inspection and why. They may want to know if
the health department has received complaints
concerning hospitals or nursing homes.
It is important that the health department
shares information concerning enforcement
actions and/or any resulting follow-up with
other agencies that have a role in educating or
providing follow-up with the enforced entity or
educating the public. Appropriate agencies
include health departments at other levels of
government: Tribal, state, or local
health departments.

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measure 6.3.5 a, continued

Required Documentation

Guidance

1. Communication protocol for interagency
notifications

1. The health department must provide a communication protocol for interagency notifications.
The protocol may be part of multiple communication protocols concerning the sharing of
information or it may be a single protocol that covers all aspects of notifying other agencies
related to enforcement actions.

2. Protocol for notification of the public
when required

2. The health department must provide a protocol for notifying the public. If there are laws that
require public notification, the reference must be submitted. The health department may also
allow for public notification without a legal requirement. In that case, include a copy of the
relevant protocol.

3. Documentation of notification of
enforcement actions, and sharing
information concerning enforcement
activities

3. The health department must provide two examples of notification of enforcement actions.
Notification can be through a variety of methods, including: posting on a website, minutes
from public meetings, conference calls, emails, correspondence, press release, public
presentation, reports, and MOUs and MOAs with other agencies that demonstrate sharing
information on enforcement activities. The two examples must be from two different
enforcement programs.
In some cases, the health department may have little or no authority to conduct enforcement
actions. In those cases, the department should be coordinating and sharing information with
agencies that do have public health related enforcement authority. In those cases, the health
department must provide documentation of the authority of the other entity that conducts
enforcement. The health department must provide documentation that it is informed of
patterns, trends, and compliance.

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Domain 7: Promote strategies to improve access to health care services
Domain 7 focuses on the link between public health activities and health care services. The health care sector provides many preventive services,
such as immunizations, cholesterol screening, screening for breast cancer, high blood pressure management, and prenatal care. Patient counseling
on health promotion, disease prevention, and chronic disease management is an important link between health care and public health. Linkages
between health care and public health ensure continuity of care and management for the population.

An important role of public health is the assessment of (1) the capacity of the health care system to meet the health care needs of the population, and
(2) community members’ access to health care services. Public health also works to increase access to needed health care services.

DOMAIN 7 INCLUDES TWO STANDARDS:

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Standard 7.1

Assess Health Care Service Capacity and Access to Health Care Services

Standard 7.2

Identify and Implement Strategies to Improve Access to Health Care Services

Public Health Accreditation Board • Standards & Measures

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STANDARD 7.1: ASSESS HEALTH CARE SERVICE CAPACITY AND
ACCESS TO HEALTH CARE SERVICES.
Public health services should link with health care services to ensure that there is continuity of services for

the population. Health departments should work with the health care system to (1) understand the capacity
of the health care system, (2) identify barriers to health care, and (3) identify populations who experience
barriers to health care services.

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Standard 7.1: Assess health care service capacity and access to health care
services.

Measure

7.1.1 A
Convene and/or participate in a collaborative
process to assess the availability of health
care services

Purpose

Significance

The purpose of this measure is to assess the
health department’s participation in a
collaborative process to develop an
understanding of the population’s access to
health care services and the capacity of the
health care system.

The health department should participate in
collaborative efforts to assess the health care
needs of the population of the Tribe, state, or
community. The focus is on the need for
primary care, particularly preventive care and
chronic disease management.
The health department might not directly
provide health care services in order to
improve access, but may provide selected
clinical services where it has authority and
responsibility.
Health care services, for access planning
purposes, include: clinical preventive services,
emergency services, urgent care, occupational
medicine, ambulatory care (primary and
specialty), inpatient care, dental treatment, and
behavioral health. (See Glossary for definition
of Health care Services.)

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Measure 7.1.1 A, continued

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Required Documentation

Guidance

1. A collaborative process to assess
availability of health care services

1. The health department must document that it has participated in a collaborative process to
assess the availability of health care services. Documentation should also demonstrate the
involvement of the health care system. Charters or meeting agendas with minutes must be
submitted. Information on the partnerships developed to assess health care availability and the
use of data in the assessment process must include rosters of coalition/network/council
members, such as health care providers, social services organizations, and other stakeholders.

2. Description of partnerships across Tribal,
state, and local health departments and the
health care system to make comprehensive
data available for the purposes of health
care access planning

2. The health department must document the sharing of public health Tribal, state and local data
and health care system data for planning purposes. Documentation can include regional
health information organizations (RHIOs) and health information exchanges (HIEs), or less
formal data sharing efforts.

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Standard 7.1: Assess health care service capacity and access to health care
services.

Measure

7.1.2 A
Identify populations who experience barriers
to health care services

173

Purpose

Significance

The purpose of this measure is to assess the
department’s knowledge of barriers to health
care and of the specific populations who
experience those barriers.

It is important for the health department to
identify populations in its jurisdiction that
experience perceived or real barriers to health
care. Part of assessing capacity and access to
health care is to identify those who are not
receiving services and to understand the
causes. Barriers may be experienced, for
example by populations who are uninsured or
under-insured, have no transportation to health
care, do not speak or understand English, are
immuno-compromised, or live where there is a
shortage of primary care practitioners. Barriers
may also be perceived by populations who do
not trust accessible providers of health care or
do not understand why certain routine medical
services or screenings are necessary for their
health. Populations who may lack access to
health care services include, for example:
pregnant women who use tobacco and are at
risk of giving birth to a low birth weight baby;
obese populations who are at risk for diabetes;
or individuals who use tobacco products and
are at risk for cancer.

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Measure 7.1.2 A, continued

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Required Documentation

Guidance

1. Reports of health care needs of
the population

1. The health department must provide documentation that shows the process and information
used to identify populations who lack access to health care. Information could be obtained
from an assessment survey and/or surveys of particular population groups. Other information
sources include: analysis of secondary data and/or health care data, such as emergency
department admissions or population insurance status data.

2. Description of the process(s), used for the
identification of program gaps and barriers
to accessing health care services

2. The health department must provide information describing the process used to identify
populations who lack access to health care services and identify who was involved in the
identification process. Documentation must reflect a range of partners, including health care
providers, communities of color, Tribal representatives, employers, low income workers, and
specific populations who lack health care and experience barriers to service. Processes may
include: sector maps, analysis of hospital admissions or emergency department data,
analysis of health insurance data, or other tools.

Public Health Accreditation Board • Standards & Measures

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Standard 7.1: Assess health care service capacity and access to health care
services.
Measure
7.1.3 A
Identify gaps in access to health care services

175

Purpose

Significance

The purpose of this measure is to assess the
health department’s knowledge of gaps in
access to health care services among the
population it serves.

It is important for health departments to
understand the gaps in access to health care
so that effective strategies can be put in place
to address the lack of access to health care.
Causes of gaps in service can range from
financial (lack of affordable services), health
care system capacity (lack of dental providers),
cultural (lack of interpreters), and geographic
(lack of transportation), among others. Shared
data among the members of the partnership
can evidence an effort to capture and
understand all possible gaps that exist.

Required Documentation

Guidance

1. Reports of analysis of data from across the
partnership (see 7.1.1) that identify the
gaps in access to health care services and
the causes of gaps in access. Reports must
include:
a. Assessment of capacity and
distribution of health care providers

1. The health department must provide reports of data analysis from various partnership
sources that identify and describe gaps in access to health care services. At a minimum,
partnership data sources should include the partners that participated in the collaborative
process described in measure 7.1.1. Data may be contributed by all partners or may be
discussed or evaluated by partners. The reports must include:
a. Assessment of capacity and distribution of health care providers. These data will
show geographic gaps in the availability of health care providers.

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Measure 7.1.3 A, continued

Required Documentation

Guidance

b. Availability of health care services

b. Assessment of the availability of health care services, such as clinical preventive
services, EMS, emergency departments, urgent care, occupational medicine,
ambulatory care (primary and specialty), inpatient care, dental, behavioral health, and
other services. These data can be useful in seeking support for a particular service.
c. Assessment of cause(s) for lack of access. Causes may include: a population that is
uninsured/under-insured, lacks transportation to health care, does not speak or
understand English, is immuno-compromised, or lives where there is a shortage of
primary care and dental practitioners. Barriers may also be the result of populations
who do not trust health care providers or do not understand why certain routine medical
services or screenings are necessary to protect their health. Barriers may include, but
not be limited to, travel distance in rural areas, inability to obtain timely appointments,
lack of ability to pay for services, or limited service hours of health care.
d. Results of periodic surveys of access, such as focus groups, studies of eligible groups
receiving services, and other assessment information, can provide perspectives from
the population that lacks access. These surveys do not have to be administered by the
health department, but the results should be considered in the assessment of gaps in
access.

c. Identification of causes of gaps in
services

d. Results of periodic surveys of
access

Assessment reports must include analysis of data and conclusions that can help develop effective
strategies to address gaps in access.

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STANDARD 7.2: IDENTIFY AND IMPLEMENT STRATEGIES TO
IMPROVE ACCESS TO HEALTH CARE SERVICES.
There are many factors that can contribute to lack of access to health care, including insurance status,

transportation, travel distance, availability of a regular source of care, wait time for appointments, and office
wait times. Social conditions also influence access to health care, including education and literacy level,
language barriers, knowledge of the importance of symptoms, trust in the health care system, and

employment leave flexibility. Once the barriers and gaps in service are identified, strategies may be
developed and implemented to address them and improve access to health care services.

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Standard 7.2: Identify and implement strategies to
improve access to health care services.
Measure
7.2.1 A
Convene and/or participate in a collaborative
process to establish strategies to improve
access to health care services

Purpose

Significance

The purpose of this measure is to assess the
health department’s involvement with the
health care system to encourage a
collaborative process to develop strategies to
increase access to health care for those who
experience barriers to services.

Factors that contribute to poor access to care
are varied. A partnership with other
organizations and agencies provides the
opportunity to address multiple factors and
coordinate strategies. The health department
need not have convened or have led the
process, but it must have participated in a
collaborative process.

Required Documentation

Guidance

1. Documentation that a
coalition/network/council is working on
collaborative processes to reduce barriers
to health care access or gaps in access

1. The health department must provide one example that demonstrates its involvement in a
collaborative process for developing strategies to improve access to health care. The
example must also demonstrate involvement of the health care system. The collaborative
process and development of strategies in this measure can be done in conjunction with 7.1.1,
and the same collaborative process/partnership can be used.
The documentation must demonstrate that the group is actively working to identify strategies.
Documentation could include: a charter for the group; membership rosters or
participant/attendance lists; meeting agendas and minutes; or workgroup reports, work plans
and white papers.

