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pdfPublic Health Accreditation Board
STANDARDS
&
Measures
VERSION 1.5
Adopted December 2013
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Introduction
This 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 beginning on July 1, 2014 and until a new version is released.
The Standards and Measures, Version 1.5 document provides guidance specifically for public health departments preparing for accreditation
and for site visit teams that review and assess documentation submitted by applicant health departments. It also serves anyone offering consultation
or technical assistance to health departments preparing for accreditation. It guides PHAB’s Board of Directors and staff as they administer the
accreditation program. This document assists health departments and their Accreditation Coordinators as they select documentation for each measure.
It directs 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,
Version 1.5 document sets forth the domains, standards, measures, and required documentation adopted by the PHAB Board of Directors in
December 2013. The document also provides guidance on the meaning and purpose of a measure and the types and forms of documentation that are
accepted to demonstrate conformity with each measure.
The Standards and Measures, Version 1.5 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 their most appropriate documentation to meet a measure.
In general, a reference in this document to “the standards” includes references to the entire document including the domains, the standards, the
measures, the required documentation, and the guidance.
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Standards & Measures
VERSION 1.5 APPROVED DECEMBER 2013
INTRODUCTION
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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 (example – Domain 5)
Standard (example – Standard 5.3)
Measure (example – Measure 5.3.2)
Tribal, State, Local or ALL
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(example – Measure 5.3.2 S for state health departments;
Measure 5.3.2 L for local health departments; Measure 5.3.2 T for Tribal health
departments; and Measure 5.3.2 A for all health departments.)
Standards & Measures
VERSION 1.5 APPROVED DECEMBER 2013
INTRODUCTION
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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 the health department meets the standards and measures. The health department is expected
to ensure that the standards are met for the population that they serve. The focus of the standards, measures, and required documentation is that
the health department ensures that the services and activities are provided to the population, irrespective of “how” those services and activities are
provided or through what organizational structure or arrangement. Many health departments have formal agreements, contracts, or partnerships with
other organizations or agencies to provide services. Health departments must submit to PHAB formal documentation of the partnership or assignment
of responsibility to others (MOU, letter of agreement, contract, legislative action, executive order, ordinance, or rules/regulations). PHAB site visitors will
want to see evidence of a formal working relationship in these cases.
Likewise, documentation may have been developed by another entity; however it must currently be utilized by the health department. The purpose of
PHAB’s review of the documentation is to confirm that materials exist and are in use in the health department being reviewed, regardless of who
originated the material. Documentation, therefore, may be products of other entities.
Documentation could be developed by:
•
•
•
•
•
health department staff;
state health departments for use by local health departments;
community partnerships or collaborations;
partners (e.g., not-for-profits and academic institutions); or
contracted service providers.
The 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 and not by the health department. It
would be advisable for the health department to include an explanation with its documentation concerning why a measure is met with documentation
developed by another organization.
Examples include:
• Health departments may have formal agreements or partnerships with other organizations to provide particular functions
or activities. For example, a health department might contract with an academic institution to collect primary data. The health department is
accountable and responsible for ensuring the high quality, accuracy, and utility of those data, but they do not have to collect the data themselves.
They must show that there is a formal mechanism for the partnership or agreement, for example, a Memorandum of Understanding (MOU), a
contract, or other written agreement.
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• Health Departments may share functions or services with other governmental agencies. For example, environmental public health is a
function that is sometimes provided by another state or local agency. There are a number of PHAB standards and measures that include or address
environmental public health. A health department’s documentation should include some examples from environmental public health and may be
documents that are produced by that other agency.
• Health departments, as agencies that are a part of a larger governmental unit, may utilize the policies, procedures, or functions
of that governmental unit. For example, a health department may utilize the human resources system of the government of which it is a part. In
this case, the documentation for “human resource policy and procedures manual or individual policies” would be the policies and procedures of the
city, county, or state government, for example.
Likewise, the health department may be part of a “Super Public Health Agency” (an agency that oversees public health, primary care, substance
abuse, and mental health), a “Super Health Agency” (an agency that oversees public health, primary care, and Medicaid), or “Umbrella Agency” (an
agency that oversees public health, primary care, substance abuse, mental health, Medicaid, and other human service programs). For the example
of Measure 11.1.5 A, the health department’s human resource policy and procedures manual would be the manual of the Super Public Health
Agency, Super Health Agency, or Umbrella Agency, of which it is a part.