2. Development of strategies through the
collaborative process to improve access to
health care services
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2. The health department must provide written reports or meeting minutes that include identified
strategies that the group developed together to improve access to health care services.

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Standard 7.2: Identify and implement strategies to
improve access to health care services.
Measure
7.2.2 A
Collaborate to implement strategies to
increase access to health care services

Purpose

Significance

The purpose of this measure is to assess the
health department’s implementation of
strategies to increase access to health
care services.

Strategies to improve access to health care
services should be implemented to provide
continuity of health promotion and disease
prevention to members of the population and to
ensure access to clinical preventive services.
The health department should conduct these
efforts in collaboration with partners, including
the health care system. Strategies may include:
linking individuals with needed services;
establishing systems of care in partnership with
other members of the Tribe, state, or
community; addressing transportation barriers;
working with employers to increase the number
of insured workers, or other strategies to
address particular barriers.

Required Documentation

Guidance

1. Documentation of collaborative
implementation of mechanisms or
strategies to assist the public in obtaining
access to health care services

1. The health department must provide two examples of collaborative implementation of
strategies to improve access to services for those who experience barriers. Partners may
include: community service providers, schools, health care providers, migrant health clinics,
social service organizations, transportation providers, and employers.
Documentation that could be submitted includes:
• A signed Memoranda of Understanding (MOU) between partners to list activities,
responsibilities, scope of work, and timelines

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Measure 7.2.2 A, continued

Required Documentation

Guidance
• A documented cooperative system of referral between partners that shows the
methods used to link individuals with needed health care services.
• Documentation of outreach activities, case findings, case management, and activities
to ensure that people can obtain the services they need.
• Documentation of assistance to eligible beneficiaries with application and enrollment
in Medicaid, workers’ compensation, or other medical assistance programs.
• Documentation of coordination of service programs (e.g., common intake form) and/or
co-location (e.g., WIC, Immunizations and lead testing) to optimize access.
• Grant applications submitted by community partnerships that address increased
access to health care services.
• Subcontracts in the community to deliver health care services in convenient and
accessible locations.
• Program/work plans documenting that strategies developed collaboratively have
been implemented.

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Standard 7.2: Identify and implement strategies to
improve access to health care services.
Measure
7.2.3 A
Lead or collaborate in culturally competent
initiatives to increase access to health care
services for those who may experience
barriers due to cultural, language, or literacy
differences

Purpose

Significance

The purpose of this measure is to assess the
health department’s incorporation of cultural
competence, language, or literacy in efforts to
address the health care service needs of
populations who experience barriers to
access to health care.

Cultural differences can present serious
barriers to receipt of health care services.
Some cultures discourage women from talking
about personal issues with people outside of
their families. Cultures may also discourage
men from seeking care, may not trust health
care providers, or may rely on health care
providers who are not trained in traditional
methods. Language, literacy, and hearing
impairment can also limit access to care.
Cultural differences must be addressed in
strategies to improve access to health care
services, if those strategies are going to be
successful.

Required Documentation

Guidance

1. Interventions delivered in a culturally
competent manner to populations within the
jurisdiction of the health department

1. The health department must provide two examples of culturally competent, language, or
literacy related interventions that it has provided to populations that experience barriers to
health care services. The interventions may be developed by the health department or in
collaboration with others.
Examples could include: use of lay health advocates indigenous to the target population;
parish nursing; informational materials developed for low literacy individuals; culturally
competent initiatives developed with members of the target population; language/interpretive
services; family-based care for some populations; or provision of health care that combines
cultural health care and the health care system.

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Domain 8: Maintain a competent public health workforce
Domain 8 focuses on the need for health departments to maintain a trained and competent workforce to perform public health duties. Effective public
health practice requires a well prepared workforce. A multi-disciplinary workforce that is matched to the specific community being served facilitates the
interdisciplinary approaches required to address the population’s public health issues. The manner in which services are provided to the public
determines the effectiveness of those services and influences the population’s understanding of, and appreciation for, public health. Continuous
training and development of health department staff is required to ensure continued competence in a field that is making constant advances in
collective knowledge and improved practices.

DoMain 8 incluDes two stanDarDs:
Standard 8.1
Standard 8.2

182

Encourage the Development of a Sufficient Number of Qualified Public Health Workers

Assess Staff Competencies and Address Gaps by Enabling Organizational and Individual Training
and Development Opportunities

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

stanDarD 8.1: encouraGe tHe DeVeloPMent oF a
suFFicient nuMBer oF QualiFieD PuBlic HealtH worKers.
Maintaining a competent public health workforce requires a supply of trained and qualified public health

workers sufficient to meet the needs of public health departments. As public health workers retire or seek

other employment opportunities, newly trained public health workers must enter the field in such areas as

epidemiology, health education, community health, public health laboratory science, public health nursing,
environmental public health, and public health administration and management. Every health department
has responsibilities for collaborating with others to encourage the development of a sufficient number of

public health students and workers to meet the staffing needs of public health departments and other public
health related organizations.

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Public Health Accreditation Board • Standards & Measures

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standard 8.1: encourage the development of a sufficient
number of qualified public health workers.
Measure
8.1.1 S
Establish relationships and/or collaborate with
schools of public health and/or other related
academic programs that promote the
development of future public health workers

Purpose

Significance

The purpose of this measure is to assess the
state health department’s contributions to the
development of qualified public health workers.

Working with schools of public health and other
related academic programs (such as public
health nursing, public health laboratory
services, health promotion, or environmental
public health) is a means to promote public
health as an attractive career choice. It
promotes the health department as an
employer of choice and establishes new
methods for staff recruitment. Collaboration
with academic programs can create paths for
internships and other ways to expose students
or new graduates to public health practice.

Required Documentation

Guidance

1. Documentation of partnerships or
collaborations with educational
organizations to promote public health
as a career or to provide training in public
health fields

1. The state health department must provide one example of a partnership or collaboration with
a school of public health and/or other related academic programs that prepare public health
workers. The documentation must show strategies for promoting public health careers or
offering training in public health.
Examples of partnership or collaboration include: a practicum, student placements/academic
service learning; internship opportunities; faculty positions or guest lectures by health
department staff; participation in high school, university, college, or Tribal college programs,
and/or job/career fairs.

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Public Health Accreditation Board • Standards & Measures

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standard 8.1: encourage the development of a sufficient
number of qualified public health workers.
Measure
8.1.1 T/L
Establish relationships and/or collaborations
that promote the development of future public
health workers

Purpose

Significance

The purpose of this measure is to assess the
health department’s activities to encourage
public health as a career choice.

Working with schools, academic programs or
other organizations is a means to promote
public health as an attractive career choice.
Collaborations can create paths for exposing
students or new graduates to public
health practice.

Required Documentation

Guidance

1. Documentation of relationships or
collaborations that promote public health
as a career

1. The health department must provide one example of a partnership or collaboration that
promotes public health as a career choice.
Examples of partnerships or collaborations include: coordinating with a high school to make
presentations to students about public health and public careers, working with a vocational
training school to promote public health, partnering with a 4H club to provide information
about public health to members, guest lecturing at a community college, or providing after
school experiences for high school students.

185

Public Health Accreditation Board • Standards & Measures

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stanDarD 8.2: assess staFF coMPetencies anD aDDress
GaPs BY enaBlinG orGaniZational anD inDiViDual
traininG anD DeVeloPMent oPPortunities.
A health department workforce development plan can ensure that staff development is addressed,

coordinated, and appropriate for the health department’s needs. Staff job duties and performance should be
regularly reviewed to note accomplishments and areas that need improvement. This should not be a

punitive process but one that identifies needs for employee training or education. This approach can provide
workforce development guidance for the individual and may point out gaps in competencies and skills for
the health department.

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standard 8.2: assess staff competencies and address gaps by enabling
organizational and individual training and development opportunities.
Measure
8.2.1 A
Maintain, implement and assess the health
department workforce development plan that
addresses the training needs of the staff and
the development of core competencies

Significance

The purpose of this measure is to assess the
health department’s planning for employee
training, implementation of those plans, and
the development of core competencies.

Employee training and core staff competencies
assure a competent workforce. Health
departments must have a competent workforce
with the skills and experience needed to
perform their duties and carry out the health
department’s mission.

Required Documentation

Guidance

1. Health department workforce development
plan that includes:
a. Nationally adopted core
competencies

1. The health department must provide a health department-specific workforce development
plan, updated annually. The plan must include:
a. Plans to develop nationally adopted public health core competencies among staff.
An example of nationally adopted core competencies is the “Core Competencies for
Public Health Professionals” from the Council on Linkages. The plan may also use
another set of competencies, such as those authorized by the health department’s
governing entity.
b. Training schedules and a description of the material or topics to be addressed in the
training curricula.

b. Curricula and training schedules

2. Documentation of implementation of the
health department workforce development
plan

187

Purpose

2. The health department must provide two examples of implementing the workforce
development plan. Documentation could include training curricula to address an identified
gap, staff attendance at state or national conferences, and staff attendance at
training/educational sessions provided by other organizations related to their area of work.

Public Health Accreditation Board • Standards & Measures

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standard 8.2: assess staff competencies and address gaps by enabling
organizational and individual training and development opportunities.
Measure
8.2.2 A
Provide leadership and management
development activities

188

Purpose

Significance

The purpose of this measure is to assess the
health department’s development of
leadership and management staff, including
efforts to build leadership skills.

In addition to their specific public health
activities, leaders and managers must
oversee the health department, interact with
stakeholders and constituencies, seek
resources, interact with governance, and
inspire employees and the community to
engage in healthful public health activities.
Development activities can assist leadership
and management staff to employ state-of-theart thinking, management processes, and
management techniques.

Required Documentation

Guidance

1. Documented training/development
activities in the past two years

1. The health department must provide two examples of its training or development programs
for leadership and/or management staff. Activities could include: education assistance,
continuing education, support for membership in professional organizations, and training
opportunities.

2. Documented participation in courses

2. The health department must provide two examples of leaders and/or managers attending a
leadership and/or management development course. Examples include: National Public Health
Leadership Institute; Environmental Public Health Leadership Institute; Tribal, regional, state, or
local public health leadership institutes; executive management seminars or programs;
graduate programs in leadership/management; and related meetings and conferences.

Public Health Accreditation Board • Standards & Measures

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standard 8.2: assess staff competencies and address gaps by enabling
organizational and individual training and development opportunities.
Measure
8.2.3 S
Provide consultation and/or technical
assistance to Tribal and local health
departments regarding evidence-based
and/or promising practices in the
development of workforce capacity, training
and continuing education

189

Purpose

Significance

The purpose of this measure is to assess the
state health department’s provision of
consultation and/or technical assistance to
Tribal and local health departments on
evidence-based and/or promising practices in
the development of workforce capacity,
workforce training, and/or continuing
education.