• Tribal, local and state health departments may have agreements with each other about the responsibility for and provision of
public health functions. For example, the state may provide the epidemiology function at the Tribal, state and/or local levels. If the state does
not serve this function, the Tribal or local health department would need to provide it some other way. And, the Tribal, state, and local health
departments need to coordinate and support one another. Therefore, even when the state, for example, has the primary responsibility to perform a
function that is specified in a measure, the Tribal or local health must still provide documentation that it is being performed. The Tribal or local health
department cannot dismiss its accountability for meeting the measure, even if the state health department is performing the function.
Some measures require documentation that addresses the entire population that the health department is authorized to serve. For example, the
community health assessment and the community health improvement plan are both required to cover the entire health department’s population. It is
acceptable if these documents cover larger geographic areas, if the parts that address the health department’s population can be identified.
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SELECTION OF DOCUMENTATION
The health department should select documentation carefully to ensure that it accurately reflects the health department, how it operates, what it
provides, and its performance. Site visitors will develop an overall summary of (1) the health department’s three greatest strengths, (2) the three most
serious/challenging opportunities for improvement, and (3) the department as a functioning health department. They will base this summary on both
the review of documentation and findings during the site visit. Therefore, it is critical that the health department select the most relevant and accurate
documentation to submit to PHAB.
a. Relevant to the Domain, Standard, and Measure
In order to ensure that the documentation provides evidence of conformity with a measure, the health department must consider the required
documentation within the context of the measure, standard, and domain. For example a required piece of documentation may be “documentation
of communications, meetings, and/or trainings.” It is important to review the measure and standard to know what the documentation of
communications, meetings, and/or trainings is meant to demonstrate (e.g., the provision of technical assistance, collaboration on an activity, or
sharing of information on a particular topic).
b. Specific to “Required Documentation” and “Guidance” in the Standards and Measures Version 1.5
The documentation submitted to PHAB will be reviewed by site visitors to determine if it is in conformity with the requirements for documentation
and to determine the health department’s conformity with each measure. Therefore, the documentation that the health department selects for each
piece of Required Documentation must be specific to that measure’s requirement and the guidance provided.
c. Focused
Documentation should be limited to the most direct and applicable documentation available to meet the documentation requirement. Additional
information is not necessary and will not be helpful.
Health departments are encouraged to select 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 is expected to include programs that address causes of public health issues, determinants of health,
and chronic disease and must address the health of the population in the jurisdiction that the health department has authority to serve.
Additionally:
• All documentation must be in use by the health department at the time of the submission of documentation to PHAB.
• No draft documents will be accepted for review by PHAB.
• All documents must show evidence of authenticity (see “Evidence of Authenticity” section).
• All documents must include a date (see “Timeframes” section).
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• Documentation submitted to demonstrate conformity with a measure does not have to be presented in a single document; several documents may
support conformity with 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 must be identified.
• 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 for which it is presented must 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. A specific example is documents
from the human resources department.
• 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 accept 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 during the site visit.
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 reports, continuing education tracking reports, work plans, financial reports,
and quality improvement reports. When minutes from meetings are used as evidence for documentation requirements, relevant attachments that are
referenced in the minutes or were discussed must be included.
• 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.
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Timeframes
All plans, policies, procedures, processes, contracts, MOUs, and partner agreements must be in use by the health department
when they are submitted to PHAB. All programs from which documentation is selected and submitted must be in place when the
documentation is submitted.
All documentation used to demonstrate conformity with measures must be dated within the timeframe indicated in the Guidance. The date indicates
when the document was created, adopted, reviewed, revised, etc. Site visitors will look for the date on the document. The first purpose of documents
being dated is that the dating of all documents is a best practice. Any organization, public health department or otherwise, needs to know when
documents were created or last updated both in order to ensure that the information is current and for version control. This is especially true in the
public health field as both best practices and populations can change quickly. The second purpose for dates on documents is to enable the PHAB Site
Visit Team to assess conformity with PHAB Standards and Measures.
The specificity of the date on the document will depend on the documentation requirement and the type of document. For example, emails provide
the full date and time. Policies may include the month, day, and year. Reports may include the month and year. A brochure may include only the year.
In most cases the month and year will be required for reviewers to evaluate conformity with the timeframes, though in some cases (for example,
brochures) only a year will be required.
Timeframes are determined by starting from the date of submission of the documentation to PHAB. For example, if the timeframe for a plan is five
years, the plan must be dated within the five years previous to submission of the documentation to PHAB.
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Evidence of Authenticity
All documents must show evidence of authenticity. That is, the document must have a logo, signature, email address, or some other evidence that the
document is “authentic” to the applicant health department. The purpose for this requirement is to provide PHAB site visitors with evidence that the
documentation does in fact “belong” to the health department being reviewed. It is also a good business practice. In some cases, documentation will be
a written policy and will include the signature of a governor, mayor, or health department director. In other cases, documentation may be an email; the
“To” and “From” and the email addresses will serve as evidence that the document is “official” health department business. In other cases, a department
logo will provide the evidence that the document is an official health department document. For example, a brochure will not have the health department
or program director’s signature, but it will include the department’s logo. Meeting minutes are usually signed but may include the department’s logo
instead, noting that it is an “official” document. Further, a document developed by a partnership or coalition of which the health department is a member,
may or may not include the health department’s logo. In this case, evidence of the health department’s membership or participation in the partnership
or coalition will suffice. Documentation developed by another entity (partner, governmental agency, contractor, etc.) must include evidence that the
documentation has been adopted by and is in use by the applicant health department.
Quality Improvement
A goal of public health department accreditation is to promote high performance and continuous quality improvement. PHAB has adopted the following
definition of quality Improvement: Quality improvement in public health is the use of a deliberate and defined improvement process that is focused on
activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable
improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which
achieve equity and improve the health of the community. (Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. Defining Quality Improvement in Public
Health. Journal of Public Health Management and Practice. January/February 2010).
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 quality improvement
throughout the standards and measures and throughout the accreditation process. For example, there are several measures that encourage a broad
continuous improvement process of evaluation and improvement: (1) plan or develop programs, process, or interventions, (2) implement, and (3)
evaluate for improvement. The accreditation process promotes quality improvement through the provision of a Site Visit Report developed by PHAB
trained peer Site Visitors that includes opportunities for improvement. Additionally, accredited health departments are required to submit an annual
report to PHAB that describes their progress and quality improvement.
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PHAB Acronyms and Glossary of Terms
The PHAB Standards and Measures, Version 1.5 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.
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.
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Sy
s
Assure
Competent
Workforce
Link
to / Provide
Care
mM
te
Monitor
Health
a na g e
Diagnose
& Investigate
m
t
While some public health departments provide mental health, substance abuse, primary care,
human services, 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 generally will not be 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
Evaluate
en
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 health,
chronic disease prevention and control, infectious disease, injury prevention, maternal and child
health, public health emergency preparedness, access to clinical services, public health laboratory
services, vital records and health statistics, 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.
Research
Enforce
Laws
Develop
Policies
Inform,
Educate,
Empower
Mobilize
Community
Partnerships
The Essential Public Health Services and Core Functions
Source: Core Public Health Functions Steering Committee, Fall 1994
Standards & Measures
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Applicability of Public Health Accreditation Standards continued
be used for public health department accreditation purposes. (See the PHAB guidance one-page tip sheet on Accepted Program Areas for PHAB
Documentation at www.phaboard.org).
Some program funding provides support for both population public health and also personal health care services. Documentation related to the
program’s population public health activities is appropriate for PHAB documentation, while documentation related to the individual, personal, or clinical
services provided by the same program, is not appropriate for PHAB documentation. That is, irrespective of the program (for example, WIC, Ryan
White, dental health, healthy mothers/healthy babies), documentation of activities related to the provision of individual patient care or clinical services
is not appropriate for PHAB documentation. For example, PHAB will accept documentation from a public health education program that informs the
public of the need for dental hygiene; PHAB will not accept documentation from a dental clinic that provides individual dental services. Documentation
of population health education about the use of condoms for disease prevention is acceptable; documentation on individual HIV testing and counseling
is not. Documentation concerning population education about the importance of prenatal care is appropriate, but documentation of the actual prenatal
care or well-baby clinics is not. Of course, this holds true for all PHAB Standards and Measures, Version 1.5. For example, documentation concerning
client satisfaction surveys or clinic wait times would not be an appropriate example of a QI project for PHAB documentation.