The state health department should share its
knowledge about workforce capacity,
workforce training, and continuing education
with Tribal and local health departments in
order to assist in addressing organizational
gaps in the public health workforce.

Required Documentation

Guidance

1. Documentation of consultation and/or
technical assistance provided to Tribal or
local health departments

1. The state health department must provide two examples of its consultation or technical
assistance efforts. Examples may include: email, phone calls, webinars,
documents/materials, site-visits, meetings, training sessions, and web postings. The state
health department should include one example of assistance provided to a Tribal health
department, and one example of assistance provided to a local health department. If the
state does not contain any Tribal health departments, then the two examples should be from
local health departments.

Public Health Accreditation Board • Standards & Measures

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Domain 9: Evaluate and continuously improve health department processes, programs,
and interventions
Domain 9 focuses on using and integrating performance management quality improvement practices and processes to continuously improve the public
health department’s practice, programs, and interventions.

DOMAIN 9 INCLUDES TWO STANDARDS:
Standard 9.1
Standard 9.2

190

Use a Performance Management System to Monitor Achievement of Organizational Objectives

Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs,
Processes, and Interventions

Public Health Accreditation Board • Standards & Measures

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STANDARD 9.1: USE A PERFORMANCE MANAGEMENT SYSTEM TO
MONITOR ACHIEVEMENT OF ORGANIZATIONAL OBJECTIVES.
For the health department to most effectively and efficiently improve the health of the population, it is

important to monitor the quality of performance of public health processes, programs, interventions and
other activities. A fully functioning performance management system that is completely integrated into

health department daily practice at all levels includes: 1) setting organizational objectives across all levels of
the department, 2) identifying indicators to measure progress toward achieving objectives on a regular

basis, 3) identifying responsibility for monitoring progress and reporting, and 4) identifying areas where
achieving objectives requires focused quality improvement processes.

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.1 A
Engage staff at all organizational levels in
establishing or updating a performance
management system

Purpose

Significance

The purpose of this measure is to assess the
health department’s engagement of
leadership and staff in developing,
establishing, and updating a performance
management system for the organization.

To continuously improve public health
practice and ultimately influence health status,
the health department leadership and staff
should commit to establishing and using a
performance management system. The
discussion must intentionally engage all levels
of the organization in reaching decisions
about the functionality and integration of
various components of the performance
management system. Staff ownership is
required because implementation of a
performance management system is
successful only when staff is involved early
and continuously in decision making.
When department leadership and staff work
together to promote the use of performance
management practices, it is easier to achieve
an integrated performance management
system. Keeping top-down and bottom-up
dialogue alive reinforces the importance of
organizational excellence inherent in a fully
functioning, completely integrated
performance management system.

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Measure 9.1.1 A, continued

193

Required Documentation

Guidance

1. Documentation of engaging the health
department leadership and management in
establishing or updating a performance
management system

1. The health department must document leadership’s engagement in setting a policy for and/or
establishing a performance management system for the department. This can be shown
through strategic and operational plans; training agendas, training programs, meeting
agendas, packets, materials and minutes; draft policies or items discussed with the
governing entity, and/or presentations to the governing entity. Documentation may include:
minutes of team meetings, quality council monthly reports, and final reports from teams
showing results achieved.

2. Documentation of engaging the health
department staff at all other levels in
establishing or updating a performance
management system

2. The health department must document engagement of staff at all levels in determining the
nature of a performance management system for the department. This can be shown through
meeting agendas, packets, materials, and minutes; orientation presentations/programs for
new personnel; health department meeting materials and operational plans.

Public Health Accreditation Board • Standards & Measures

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.2 A
Implement a performance management
system

Purpose

Significance

The purpose of this measure is to assess the
health department’s capability to support
management practices for assessing
performance and identifying and managing
opportunities for improvement.

A performance management system
encompasses all aspects of using objectives
and measurement to evaluate performance of
programs, policies, and processes, and
achievement of outcome targets. Assessing
current capability helps identify objectives in a
structured way. There are a variety of
performance management system models to
assess and manage performance and identify
opportunities for improvement.
Formal, fully functioning, integrated
performance management systems are
feasible in every health department, yet health
departments may be using only some
components of a performance management
system. Identifying the performance
management practices being used will help
determine the extent to which components of
a performance management system exist and
which components need to be developed.

194

Public Health Accreditation Board • Standards & Measures

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Measure 9.1.2 A, continued

Required Documentation

Guidance

1. A completed performance management
self-assessment

1. The health department must provide a completed performance management selfassessment that reflects the extent to which performance management practices are being
used.
The health department may develop its own performance management assessment or use
existing models, such as The Performance Management Self-Assessment Tool from the
Turning Point Performance Management National Excellence Collaborative
(http://www.phf.org/resourcestools/Documents/PM_Self_Assess_Tool.pdf).
Self-assessment tools are also available through the Baldrige Performance Excellence
Program (http://www.nist.gov/baldrige/enter/self.cfm).

2. A current, functioning performance
management committee or team

195

2. The health department must provide documentation of a department committee, team,
council, executive team, or some other entity that is responsible for implementing the
performance management system. Documentation could be a charter, agendas, minutes,
reports, or protocols of the subsidiary body responsible.

Public Health Accreditation Board • Standards & Measures

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.3 A
Use a process to determine and report on
achievement of goals, objectives, and
measures set by the performance
management system

196

Purpose

Significance

The purpose of this measure is to assess the
health department’s use of a continuous
process to evaluate and report on
achievement of the goals, objectives, and
measures set by the performance
management system.

Public health has long recognized the essential
role evaluation plays in effectively managing
practice and in producing desired results.
Performance management uses a systematic
process to evaluate organizational excellence
by monitoring a set of selected indicators that
can analyze progress toward achieving goals
and objectives by specific dates.
While numerous types of evaluation are used
in public health practice, this measure
focuses on the process that the health
department designs, adapts and uses to
formally examine progress toward achieving
objectives and performance measures within
time-framed targets.

Required Documentation

Guidance

1. Written goals and objectives which include
time frames for measurement

1. The health department must provide two examples that demonstrate implementation of the
performance management system in monitoring and evaluating achievement of goals and
objectives with the identified time frames. One example must be from a programmatic area
and the other from an administrative area. These examples could be provided in narrative,
table, or graphic form, depending on the chosen reporting method.

2. Demonstration of a process for monitoring
of performance of goals and objectives

2. The health department must demonstrate that actual performance towards the two objectives
cited in 1) above was monitored. Evidence can come from run charts, dashboards, control

Public Health Accreditation Board • Standards & Measures

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Measure 9.1.3 A, continued

Required Documentation

Guidance
charts, flowcharts, histograms, data reports, monitoring logs, or other statistical tracking forms
demonstrating analysis or progress in achieving measures. Also useful: statistical summaries
and graphical presentations of performance on the measures, such as run charts, control
charts, and meeting minutes from a quality team.

197

3. Demonstration of analysis of progress
toward achieving goals and objectives,
and identify areas in need of focused
improvement processes

3. The health department must provide evidence that actual performance of the two objectives
identified in 1) above was analyzed according to the time frames. Evidence for determining
opportunities for improvement can be shown through the use of tools and techniques, such
as root cause analysis, cause and effect/Fishbone, force; or interrelationship digraphs or
other analytical tools.

4. Documentation of results and next steps

4. The health department must provide evidence that actual performance results, opportunities
for improvement, and next steps for the identified goals and corresponding objectives were
documented and reported.

Public Health Accreditation Board • Standards & Measures

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.4 A
Implement a systematic process for assessing
customer satisfaction with health department
services

198

Purpose

Significance

The purpose of this measure is to assess the
health department’s process to measure the
quality of customer relationships and service.

Customer focus is a key part of an
organization’s performance management
system. To evaluate the effectiveness and
efficiency of the health department’s work, it is
essential to identify customers and
stakeholders, both internal and external. A
health department also needs a process to
capture and analyze customer feedback in
order to address the expectations of various
public health customers.

Required Documentation

Guidance

1. Description of the process used to collect
and analyze feedback from two different
customer groups

1. Using a broad, customer/stakeholder identification list developed as part of a strategic
planning or health improvement planning process, the health department must provide two
examples of how customer/stakeholder feedback was collected and analyzed from two
different types of customers (e.g., vital statistics customers; food establishment operators;
individuals receiving immunizations, screenings, or other services; partners and contractors;
elected officials, etc.). Examples of documentation to collect customer/stakeholder
satisfaction could include: forms, surveys, or other methods. Results and conclusions could
be in a report, memo, or other written document.

Public Health Accreditation Board • Standards & Measures

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.5 A
Provide staff development opportunities
regarding performance management

199

Purpose

Significance

The purpose of this measure is to assess the
health department’s support to expand and
enhance performance management capacity
in the department.

For a health department to be effective in
establishing and implementing a performance
management system, the staff must
understand what a performance management
system is and how evaluation integrates with
performance management. The department
needs to ensure staff competence in the
appropriate use of tools and techniques for
monitoring and analyzing objectives
and indicators.

Required Documentation

Guidance

1. Documentation of staff development in
performance management

1. The health department must document its staff development in the area of performance
management. Documentation can be training attendance rosters, training curricula and
objectives, presentations and other training materials, or specific work with consultants or
technical assistants in performance. At a minimum, targeted staff should include those who
will be directly working on performance measure monitoring and analysis, and/or serving on a
quality team that assesses the department’s implementation of performance management
practices and/or system.

Public Health Accreditation Board • Standards & Measures

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Standard 9.1: Use a performance management system to
monitor achievement of organizational objectives.
Measure
9.1.6 S
Provide technical assistance and/or training
on performance management to Tribal and
local health departments

200

Purpose

Significance

The purpose of this measure is to assess the
state health department’s capacity to provide
performance management
orientation/training, evaluation training, and/or
technical assistance to Tribal and local health
departments.

State health departments have internal
capacity or access to performance
management and evaluation expertise to
assist Tribal and local health departments in
building or enhancing their performance
management and evaluation capacity. States
have an opportunity to share their expertise
and best practice experiences with Tribal and
local partners and create conditions in which
the state’s population benefits from locally
improved processes, programs, and
interventions.