Some public health activities are population based or clinical, depending on how they are provided. For example, a clinic where personal health services
are provided will provide vaccinations. This is considered a clinical service. The health department may provide vaccinations as a population based
service, e.g., influenza vaccinations available to the public, measles vaccinations for an Amish population where a measles outbreak has occurred, or
pertussis vaccinations available to the public due to a rise in incidence of pertussis. These are examples of population based public health services and
may be used for PHAB accreditation documentation.
PHAB standards and measures are applicable to public health activities provided by another governmental department, organization, or partner through
a formal written agreement. Formal arrangements may be contracts, compacts, or memoranda of agreement. 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. The fact that an activity is provided by another entity does not abrogate
the health department from the responsibility to ensure that it is provided to the population that the health department serves.
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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 SelfDetermination 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. The chart below provides
an example of the layout for standards, measures, and required documentation, guidance, number of examples, and timeframe 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
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
Documentation of:
1. The health department must provide/document that . . . .
X examples
X years
This section lists the
documentation that the health
department must provide as
evidence that it is in conformity
with the measure.
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.
This section
states the
number of
examples
required
This section
states the time
frame for the
date on the
documentation.
This section describes the public health
capacity or activity on which the health
department is being assessed.
The documentation will be
numbered:
1. Xxx
2. Xxx
a) xxx
b) xxx
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Standards & Measures
The date on the
documentation
must be within
the number
of months or
years specified
before the date
of submission
of all of the
documentation
to PHAB.
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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 ongoing 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 collaborative process for the development of a shared, comprehensive health assessment of the community, its
health challenges, and its resources.
DOMAIN 1 INCLUDES FOUR STANDARDS:
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DOMAIN 1
Standard 1.1:
Participate in or Lead a Collaborative Process Resulting in a Comprehensive Community
Health Assessment
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
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
Standard 1.4:
Provide and Use the Results of Health Data Analysis to Develop Recommendations Regarding
Public Health Policy, Processes, Programs, or Interventions
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 10
DOMAIN 11
DOMAIN 12
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STANDARD 1.1: Participate in or lead a collaborative process resulting in a
comprehensive community health assessment.
The purpose of the community health assessment is to learn about the community: the health of
the population, contributing factors to higher health risks or poorer health outcomes of identified
populations, and community resources available to improve the health status. Community health
assessments describe the health of the population, identify areas for health improvement, identify
contributing factors that impact health outcomes, and identify community assets and resources that can
be mobilized to improve population health. Community health assessments are developed at the Tribal,
state, and local levels and cover 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
or using resources in different ways, adopting or revising policies, and planning actions to improve
the population’s health. The development of a community health assessment involves the systematic
collection and analysis of data and information to provide a sound basis for decision-making and
action. Community health assessments are conducted in partnership with other organizations and
members of the community and include data and information on demographics; socioeconomic
characteristics; quality of life; community resources; 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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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 11
DOMAIN 12
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STANDARD 1.1: Participate in or lead a collaborative process resulting in a
comprehensive community health assessment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.1.1 S
A state partnership that
develops a comprehensive state
community health assessment
of the population of the state
The purpose of this measure is to assess
the state health department’s collaborative
process for sharing and analyzing data and
information concerning state health, state
health challenges, and state resources to
develop a state level community health
assessment.
The development of a state community health assessment
requires partnerships with other organizations in order to
access data, provide various perspectives in the analysis of
data and determination of contributing factors that impact
health outcomes, present data and findings, and share a
commitment for using the assessment. Assets and resources
in the state must be addressed in the assessment, as well
as health challenges. Data are not limited to traditional public
health data but may include information, for example, quality
of life, attitudes about health behavior, socioeconomic factors,
environmental factors (including the built environment), and
social determinants of health. Data are provided from a variety
of sources and through various methods of data collection.