Required Documentation

Guidance

1. Performance management system
technical assistance provided

1. The state health department must document that it has offered technical assistance and/or
training in performance management practices, methods, and/or tools to Tribal and local
health departments. The technical assistance can be provided “as requested,” or can be
scheduled, or provided as needed. It can be delivered by in-person sessions, webinars,
individual studies, hard copy, or on-line. The technical assistance does not have to be used
by Tribal or local health departments, but must be made available. This documentation can
be attendance rosters, curricula, presentations, exercises to apply tools and techniques,
newsletters, briefing papers, e-newsletters, email notification, or flyer or brochure distribution.

Public Health Accreditation Board • Standards & Measures

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STANDARD 9.2: DEVELOP AND IMPLEMENT QUALITY
IMPROVEMENT PROCESSES INTEGRATED INTO
ORGANIZATIONAL PRACTICE, PROGRAMS, PROCESSES,
AND INTERVENTIONS.
Performance management system concepts and practices serve as the framework to set targets, measure
progress, report on progress, and make improvements. An important component of the performance

management system is quality improvement and the implementation of a quality improvement program.
This effort involves integration of a quality improvement component into staff training, organizational

structures, processes, services, and activities. It requires application of an improvement model and the
ongoing use of quality improvement tools and techniques to improve the public’s health. Performance
management leads to the application of quality improvement processes.

Quality improvement is the result of leadership support. It requires staff commitment at all levels within an

organization to infuse quality improvement into public health practice and operations. It also involves regular
use of quality improvement approaches, methods, tools and techniques, as well as application of lessons
learned from evaluation.

201

Public Health Accreditation Board • Standards & Measures

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Standard 9.2: Develop and implement quality improvement processes
integrated into organizational practice, programs, processes, and interventions.
Measure
9.2.1 A
Establish a quality improvement program
based on organizational policies and direction

202

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to develop and
implement a quality improvement program
that is integrated into all programmatic and
operational aspects of the organization.

To make and sustain quality improvement
gains, a sound quality improvement
infrastructure is needed. Part of creating this
infrastructure involves writing, updating, and
implementing a health department quality
improvement plan. This plan is guided by the
health department’s policies and strategic
direction found in its mission and vision
statements, in its strategic plan, and in its
health improvement plan.

Required Documentation

Guidance

1. A written quality improvement plan

1. The health department must provide a quality improvement plan. An example of an
acceptable plan is one that describes:
• Key quality terms to create a common vocabulary and a clear, consistent message.
• Culture of quality and the desired future state of quality in the organization.
• Key elements of the quality improvement plan’s governance structure, such as:
--Organization structure
--Membership and rotation
--Roles and responsibilities
--Staffing and administrative support
--Budget and resource allocation

Public Health Accreditation Board • Standards & Measures

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Measure 9.2.1 A, continued

Required Documentation

Guidance
• Types of quality improvement training available and conducted within the
organization, such as:
--New employee orientation presentation materials
--Introductory online course for all staff
--Advanced training for lead QI staff
--Continuing staff training on QI
--Other training as needed – position-specific QI training (MCH, Epidemiology, etc.)
• Project identification, alignment with strategic plan and initiation process:
--Describe and demonstrate how improvement areas are identified
--Describe and demonstrate how the improvement projects align with the health
department’s strategic vision/mission
• Goals, objectives, and measures with time-framed targets:
--Define the performance measures to be achieved.
--For each objective in the plan, list the person(s) responsible (an individual or team)
and time frames associated with targets
--Identify the activities or projects associated with each objective and describe the
prioritization process used
• The health department’s approach to how the quality improvement plan is monitored:
data are collected and analyzed, progress reported toward achieving stated goals
and objectives, and actions taken to make improvements based on progress reports
and ongoing data monitoring and analysis.
• Regular communication of quality improvement activities conducted in the health
department through such mechanisms as:
--Quality electronic newsletter
--Story board displayed publicly
--Board of Health meeting minutes
--Quality Council meeting minutes
--Staff meeting updates

203

Public Health Accreditation Board • Standards & Measures

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Measure 9.2.1 A, continued

Required Documentation

Guidance
• Process to assess the effectiveness of the quality improvement plan and activities,
which may include:
--Review of the process and the progress toward achieving goals and objectives
--Efficiencies and effectiveness obtained and lessons learned
--Customer/stakeholder satisfaction with services and programs
--Description of how reports on progress were used to revise and update the quality
improvement plan.

204

Public Health Accreditation Board • Standards & Measures

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Standard 9.2: Develop and implement quality improvement processes
integrated into organizational practice, programs, processes, and interventions.
Measure
9.2.2 A
Implement quality improvement activities

205

Purpose

Significance

The purpose of this measure is to assess the
health department’s use of quality
improvement to improve processes,
programs, and interventions.

It takes practice to effectively use the quality
improvement plan to improve processes,
programs, and interventions. Staff benefit from
seeing the plan put into action and receiving
regular feedback on progress toward achieving
stated objectives, as well as on how well they
have executed their respective roles and
responsibilities.

Required Documentation

Guidance

1. Documentation of quality improvement
activities based on the QI plan

1. The health department must provide two examples that demonstrate implementation of
quality improvement activities. One example must be from a program area and the other from
an administrative area. The examples should illustrate the health department’s application of
its process improvement model. The examples should demonstrate:
• how staff problem-solved and planned the improvement,
• how staff selected the problem/process to address and described the
improvement opportunity,
• how they described the current process surrounding the identified
improvement opportunity,

Public Health Accreditation Board • Standards & Measures

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Measure 9.2.2 A, continued

Required Documentation

Guidance
• how they determined all possible causes of the problem and agreed on root
cause(s), and
• how they developed a solution and action plan, including time-framed targets
for improvement.
The example should also demonstrate what the staff did to implement the solution or process
change. It should also show how they reviewed and evaluated the result of the change, and
how they reflected and acted on what they learned.
Examples of acceptable documentation include quality improvement project work plans or
storyboards that identify achievement of objectives and include evidence of action and
follow-up. The health department’s documentation should demonstrate ongoing use of an
improvement model, including showing the tools and techniques used during application of
the process improvement model. Documentation should also describe: actions taken,
improvement practices and interventions, data collection tools and analysis, progress reports,
evaluation methods, and other activities and products that resulted from implementation of
the plan.

2. Demonstrate staff participation in quality
improvement activities based on the
QI plan

206

2. The health department must demonstrate how staff were involved in the implementation of the
plan, worked on improvement interventions or projects, or served on a quality team that
oversees the health department’s improvement efforts. Examples of documentation may
include minutes, memos, reports, or committee or project responsibilities listings.

Public Health Accreditation Board • Standards & Measures

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Domain 10: Contribute to and apply the evidence base of public health
Domain 10 focuses on the role that health departments play in building and advancing the science of public health. Public health is strengthened when
its practitioners continually add to the body of evidence for promising practices -- those practices that have the potential to become evidence-based over
time. Health departments should employ evidence-based practices for increased effectiveness and credibility. Health departments also have important
roles in developing new evidence. Health departments should apply innovation and creativity in providing public health services appropriate for the
populations they serve.

DOMAIN 10 INCLUDES TWO STANDARDS:
Standard 10.1
Standard 10.2

207

Identify and Use the Best Available Evidence for Making Informed Public Health Practice Decisions

Promote Understanding and Use of Research Results, Evaluations, and Evidence-based Practices with
Appropriate Audiences

Public Health Accreditation Board • Standards & Measures

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STANDARD 10.1: IDENTIFY AND USE THE BEST AVAILABLE
EVIDENCE FOR MAKING INFORMED PUBLIC HEALTH
PRACTICE DECISIONS.
Public health evidence-based practice requires that a health department use the best available evidence in
making decisions and in ensuring the effectiveness of processes, programs, and interventions. Evidence-

based practice assures that a health department’s resources are being used in the most effective manner.
Health departments should access information about evidence-based practices and apply that information
to their processes, programs, and interventions.

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Standard 10.1: Identify and use the best available evidence
for making informed public health practice decisions.
Measure
10.1.1 A
Identify and use applicable evidence-based
and/or promising practices when
implementing new or revised processes,
programs and/or interventions

Significance

The purpose of this measure is to assess the
health department’s use of evidence-based
and/or promising practices in its design of
new process, programs, or interventions or in
revisions of programs.

It is important that public health efforts have
the maximum positive impact possible.
Evidence-based practices have been
evaluated or researched and have been
found to be effective.
Health departments should be aware of
practices that are evidence-based and
incorporate them into their processes,
programs, and interventions. Evidence-based
practice ensures that health department
resources are being applied effectively.
Promising public health practices also have
the potential for evaluation and designation as
evidence-based.

Required Documentation

Guidance

1. Two examples from within the past three
years of evidence-based or promising
practices, including:

1. The health department must provide two examples of the incorporation of an evidence-based
or promising practice in a public health process, program, or intervention. The examples must
have occurred within the previous three years. Examples must come from two different
program areas, one of which is a chronic disease program.
a. The health department must show the source of the information concerning the
evidence-based or promising practice. The source of the practice could be (1) The
Guide to Community Preventive Services, (2) the result of an information search
(web, library, literary review), or (3) result of interaction with consultants, academic
faculty, researchers, other health departments, or other experts.

a. Source of evidence-based or
promising practice

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Purpose

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Measure 10.1.1 A, continued

Required Documentation

Guidance

b. Description of how evidencebased or promising practice was
implemented in agency processes,
programs, and/or interventions

b. The health department must provide a description of how the evidence-based or
promising practice identified in (a) above was incorporated into the design of a new
or revised process, program, or intervention. Documentation may be in the form of
internal memos, annual reports, program descriptions in public information (reports,
newsletters), or other program descriptions written by the department.
Due to the limited availability of evidenced-based practices or promising practices in Tribal
communities, Tribal health departments may provide documentation of how evidence-based
practices or promising practices have been adapted to integrate cultural values, beliefs, and
traditional healing practices of the Tribe.

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Standard 10.1: Identify and use the best available evidence
for making informed public health practice decisions.
Measure
10.1.2 T/S
Foster innovation in practice and research

211

Purpose

Significance

The purpose of this measure is to assess the
Tribal or state health department’s efforts to
promote and support innovations in public
health practice and research.

Public health addresses complex, multisectoral problems that are changing as
rapidly as our social, cultural, and
technological environment is changing. The
need for innovation in public health practice
and research is more urgent, given the
increasingly rapid pace of change in the
environment that affects the public’s health.

Required Documentation

Guidance

1. Relationships with academic institutions,
research centers/institutes

1. The Tribal or state health department must provide documentation that it has a working
relationship with academic institutions and/or research centers/institutes. In some cases, the
relationship may be a formal relationship that can be documented by a contract or a
MOA/MOU. In other cases, the working relationship may be less formal. In those cases,
meeting minutes, emails, and meeting agenda could demonstrate collaboration with
academic institutions and/or research centers/institutes. Additionally, jointly written reports,
white papers, and research studies could demonstrate collaboration with academic
institutions and/or research centers/institutes.

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Measure 10.1.2 T/S, continued

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Required Documentation

Guidance

2. Participation in research agenda-setting,
practice-based research networks, or other
research efforts

2. The Tribal or state health department must document that it is engaged with the work of the
research community. Documentation that demonstrates membership in a practice-based
research network, either with other states, institutions, or within the state, could show
conformity with the measure. For Tribal health departments, this may include the incorporation
of practice-based evidence grounded in cultural values, beliefs, and traditional practices.
This documentation could be a membership list or meeting attendance roster. Another vehicle
to demonstrate conformity with the measure is IRB documentation, such as meeting minutes
or submission of IRB documentation showing participation in research (minutes, submission
documentation).

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STANDARD 10.2: PROMOTE UNDERSTANDING AND USE OF THE
CURRENT BODY OF RESEARCH RESULTS, EVALUATIONS, AND
EVIDENCE-BASED PRACTICES WITH APPROPRIATE AUDIENCES.
Lack of communication or understanding between public health researchers and public health practitioners
often exists. Gaps in understanding may also occur between the public health department and the general
public. Communication can help bridge the areas where understanding is lacking and can strengthen the
relationship and trust among researchers, public health practitioners, and the public. Communication

between public health practitioners and the public, governing entities, and other audiences could encourage
others to become advocates for research and to contribute to the science of public health. Health

departments should encourage the use of research results, evaluations, and evidence-based practices.

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Standard 10.2: Promote understanding and use of the current body of research
results, evaluations, and evidence-based practices with appropriate audiences.
Measure
10.2.1 A
Ensure human subjects are protected when
the health department is involved in or
supports research activities

214

Purpose

Significance

The purpose of this measure is to assess the
health department’s policies and practices for
the protection of human subjects in research
in which it is involved.

Many public health studies involve recipients
of public health services or public health staff.
Institutions that receive government funds for
research are required to have the research
that involves human subjects approved by a
registered institutional review board (IRB) to
ensure the ethical treatment of human
subjects. Ethical treatment of human subjects
is a basic value of public health research and
programs. Appropriate efforts must be made
to protect the rights, welfare, and well-being of
subjects involved in research.

Required Documentation

Guidance

1. Human subjects research protection policy

1. The health department must provide a copy of a policy regarding research, such as an IRB
review policy. If the health department does not have its own internal IRB process, the health
department should have a copy of the IRB approval from the institution where the IRB review
was done. If the health department is never involved with research that involves human
subjects, a policy stating that fact could be accepted as documentation.

Public Health Accreditation Board • Standards & Measures

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Standard 10.2: Promote understanding and use of the current body of research
results, evaluations, and evidence-based practices with appropriate audiences.
Measure
10.2.2 A
Maintain access to expertise to analyze
current research and its public health
implications

215

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to review and
interpret research findings.

Health departments must have the internal
capacity for, or ability to access, expert review
and interpretation of research findings.
Interpreting research findings is important
when communicating the public health
implications of those findings to stakeholders,
partners, and the public. It is also important
when incorporating research findings into
department processes, programs, or
interventions.

Required Documentation

Guidance

1. Documentation of availability of expertise
(internal or external) for analysis of research

1. The health department must document that it has expert staff or outside experts who can
analyze research and its public health implications. A list of experts and a description of their
training or expertise could demonstrate conformity with this measure. The expertise may be
within the department or may reside outside the health department, such as an academic
institution, research center, Tribal epidemiology center, public health institute, or consultant. If
the expertise is outside of the health department, the health department must show a written
agreement (contract, MOA/MOU, etc.) that demonstrates access to such expertise. This
measure includes analysis of the current body of research relevant to public health practice,
irrespective of whether or not the research was conducted in the Tribe, state, or community.

Public Health Accreditation Board • Standards & Measures

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Standard 10.2: Promote understanding and use of the current body of research
results, evaluations, and evidence-based practices with appropriate audiences.
Measure
10.2.3 A
Communicate research findings, including
public health implications

216

Purpose

Significance

The purpose of this measure is to assess the
health department’s efforts to keep others,
both within and outside the public health
profession, informed about the findings of
public health research and the public health
implications of those findings.

Public health research provides the
knowledge and tools that people and
communities need to protect their health.
However, research findings can be confusing
and difficult to translate into knowledge that
steers action toward improved public health.
Health departments can communicate the
facts and implications of research so that
individuals and organizations are informed
and knowledgeable, and can act accordingly.

Required Documentation

Guidance

1. Documentation of communication of
research findings and their public health
implications to stakeholders, public health
system partners, and/or the public

1. The health department must provide two examples of communication through which the
department conveyed research findings and their public health implications to stakeholders,
other health departments, members of the public health system and non public health system
partners, and/or the public. Documentation could include: a presentation, prepared report,
discussion at a meeting recorded in the minutes, web posting, email list serve, newspaper
article, webinar, or press release. Appropriate audiences could include: the health
department’s governing entity; elected/appointed officials; agencies, departments, or
organizations that collaborate with the health department in the delivery of services;
community and healthcare partners; and the general public. Audiences would be especially
appropriate if involved in or affected by the research.

Public Health Accreditation Board • Standards & Measures

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Measure 10.2.3 A, continued

Required Documentation

Guidance
The research must have been evaluated by experts to provide valid implications.
In any state health department distribution list of research findings, the Tribal and local health
departments in the state must be included.
In any local health department distribution list of research findings, the Tribal and state health
department(s) in the state must be included.
In any Tribal health department distribution list of research findings, the state and local health
department(s) in the state must be included.

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Standard 10.2: Promote understanding and use of the current body of research
results, evaluations, and evidence-based practices with appropriate audiences.
Measure

10.2.4 S
Provide consultation or technical assistance to
Tribal and local health departments and other
public health system partners in applying
relevant research results, evidence-based
and/or promising practices

Purpose

Significance

The purpose of this measure to assess the
state health department’s provision of
assistance to Tribal and local health
departments on the application of relevant
research results and evidence-based
/promising practices.

Scientifically sound public health practices are
essential for public health interventions to be
effective. Public health practices are continually
being researched and tested, and new findings
are being made available to the field. State
health departments should share their
knowledge and expertise concerning research
findings and evidence-based or promising
practices with Tribal and local health
departments in their state. State health
departments can provide consultation or
technical assistance on employing research and
modifying practices to best suit the population
served by the Tribal or local health department.

Required Documentation

Guidance

1. Consultation or technical assistance
provided to Tribal and/or local health
departments, and/or other health system
organizations in applying relevant research,
evidence-based and/or promising practices

1. The state health department must submit two examples of how it has provided consultation,
technical assistance, advice, direction, or guidance to Tribal and/or local health departments
and/or members of the public health system in the application of relevant research or
evidence-based and/or promising practices. This assistance must be specific to the
application of relevant research results or the employment of evidence-based and/or
promising practices. This assistance can be provided to local health departments, Tribal
health departments in the state, or other partners or stakeholders.
The state health department cannot use examples of providing assistance to program
divisions within the state health department.

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Standard 10.2: Promote understanding and use of the current body of research
results, evaluations, and evidence-based practices with appropriate audiences.
Measure
10.2.4 T
Provide technical assistance to the state
health department, local health departments,
and other public health system partners in
applying relevant research results, evidencebased and/or promising practices

219

Purpose

Significance

The purpose of this measure to assess the
Tribal health department’s provision of
assistance to the state and local health
departments and other Tribal health
departments on the application of relevant
research results and evidence-based
/promising practices.

Scientifically sound public health practices
are essential for public health interventions to
be effective. Public health practices are
continually being researched and tested, and
new findings are being made available to the
field. Tribal health departments should share
their knowledge and expertise on research
findings and evidence-based or promising
practices with state and local health
departments, other Tribal health departments,
and/or Tribal organizations. Tribal health
departments can provide consultation or
technical assistance on employing research
and modifying practices to best suit the
population being served. Tribal health
departments should share with state and local
health departments their knowledge and
expertise on research methods that are
culturally relevant or appropriate approaches
to applying research in Tribal communities.

Public Health Accreditation Board • Standards & Measures

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Measure 10.2.4 T, continued

Required Documentation

Guidance

1. Consultation or technical assistance to state
and/or local health departments, other
Tribal health departments, and/or Tribal
organizations in applying relevant research,
evidence-based, promising practices,
and/or practice-based evidence

1. The health department must submit two examples of providing consultation, technical
assistance, advice, direction, or guidance to others in the application of relevant research or
evidence-based, promising practices, and/or practice-based evidence. This assistance must
be specific to the application of relevant research results or the employment of evidencebased and/or promising practices. This assistance can be provided to the state health
department, local health departments, other Tribal health departments in the state, or other
partners or stakeholders.
Examples of technical assistance provided by the Tribe may be done together with a federal
partner, such as I.H.S, a Tribal Epidemiology Center or other Tribal department.
The Tribal health department cannot use examples of providing assistance to itself, such as to
program divisions within the Tribal health department.

220

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Domain 11: Maintain administrative and management capacity
Domain 11 focuses on health department management and administration capacity. Health department leaders and staff must be knowledgeable about
the structure, organization, and financing of their public health department and other agencies and organizations that provide public health services.
Health departments must have a well managed human resources system, be competent in general financial management, and knowledgeable about
public health authorities and mandates.

DoMain 11 incluDes TWo sTanDarDs:

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Standard 11.1

Develop and Maintain an Operational Infrastructure to Support the Performance of Public Health Functions

Standard 11.2

Establish Effective Financial Management Systems

Public Health Accreditation Board • Standards & Measures

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sTanDarD 11.1: DeVeloP anD MainTain an oPeraTional
inFrasTrucTure To suPPorT THe PerForMance oF PuBlic
HealTH FuncTions.
A strong operational infrastructure is necessary in order to administer public health services efficiently and
effectively to meet the needs of the population. By maintaining a strong organizational infrastructure, the
health department can assess and improve its operations, staffing, and program support systems.

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standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.1 A
Maintain policies and procedures regarding
health department operations, review policies
and procedures regularly, and make them
accessible to staff

223

Purpose

Significance

The purpose of this measure is to assess the
health department’s processes for maintaining
policies and procedures, which includes
developing, writing, reviewing, revising,
training, and sharing health department policy
and procedures with staff. This measure
focuses on health department policies that
direct organizational operations, not programs
and program guidelines.