REQUIRED DOCUMENTATION
GUIDANCE
1. Participation of
representatives from a
variety of state sectors
1. The state health department must document 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.
NUMBER OF
EXAMPLES
DATED
WITHIN
1
5 years
Documentation
must include the
month and year.
The collaboration must include various sectors of the state, as appropriate
for the state: for example, state government (for example, community
development, education, aging, etc.), for-profits (for example, businesses,
industries, and major employers in the state), statewide not-for -profits
(for example, hospital association, Kids Count, Childhood and Women’s
Death Review organizations, Cancer Society, public health institutes,
environmental public health groups, groups that represent minority health,
etc.), voluntary organizations, health care representatives (for example,
hospital associations or primary care associations), academia, military
installations in the state, and representatives of local or regional health
departments in the state and of Tribal health departments in the state.
15
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 15
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.1 S, continued
REQUIRED DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
of meetings
and communications or
documentation
that identifies
the frequency
of meetings
5 years
Representation of two or more populations that are at higher health risk or
have poorer health outcomes must be included.
Documentation could be, for example, a membership list and meeting
attendance records.
2. Regular meetings or
communications with
partners
2. The health department must document that the partnership
meets and communicates on a regular basis to consider
new data sources, review newly collected data, consider
assets and resources that are changing, and conduct
additional data analysis.
The frequency of meetings or communications is determined by the
partnership and may change, as required by the stage of the process.
Meetings and communications may be in-person, via conference calls, or
via other communication methods, for example, list-serves or other digital
communication methods.
Documentation
must include the
month and year.
Documentation could be, for example, meeting agenda, meeting minutes,
and copies of emails. Documentation could also be reports or other
documents that show meeting frequency.
16
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 16
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.1 S, continued
REQUIRED DOCUMENTATION
GUIDANCE
3. The process used to
identify health issues
and assets
3. The state health department must document the collaborative
process used 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 national model; state-based model; a model from the public,
private, or business sector; or other participatory process model. When
a specific model is not used, the key steps undertaken that outline the
process used should be described.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 process
5 years
National models include, for example, Mobilizing for Action through
Planning and Partnerships (MAPP) (developed for local health
departments but can be used in state health departments), Association for
Community Health Improvement (ACHI) Assessment Toolkit, Assessing
and Addressing Community Health Needs (Catholic Hospital Association
of the US) (http://www.chausa.org/docs/default-source/general-files/
cb_assessingaddressing-pdf.pdf?sfvrsn=4), and the University of Kansas
Community Toolbox (http://ctb.ku.edu/en/node/9).
Examples of tools or resources that can be adapted or used throughout,
or as part of, the community health assessment process include
NACCHO’s Resource Center for Community Health Assessments and
Community Health Improvement Plans, Community Indicators process
project, Asset Based Community Development model, Tribal Accreditation
Readiness Guidebook and Roadmap, Inter Tribal Council of Arizona’s
Tribal CHA Toolkit, National Public Health Performance Standards
Program (NPHPSP), Assessment Protocol for Excellence in Public Health
(APEX/PH), Guide to Community Preventive Services, and Healthy
People 2020.
17
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 17
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.1: Participate in or lead a collaborative process resulting in a
comprehensive community health assessment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.1.1 T/L
Tribal/local partnership that
develops a comprehensive
community health assessment
of the population served by the
health department
The purpose of this measure is to assess
the health department’s collaborative
process for sharing and analyzing data and
information concerning population health,
health challenges, 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 analysis of data and determination of factors that impact
health outcomes, present data and findings, and share a
commitment for using the assessment. Assets and resources
in the Tribal/local community must be addressed in the
assessment, as well as health challenges. Data are not limited
to traditional public health data but include, for example, quality
of life, attitudes about health behavior, socioeconomic factors,
environmental factors (including the built environment), and
social determinants of health. Data are provided from a variety
of sources and through various methods of data collection.
REQUIRED DOCUMENTATION
GUIDANCE
1. Participation of
representatives from a
variety of sectors of the
Tribal or local community
1. The health department must document that the process for
the development of a community health assessment includes
participation of partners outside of the health department that
represent Tribal/community populations and health challenges.
NUMBER OF
EXAMPLES
DATED
WITHIN
1
5 years
Documentation
must include the
month and year.
The collaboration must include various sectors of the community, as
appropriate for the community: for example, local government (for example,
elected officials, law enforcement, correctional agencies, housing and
community development, economic development, parks and recreation,
planning and zoning, schools boards, etc.), for-profits (for example,
businesses, industries, and major employers in the community), not-forprofits (for example, chamber of commerce, civic groups, hospitals and
other health care providers, local Childhood and Women’s Death Review
organizations, public health institutes, environmental public health groups,
groups that represent minority health, etc.), community foundations and
philanthropists, voluntary organizations, health care providers (including
hospitals), academia, the state health department and Tribal health
departments located in the health department’s jurisdiction, and military
installations located in the health department’s jurisdiction.
18
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 18
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.1 T/L, continued
REQUIRED DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
of meetings
and communications or
documentation
that identifies
the frequency
of meetings
5 years
Representation of two or more populations that are at higher health risk or
have poorer health outcomes must be included.
Documentation could be, for example, a membership list and meeting
attendance records.
2. Regular meetings or
communications with
partners
2. The health department must document that the partnership
meets and communicates on a regular basis to consider
new data sources, review newly collected data, consider
assets and resources that are changing, and conduct
additional data analysis.
The frequency of meetings and 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, for example, list-serves or other digital
communication methods.
Documentation could be, for example, meeting agenda, meeting minutes,
and copies of emails. Documentation could also be reports or other
documents that show meeting frequency.
19
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 19
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.1 T/L, continued
REQUIRED DOCUMENTATION
GUIDANCE
3. The process used to
identify health issues
and assets
3. The health department must document the collaborative
process used 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 national model; state-based model;
a model from the public, private, or business sector; or other
participatory process model. When a specific model is not used,
the key steps undertaken that outline the process used should be
described.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 process
5 years
National models include, for example, Mobilizing for Action through
Planning and Partnerships (MAPP), Association for Community
Health Improvement (ACHI) Assessment Toolkit, Assessing and
Addressing Community Health Needs (Catholic Hospital Association
of the US) (http://www.chausa.org/docs/default-source/general-files/
cb_assessingaddressing-pdf.pdf?sfvrsn=4), and the University of Kansas
Community Toolbox (http://ctb.ku.edu/en/node/9).
Examples of tools or resources that can be adapted or used throughout,
or as part of, the community health assessment process include
NACCHO’s Resource Center for Community Health Assessments and
Community Health Improvement Plans, Community Indicators process
project, Asset Based Community Development model, Tribal Accreditation
Readiness Guidebook and Roadmap, Inter Tribal Council of Arizona’s
Tribal CHA Toolkit, National Public Health Performance Standards
Program (NPHPSP), Assessment Protocol for Excellence in Public Health
(APEX/PH), Guide to Community Preventive Services, and Healthy
People 2020, RWJ County Health Rankings and Roadmaps: Assess
(http://www.countyhealthrankings.org/roadmaps/action-center/assessneeds-resources).
20
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 20
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.1: Participate in or lead a collaborative process resulting in a
comprehensive community health assessment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.1.2 S
The purpose of this measure is to assess
the state health department’s 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, policy changes, coordination of resources,
and new ways to collaboratively use state assets to improve
the health of the population. A community health assessment
provides the general public and policy leaders with information
on the health of the population and the broad range of factors
that impact health on the population level as well as existing
assets and resources to address health issues. The health
assessment provides the basis for the development of the state
health improvement plan.
A state level community health
assessment
REQUIRED DOCUMENTATION
GUIDANCE
1. A state level community
health assessment that
includes:
1. The state health department must document the identification
and description of the state’s health and areas of health
improvement, the factors that contribute to the health
challenges, and the existing state resources that can be
mobilized to address them. The state’s community health
assessment must include all of the following:
DOMAIN 1
PHABStandardsMeasures4-30-14.indd 21
DOMAIN 3
1 community
health
assessment
5 years
Documentation
must include the
month and year.
Qualitative data as well as quantitative data must be utilized.