Standardized written policies and procedures
are needed to operate an organization
efficiently and effectively. Regular review and
revision of those policies and procedures is
important for continuous quality improvement.
Staff need to have ready access to policies
and procedures to be informed of
organizational and operations expectations.

Required Documentation

Guidance

1. Policy and Procedure Manual or
individual policies

1. The health department must provide written operational policies. The policies can be in hard
copy or in an electronic format. If electronic, the policies can be files on a server or postings
on the web. Only the most recent version of policies must be presented. Some health
departments may use policies and procedures that are not specific to the health department,
but are government-wide (i.e., state, city or county) or relate to a larger super-health agency
or umbrella agency. These policies and procedures could demonstrate compliance with the
measure if they apply to the health department as well as other government agencies.

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Measure 11.1.1 a, continued

Required Documentation

Guidance

2. Health department organizational chart

2. The health department must provide its current health department organizational chart. If the
health department is part of a super-agency or umbrella agency, and some of the
documentation provided is from other divisions within the umbrella agency, then an
organizational chart showing the health department’s relationship with the other divisions is
also required
The health department’s organizational chart must show leadership, upper management
positions, and the organization of programs. It need not detail every staff person.
If changes occur to the organizational chart between the submission of documentation to
PHAB and the site visit, the health department must have a copy of the revised chart
available for the site visit team. This is the only instance where information may be changed or
updated between the submission of the health department’s documents to PHAB and the
time of the site visit.

224

3. Reports of review at least every five years
or proof of regular updating process

3. The health department must provide reports, such as meeting agenda and memoranda,
showing that reviews of policies and procedures have taken place. The original policies and
procedures may have been in place for many years; official dates of policy revisions
demonstrate that a review has been conducted within the last five years. The health
department must provide a description of the process to update and revise policies and
procedures.

4. Description of methods for staff access
to policies

4. The health department must provide a written description of how staff may access policies.
Access methods can include: website; health department intranet; server access; or
distribution of a hard copy, available from supervisors, or located in central locations.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.2 A
Maintain written policies regarding
confidentiality, including applicable HIPAA
requirements

Purpose

Significance

The purpose of this measure is to assess how
the health department protects client and
health department staff confidentiality.

It is critical that health departments and the
individuals who work in them maintain client
confidentiality and protect client/patient
health information. Lack of attention to
confidentiality policies and their
implementation can lead to violations of
confidentiality. This creates liability to the
health department and lessens credibility.

Required Documentation

Guidance

1. Confidentiality policies

1. The health department must provide written confidentiality policies and procedures. Policies
must define the health department’s processes for protecting client confidentiality, both
personal (directed toward the individual) and informational (directed at their health data and
records). This may include policies concerning such processes as clinical protocols, staff
access to records, computer use, business associate agreements and electronic transfer
of data.
Policies may be either hard copy or in an electronic format. If electronic, the policies can be
files on a server or posted on the web. Only the most recent version of policies must be
presented. Some health departments may use confidentiality policies and procedures that
are not specific to the health department, but are government-wide (i.e., state, city or county)
or relate to a larger super-health agency or umbrella agency.

225

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Measure 11.1.2 a, continued

226

Required Documentation

Guidance

2. Training content and staff participants

2. The health department must provide evidence of staff training on confidentiality policies,
including training content and names of those who received the training. Evidence may be a
copy of training materials and an agenda for the training session – whether group or
individual. The health department must have a record of who attended the training. This may
be a log, a sign-in sheet or a record/statement from web-based training.

3. Signed employee confidentiality forms, as
required by policies

3. The health department must provide a confidentiality form or agreement that is signed by
employees. Through this form, staff will acknowledge their responsibilities for protecting
confidentiality. The health department can submit a copy of the form. There is no need to
submit copies of every employee-signed form; a log showing that employees have signed the
form is sufficient.

Public Health Accreditation Board • Standards & Measures

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standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.3 A
Maintain socially, culturally, and linguistically
appropriate approaches in health department
processes, programs, and interventions,
relevant to the population served in its
jurisdiction

Purpose

Significance

The purpose of this measure is to assess the
health department’s social, cultural, and
linguistic competence in working with its own
employees and in providing public health
programs to the populations in its jurisdiction.

Public health departments are responsible for
all residents in the health department’s
jurisdiction, and usually that includes people
of various backgrounds and cultures. It is
important for health departments to
understand how values, norms, and traditions
of the populations served affect how
individuals perceive, think about, and make
judgments about health, health behaviors,
and public health services. Those values,
norms and traditions affect how populations
interact with public health workers and how
open they are to health information, health
education, and changing health behaviors.
Ensuring that the health department’s
services, materials, and processes address
these social, cultural, and language
differences (including low literacy, non-English
speaking populations, and the visually or
hearing impaired) will enhance the health
department’s ability to provide the most
effective services to meet the needs of
the population.

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Measure 11.1.3 a, continued

Required Documentation

Guidance

1. Policy or procedure for the development of
interventions and materials that are
culturally and linguistically appropriate for
the population it serves in its jurisdiction

1. The health department must provide written policies or procedures that demonstrate how
social, cultural, and linguistic characteristics of the various populations groups of the
residents it serves are incorporated into processes, programs, and interventions.
Characteristics addressed in the policy or procedure may include social, racial, ethnic,
cultural, and linguistic, including low literacy, non-English speaking populations, and the
visually or hearing impaired.

2. Demonstration of providing two different
processes, programs or interventions in
culturally or linguistically competent
manner, including application of social
marketing activities

2. The health department must provide two examples of a process, program, or intervention that
is culturally or linguistically appropriate, as defined above. The examples should demonstrate
the use of social marketing methods. The two examples must come from different program
areas of the health department and may be selected by the department.
Oral communication is integral to many Tribal cultures. If oral communication is used to
ensure that programs, processes, and interventions are culturally competent, the health
department must provide documentation of its use, such as plans, protocols, or objectives for
focus groups, community gatherings, roundtables, talking circles, digital storytelling, or other
activities. Tribal health departments may serve Tribal members from more than one Tribe or
non-Tribal individuals. If this is the case, examples of culturally and linguistically competent
services provided to these groups. (e.g., interpretation, materials in other languages) are
acceptable documentation.

3. Documentation of one training session
content and staff participants

3. The health department must provide one example of staff training on social, cultural, and/or
linguistic factors. Training may include: examining biases and prejudices; developing crosscultural skills; learning about specific populations’ values, norms and traditions; and/or
learning about how to develop programs and materials for low literacy individuals or the
visually or hearing impaired.
Documentation must show the content of the training. Evidence could be a copy of the
training materials or an agenda for the training session. The health department must have a
record of who attended the training. This may be a log, a sign-in sheet, or a record/statement
from web-based training.

228

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Measure 11.1.3 a, continued

229

Required Documentation

Guidance

4. Report of a cultural and linguistic
competence assessment of the health
department

4. The health department must provide evidence of an assessment of cultural and linguistic
competence. This could be the Cultural and Linguistic Competency Policy (CLCPA) selfassessment from the National Center for Cultural Competence, assessment against Culturally
and Linguistically Appropriate Services (CLAS) standards, or another assessment tool.

Public Health Accreditation Board • Standards & Measures

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standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.4 A
Maintain a human resources system

230

Purpose

Significance

The purpose of this measure is to assess the
health department’s management of its
human resources. The human resource
system may be fully contained within the
health department, or it may be located in its
own governmental agency (for example, an
office of management), in an office outside the
health department, or may be implemented
as a combination. A health department may
also contract for certain human resource
actions to an outside organization that
specializes in human resource management.

A well defined and structured human
resources system is important for any
organization. It provides the health
department with the processes to hire,
manage, evaluate, and improve performance
of personnel.

Required Documentation

Guidance

1. Human resource policy and procedure
manual or individual policies

1. The health department must provide a human resource manual or set of policies and
procedures. They may be in hard copy, electronic, or web based. The policies and
procedures must address all of the following:
• Personnel recruitment, selection, and appointment;
• Equal opportunity employment;
• Salary structure;
• Hours of work;
• Benefits package;

Public Health Accreditation Board • Standards & Measures

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Measure 11.1.4 a, continued

Required Documentation

Guidance
• Performance evaluation process and individualized development plans; and
• Problem solving and complaint handling, including sexual harassment.
Some health departments may use a human resource system that is not specific to the health
department, but is government-wide (i.e., state, city or county). The policies and procedures
may not, therefore, be specific to only the health department but to all of city, county, state, or
Tribal government. These policies and procedures could demonstrate compliance with the
measure if they apply to the health department, as well as other government agencies.
Indian Preference Policies may be submitted in place of personnel selection and appointment
and/or Equal Opportunity Employment policies. It may also be applicable that Tribal health
departments provide MOAs for assignment of personnel [e.g., U.S. Public Health
Service/Indian Health Service or other personal service contracts or agreement (PSA)].

231

2. Labor agreements, employment
agreements, or contracts, including
descriptions of mechanisms for working
relationships

2. The health department must provide an example of labor agreements (if appropriate),
employment agreements, or contracts. The documentation provided must include a
description of the mechanisms for working relationships.

3. Description of methods for staff access to
human resources policies and procedures

3. The health department must provide a written description of how staff access human
resources policies and procedures. Access methods can include: web based; health
department intranet; server access; or distribution of a hard copy, available from supervisors
or located in central locations.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.5 A
Implement and adhere to the health
department’s human resources policies
and procedures

232

Purpose

Significance

The purpose of this measure is to assess the
health department’s execution of its human
resources policies and procedures.

Health departments’ success, as in all
organizations, depends on the capabilities
and performance of its staff. Actions that
maximize staff capabilities and performance
are necessary for the health department to
function at a high level. It is important that
hiring practices are effective and that human
resource policies and procedures are
implemented in a fair and consistent manner
to share information and retain staff.

Required Documentation

Guidance

1. Documentation of the recruitment of
qualified individuals that reflect the
population served

1. The health department must provide two examples of the recruitment of individuals who are
qualified for their positions and who reflect the population that the health department serves.
Examples include: a job description and posting that specifies the level of skills, training,
experience, and education that the applicant should possess to qualify for the position.
These recruitment examples provide evidence of the efforts of the health department, not
the success or failure to achieve the desired applicant pool.

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Measure 11.1.5 a, continued

Required Documentation

Guidance

2. Documentation of retention activities
conducted

2. The health department must provide two examples of activities to retain staff. Examples
include: employee satisfaction survey results, needs assessments of work environment,
reward and recognition programs, career ladders, promotion opportunities, and supervisor
mentoring programs.

3. Position descriptions, available to staff

3. The health department must provide two examples of position descriptions, or job
descriptions, and also demonstrate how the descriptions are made available to staff. They
may be made available through the internet, a policy procedures manual, or through the
human resources department.

4. Description of process to verify
staff qualifications

4. The health department must provide a description of the process used to verify staff
qualifications. This process may be defined in policy; or it may be found in personnel
guidelines that are part of the human resources system or a central administrative unit, such
as a civil service system. Other examples include: guidelines used by all county/state
agencies or a separate process defined and used by the health department. The process
may include: reference checks; confirmation of transcripts with the issuing academic
institution; confirmation of any registration, certification, or license with the issuing institution,
or other check of credentials provided by the staff member. For Tribal health departments
using the Indian Preference law, proof of enrollment may be required.

5. Evidence that qualifications have been
checked for all staff hired in the last
two years

5. The health department must provide documentation that qualifications have been checked
for all staff hired in the past two years. The format of the documentation is defined by the
health department and can include examples from personnel files, a log or spreadsheet, or a
template or form used by the health department. Also acceptable: evidence from a county or
state personnel office demonstrating that the person is qualified for the position. Reviews
should include tracking required recertification.
Tribes often operate a human resources department to support its administration, including the
Tribal health department. If this is the case, the health department must demonstrate how it
works with human resources to ensure that it follows the appropriate policies and procedures.

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standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.6 A
Use information systems that support the
health department mission and workforce by
providing infrastructure for data
collection/analysis, program management,
and communication

234

Purpose

Significance

The purpose of this measure is to assess the
health department’s capacity to collect and
manage information and data.

A health department has access to a wealth
of data, either created by the department or
collected from others. To use this data
effectively, the health department must
maintain an information system that provides
the ability to process and manage information.

Required Documentation

Guidance

1. Demonstration of the use of technology to
support public health functions

1. The health department must provide two examples of how technology supports functions of
the department. The two examples must be from different program areas. The health
department may select the programs. Examples that will meet this measure include: a
scanning system to preserve records, an electronic billing and/or grant system, standard
employee computer hardware and software package, an educational kiosk, vital records
systems, program (such as WIC) information systems, licensing information systems,
electronic medical records, a client self-check in, patient registries, and on-line data services.

2. Inventory of hardware

2. The health department must provide an inventory of hardware to demonstrate the capacity of
staff access to technology and to the internet and web-based applications.

3. Inventory of software, including capacity for
data analysis, word processing, and
internet/website

3. The health department must provide an inventory of software that allows the department staff
to enter, analyze, and maintain data.

Public Health Accreditation Board • Standards & Measures

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standard 11.1: Develop and maintain an operational infrastructure
to support the performance of public health functions.
Measure
11.1.7 A
Maintain facilities that are clean, safe,
accessible, and secure

235

Purpose

Significance

The purpose of this measure is to assess the
health department’s facilities for use by both
staff and the public.

In order for the health department to
implement the processes, programs, and
interventions, the facilities must be adequate.
All facilities that are operated by the health
department must be clean, safe, accessible,
and secure for both staff and the public.

Required Documentation

Guidance

1. Licenses for clinics and laboratory

1. The health department must provide copies of licenses to meet national or state requirements
appropriate for any clinical services it provides. Select Agent certification is required for a
public health laboratory.

2. Inspection reports and/or certificate of
occupancy

2. The health department must provide samples of inspection reports, such as OSHA, internal
(department conducted), or external (an independent organization) inspection reports,
cleaning and maintenance policies, logs, records, contracts or orders, medical waste
storage. Other examples of documentation include environmental public health and safety
committee meeting minutes and federal or Tribal environmental audits.

3. ADA compliance audit

3. The health department must provide a copy of the ADA compliance report.

Public Health Accreditation Board • Standards & Measures

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sTanDarD 11.2: esTaBlisH eFFecTiVe Financial
ManaGeMenT sYsTeMs.
Sound financial practices are basic to any organization and enhance the health department’s ability to

manage resources wisely, to analyze present and future needs, and to sustain operations. This standard
measures the capacity of the health department to manage the organization’s finances.

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standard 11.2: establish effective financial management systems.
Measure
11.2.1 A
Comply with external requirements for the
receipt of program funding

237

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to manage grants
and contracts and comply with funding
requirements.

Health departments receive funding from
varied sources. Each funding source has
specific requirements for the use of the funds
and for reporting to the funding agency. It is
important that funds are used appropriately
and legitimately.

Required Documentation

Guidance

1. Audited financial statements

1. The health department must provide annual financial audit reports for the previous two
fiscal years.

2. Two program reports

2. The health department must provide two program reports that it has submitted to funding
organizations. Program reports that will meet this standard include: compliance reports to
federal funders, reports to legislatures or local city/county/Tribal councils, and reports to
foundations. Also acceptable: program reports, monitoring reports, or corrective action plans
that show compliance with funding requirements. Contracts or agreements between States,
Local and/or Tribal health departments to provide services may show the expectations for
funding but may not show the compliance with requirements. If such contracts are used, they
must be combined with follow-up reports that validate the compliance.

Public Health Accreditation Board • Standards & Measures

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standard 11.2: establish effective financial management systems.
Measure
11.2.2 A
Maintain written agreements with entities
providing processes, programs and/or
interventions delegated or purchased by the
public health department

Purpose

Significance

The purpose of this measure is to assess the
health department’s management of
arrangements for other organizations to
provide processes, programs, or interventions
on behalf of the health department.

The public health department may not directly
deliver or provide all services and may
depend on other entities to act on its behalf.
These could be services related to
organizational, management, or administrative
functions, or program services or interventions
delivered to the public.

Required Documentation

Guidance

1. Current written contracts/MOUs/ MOAs for
processes, programs and/or interventions

1. The health department must provide two examples of current contracts or MOU/MOAs. The
examples must be from two different program/administrative areas featuring written
agreements with different entities. The agreements must be current, having been executed
(or updated) in the past two years. Agreements used as documentation must still be in effect
and must contain the financial provisions.
State health departments may provide a written agreement with a local or district health
department for one of the examples. The other example must be with another governmental
agency or organization.

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Measure 11.2.2 a, continued

Required Documentation

Guidance
Local health departments may provide a written agreement with the state health department
for one of the examples. The other example must be with another agency or organization.
Tribal health departments may provide a written agreement with a local, district, or state
health department for one of the examples. The other example must be with another agency
or organization. Tribal health departments may use the compact or funding agreement with
the U.S. DHHS to carry out programs of the Indian Health Service. Also acceptable for
documentation: agreements with non-Tribal entities to provide Contract Health Services (CHS)
to beneficiaries of the Tribal health department, as well as MOA/MOUs or other agreements
with other entities, such as epidemiological services provided to Tribes from Regional Epi
Centers funded by IHS.

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standard 11.2: establish effective financial management systems.
Measure
11.2.3 A
Maintain financial management systems

240

Purpose

Significance

The purpose of this measure is to assess the
health department’s ability to manage finances.

Sound management of financial resources is a
basic function of a public health department.
Health departments are accountable to their
governing entity, elected officials, and the
public they serve for the responsible oversight
of public funds.

Required Documentation

Guidance

1. Approved health department budget

1. The health department must provide the approved budget that is in effect when the
documentation for accreditation is submitted to PHAB. If a new budget is approved before
the site visit, that budget must be provided (electronically) to the site visit team through PHAB.
The budget may be approved by the governing entity or other body with approval authority,
such as a governor’s budget office.

2. Quarterly financial reports

2. The health department must provide two examples of financial reports. Financial reporting is
expected, at a minimum, on a quarterly basis. Types of reports can include: expense reports,
reimbursement reports, reports to governing entities, and/or monthly budget reports –
summarized or itemized. The examples provided may demonstrate two different types of
reporting or may be two successive reports of the same type.

Public Health Accreditation Board • Standards & Measures

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standard 11.2: establish effective financial management systems.
Measure
11.2.4 A
Seek resources to support agency
infrastructure and processes, programs, and
interventions

Purpose

Significance

The purpose of this measure is to assess the
health department’s activities to increase
financial resources to support its infrastructure
and to enhance or develop processes,
programs, and interventions.

The availability of funding for public health
departments has historically been limited.
Additional funding should be sought through
a variety of means, including: budget increase
requests, budget revision requests, and
grants. Financial resources should be
maximized by leveraging funds to increase
resources available for public health.

Required Documentation

Guidance

1. Grant applications and or examples of
leveraging funds to increase resources

1. The health department must provide two examples of grant applications (funded or
unfunded) or documentation of leveraging funds to obtain additional resources.

2. Appropriate communications with others
concerning the need for improvement in
public health

2. The health department must provide two examples of communicating the need for additional
investment in public health. Examples could be articles or letters to the editor of a newspaper,
presentations to the community, or testimony. Letters, articles, presentations, or testimony can
be issue specific or may address public health in general.
Tribal examples include: Tribal letters or resolutions of support, Tribal public health assessments
for the purpose of demonstrating resources needed, or executive order adding resources.

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Domain 12: Maintain capacity to engage the public health governing entity
Domain 12 focuses on the health department’s capacity to support and engage its governing entity in maintaining the governmental public health
infrastructure for the jurisdiction served. Governing entities play an important role in the function of many public health departments. Governing entities
both directly and indirectly influence the direction of a health department and should play a key role in accreditation efforts. However, much variation
exists regarding the structure, definition, roles, and responsibilities of governing entities.
A governing entity, as it relates to the accreditation process, should meet the following criteria:
1. It is an official part of Tribal, state, regional, or local government.
2. It has primary responsibility for policy-making and/or governing a Tribal, state, or local, health department.
3. It advises, advocates, or consults with the health department on matters related to resources, policy making, legal authority, collaboration,
and/or improvement activities.
4. It is the point of accountability for the health department.
5. In the case of shared governance (more than one entity provides governance functions to the health department), the governing entity, for
accreditation purposes, is the Tribal, state, regional, or local entity that, in the judgment of the health department being accredited or PHAB site
visitors, has the primary responsibility for supporting the applicant health department in achieving accreditation.

DoMain 12 incluDes three stanDarDs:
Standard 12.1
Standard 12.2
Standard 12.3

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Maintain Current Operational Definitions and Statements of the Public Health Roles, Responsibilities,
and Authorities
Provide Information to the Governing Entity Regarding Public Health and the Official Responsibilities of the
Health Department and of the Governing Entity
Encourage the Governing Entity’s Engagement in the Public Health Department’s Overall Obligations
and Responsibilities

Public Health Accreditation Board • Standards & Measures

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stanDarD 12.1 : Maintain current oPerational
DeFinitions anD stateMents oF PuBlic health roles,
resPonsiBilities, anD authorities.
A governmental public health department operates with specific authorities to protect and preserve the

health of the population within its jurisdiction. These authorities may be set forth in state statute, rules and

regulation, local ordinances, administrative code, charters, or resolutions. Authorities may be regulatory or
programmatic. This standard assures that the health department understands its authority and that of its

governance entity for the department’s roles and responsibilities and that such authority is put into practice.

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standard 12.1: Maintain current operational definitions and
statements of public health roles, responsibilities, and authorities.
Measure
12.1.1 A
Provide mandated public health operations,
programs, and services

Purpose

Significance

The purpose of this measure is to assess the
health department’s knowledge and provision
of the operations, programs, and services that
it is mandated to provide and that those
mandates are put into action.

Each health department has a set of
mandated operations, programs, and
services that it provides to protect and
preserve the health of the population within
the jurisdiction that it serves. It is important
that the health department is knowledgeable
of these mandates and performs them as
required.

Required Documentation

Guidance

1. Authority to conduct public health activities

1. The health department must provide a copy of the body of law (statutes, rules, regulations,
ordinances) that sets forth its mandated public health operations, programs, and services or
a listing of mandated public health services and the reference to the legal citation. The health
department must have copies or access to the laws and regulations available to the site
visit team.
An example is the disease reporting rules or regulations reflected by the Council of State and
Territorial Epidemiologist’s list of Nationally Notifiable Conditions. Other examples include:
mandated vaccinations; mandated oversight of environmental public health conditions, such
as solid waste, small public water systems, underground storage tanks, and hazardous
materials; and various inspection programs, such as restaurant inspections.
Examples of documentation for Tribal health departments may include: Tribal resolution,
ordinance, or executive order.

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Measure 12.1.1 a, continued

245

Required Documentation

Guidance

2. Description of operations that reflect
authorities

2. The health department must provide a written description that shows how the health
department implements the mandated responsibility through a process, program, or
intervention. Documentation can be service descriptions, annual reports, meeting minutes,
reports to governance, functional descriptions, organizational descriptions, or other
written material.

Public Health Accreditation Board • Standards & Measures

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standard 12.1: Maintain current operational definitions and
statements of public health roles, responsibilities, and authorities.
Measure
12.1.2 A
Maintain current operational definitions and/or
statements of the public health governing
entity’s roles and responsibilities

246

Purpose

Significance

The purpose of this measure is to assess the
health department’s knowledge of the
governing entity’s operational definition and/or
governing entity’s roles and responsibilities.

The health department should have a clear
understanding of expectations for its
accountability. The governing entity is that point
of accountability, and the health department
should understand the governing authority’s
structure, responsibilities, and expectations.

Required Documentation

Guidance

1. Authority of the governing entity

1. The health department must provide a written description of its governing entity’s authority.
Documentation could be a copy of the body of law (statutes, rules, regulations, ordinances)
that sets forth the mandated authority, or a description of the authority and the reference to
the legal citation. Examples of documentation for Tribal health departments may include Tribal
resolution, ordinance, or executive order.

2. Description of governing entity

2. The health department must provide a written description of the governing entity. The
governing entity could be, for example, a board of health, a governor’s office, county
commissioners, or other point of accountability. Documentation could be a statute, rules,
regulations, a charter, a charge statement, or other written description.

Public Health Accreditation Board • Standards & Measures

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stanDarD 12.2: ProViDe inForMation to the GoVerninG
entitY reGarDinG PuBlic health anD the oFFicial
resPonsiBilities oF the health DePartMent anD oF the
GoVerninG entitY.
The governing entity is the point of accountability for the health department. The governing entity is

accountable for the health department achieving its mission, goals and objectives to protect and preserve
the health of the population within its jurisdiction. This standard addresses the health department’s

capacity for keeping the governing entity updated on the department’s overall legal authority, obligations
and responsibilities, and on the governing entity’s supporting role.

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standard 12.2: Provide information to the governing entity regarding
public health and the official responsibilities of the health department
and of the governing entity.

Measure

12.2.1 A
Communicate with the governing entity
regarding the responsibilities of the public
health department

248

Purpose

Significance

The purpose of this measure is to assess the
health department’s communications with its
governing entity regarding the health
department’s responsibilities.

Governing entities significantly influence the
direction of health departments through policy
making and other similar activities. As a result,
they may heavily influence whether health
departments are fulfilling their responsibilities.
The health department must educate the
governing entity about the department’s
responsibilities.

Required Documentation

Guidance

1. Two examples of communications provided
to the governing entity regarding the
responsibilities of the public health
department

1. The health department must provide two examples of communication to the governing entity
on the health department’s official responsibilities. Documentation should demonstrate the
process of informing the governing entity about the responsibilities of the health department.
The health department should select its documentation for this measure based on the model
of governance in place for the health department. Documentation could be reports,
testimonies, speeches, presentations, or emails.

Public Health Accreditation Board • Standards & Measures

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standard 12.2: Provide information to the governing entity regarding
public health and the official responsibilities of the health department
and of the governing entity.

Measure

12.2.2 A
Communicate with the governing entity
regarding the responsibilities of the
governing entity

249

Purpose

Significance

The purpose of this measure is to assess the
health department’s communications with its
governing entity concerning the roles and
responsibilities of the governing entity.

Many governing entities have key roles in
resources, policy making, legal authority,
collaboration, and/or improvement activities.
The governing entity, to be an effective
advocate for public health and for the agency,
must be aware of its responsibilities and duties.
This information should include orientation for
new governing entities and new governing
entity members, as well as for routine updates.
While Domain 6 relates to the governing entity’s
role in reviewing and updating specific laws,
rules and regulations, this measure targets the
overall public health responsibilities that the
governing agency oversees or advises,
including training on those responsibilities.

Required Documentation

Guidance

1. One example of a communication with the
governing entity about their operational
definitions and/or statements of the public
health governing entity’s roles and
responsibilities

1. The health department must provide one example of sharing with the governing entity
operational definitions and/or statements of the public health governing entity’s roles and
responsibilities. The health department should select its documentation for this measure
based on the model of governance in place for the health department. Documentation could
be in the form of meeting minutes, memos, emails, briefing papers, or other correspondence.

Public Health Accreditation Board • Standards & Measures

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stanDarD 12.3: encouraGe the GoVerninG entitY’s
enGaGeMent in the PuBlic health DePartMent’s
oVerall oBliGations anD resPonsiBilities.
Public health governing agencies exercise a wide range of responsibilities, including: advisory, statutory,

personnel, property ownership, taxing authority, public health rule-making, policy-making, and budgetary.
These responsibilities demand that the governing entity is well-versed in public health and in the work of

the health department. The governing entity and the health department should communicate regularly on
health department issues, program activities, and improvement activities.

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standard 12.3: encourage the governing entity’s engagement in the
public health department’s overall obligations and responsibilities.
Measure
12.3.1 A
Provide the governing entity with information
about important public health issues facing
the health department and/or the recent
actions of the health department

251

Purpose

Significance

The purpose of this measure is to assess
health department communications to keep
the governing entity informed of public health
issues and health department activities.

The health department needs to communicate
with its governing entity to ensure that the
governing entity’s policies and decisions are
informed. A regular flow of information helps
to ensure that the governing entity acts in the
best interests of the public’s health.
Information also needs to flow from the
governing entity to the health department to
ensure mutual understanding of policy options
and implications.

Required Documentation

Guidance

1. Two examples of communications with the
governing entity regarding important public
health issues and/or recent actions of the
health department

1. The health department must provide two examples of information exchange between the
health department and the governing entity. Communication exchanges include discussions
or dialogue with the governing entity regarding public health issues. These could be
demonstrated through reports, testimonies, formal meeting minutes, meeting summaries,
program updates, reports on identified public health hazards, community health assessment
findings, community dashboards, outbreak and response efforts, annual statistical reports, or
other written correspondence (memos, emails), and other informal approaches.

Public Health Accreditation Board • Standards & Measures

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standard 12.3: encourage the governing entity’s engagement in the
public health department’s overall obligations and responsibilities.
Measure
12.3.2 A
Track actions taken by the governing entity

252

Purpose

Significance

The purpose of this measure is to assess the
health department’s review of the governing
entity’s actions in order to identify public
health successes, patterns of issues, and/or
areas for increased communication.

The health department should thoroughly
understand the priorities, policy positions,
opinions, and actions of the governing entity
in order to continually improve communication
and effectiveness.

Required Documentation

Guidance

1. Review issues discussed, actions taken,
and policies set by the governing entity at
least annually

1. The health department must provide documentation that it reviewed the governing entity’s
discussions of issues, actions taken, and policies set. The reviews of governing entity’s
discussions, actions, and policies must take place at least annually. Reviews should include:
an assessment of public health successes, patterns of issues, and/or topic or issue areas
where increased communication is desirable. Documentation could be meeting minutes,
reports, dashboards, presentations, memos, or other record of discussion of governing
entity actions.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

standard 12.3: encourage the governing entity’s engagement in the
public health department’s overall obligations and responsibilities.
Measure
12.3.3 A
Communicate with the governing entity about
assessing and improving the performance of
the health department

253

Purpose

Significance

The purpose of this measure is to assess the
health department’s communication with the
governing entity on assessing and improving
the overall performance of the health
department.

The governing entity should be
knowledgeable about the health department’s
overall assessment and quality improvement
initiatives. The governing entity will be in a
better position to guide, advocate for, and
engage with the health department if they are
aware of improvements being undertaken.

Required Documentation

Guidance

1. Two examples of communication with the
governing entity concerning assessment of
the health department’s performance

1. The health department must provide two examples of communications with the governing
entity on its plans and process for improving health department performance. The health
department should select its documentation for this measure based on the model of
governance in place for the health department. Examples of improvement efforts could
include: program reviews, accreditation efforts, quality improvement projects, and other
performance improvement activities. Documentation could be meeting minutes, reports,
presentations, memos, or other discussion records.

2. Two examples of communication with the
governing entity concerning the
improvement of the health department’s
performance

2. The health department must provide two examples of communication with the governing
entity on its performance improvement as a result of performance improvement processes
and/or activities. The health department should select its documentation for this measure
based on the model of governance in place for the health department. Documentation could
include: annual reports, department dashboards, program reviews, meeting minutes, reports,
presentations, memos, or other record of discussion.

Public Health Accreditation Board • Standards & Measures

Version 1.0 • Approved May 2011

This publication was supported through grant funding from the Robert Wood Johnson Foundation (RWJF) and Cooperative
Agreement #5U38HM000415-04 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the
responsibility of the authors and do not necessarily represent the official views of the CDC or RWJF.
Copyright © 2011 Public Health Accreditation Board. All rights reserved.