Qualitative data may address, for example, the population’s
perception of health, factors that contribute to higher health risks and
poorer health outcomes, or attitudes about health promotion and
health improvement. Data collection methods include, for example,
surveys, asset mapping, focus groups, town forums, and state
listening sessions.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
DATED
WITHIN
a. Evidence that comprehensive, broad-based data and information from
a variety of sources were used to create the state health assessment.
a. Data and information
from various sources
contributed to the
community health
assessment and how the
data were obtained
21
NUMBER OF
EXAMPLES
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 S, continued
REQUIRED DOCUMENTATION
NUMBER OF
EXAMPLES
GUIDANCE
DATED
WITHIN
Quantitative data may, for example, include vital statistics; graduation
rates; morbidity and mortality numbers and rates; and rates of behavioral
risks, such as tobacco use.
The assessment must include both primary and secondary data.
Examples of sources of state secondary data include Federal,
Tribal, state, and local health department data, hospitals and
healthcare providers, schools, academic institutions, other
departments of government (for example, departments of
education, transportation, community and economic development,
etc.), and statewide not-for-profits.
Data sources also include, for example, the County Health Rankings,
Community Health Needs Assessment Toolkit, CDC Community Health
Status Indicators, CDC Disability and Health Data System, US Census
American Factfinder, Dartmouth Atlas of Health Care, National Health
Indicators Warehouse, and CDC Wonder. Another data resource
is ASTHO’s Public Health Data Sources and Assessment Tools: A
Resource Compendium to Measure Access and Health Disparities.
b. Demographics of the
population
22
DOMAIN 1
b. A description of the demographics of the population served by
the state health department, for example, gender, race, age,
socioeconomic factors, income, disabilities, mobility (travel time to
work or to health care), educational attainment, home ownership,
employment status, immigration status, sexual orientation, etc.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 22
DOMAIN 3
Examples of primary data include surveys (for example, surveys of
high school students and/or parents), focus groups (for example,
to discuss community health issues), or other data that the health
department collects to better understand contributing factors or
elements of secondary data sets.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 S, continued
REQUIRED DOCUMENTATION
c. Description of health
issues and descriptions
of specific population
groups with particular
health issues and health
disparities or inequities
c. A description of the health issues in the state and their distribution,
based on analyses of the data listed in a) above. The description must
include the existence and extent of health inequities between and
among specific populations or areas of the state: populations with an
inequitable share of poorer health outcomes must be identified.
d. Description of factors
that contribute to the
state populations’ health
challenges
d. A discussion of the contributing causes of the health challenges, for
example behavioral risk factors, environmental factors (including the
built environment), socioeconomic factors, policies (e.g., taxation,
education, transportation, insurance status, etc.), injury, maternal
and child health issues, infectious and chronic disease, or the unique
characteristics of the state that impact of health status. Multiple
determinants of health, particularly social determinants, must be
included. Health disparities and high health-risk populations must be
addressed. Factors that contribute to higher health risks and poorer
health outcomes in specific populations must be considered.
e. Description of existing
state assets or resources
to address health issues
e. A listing or description of state assets and resources that can be
mobilized and employed to address health issues. These must 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.
2. Opportunity for the
state population at
large to review drafts
and contribute to the
community health
assessment
23
DOMAIN 1
GUIDANCE
2. The health department must document that the preliminary
findings of the state level community health assessment were
distributed to the population at large and that their input was
sought. Examples of methods to seek input include: publication of a
summary of the findings in the press with feedback or comment forms,
publication on the health department’s website and website comment
form, town forums, listening sessions, newsletters, presentations and
discussions at state-wide organizations’ meetings (for example the state
public health association), etc.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 23
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 S, continued
REQUIRED DOCUMENTATION
GUIDANCE
3. The ongoing monitoring,
refreshing, and adding of
data and data analysis
3. The health department must document the gathering of
information, collection of data, conduct of community
dialogues, and/or identification of assets specific to populations
and/or geographic areas in the state where health inequities
and poorer health indicators were identified in the community
health assessment. Additionally, data analysis is expected to seek
to understand health inequities and the factors that create them.
Geographic information analysis of socioeconomic conditions would be
appropriate information to include in an annual update or supplement.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
14 months –
If the CHA is
two years or
more old, then
the examples
must be from
two different
years.
or, if the CHA
is 2 years old
or older, 1
example within
the last 14
months and 1
example from
another year
since the CHA
was adopted.
A complete revision or overhaul of the community health assessment is
not required, but for a continuous effort to better understand the health
of the population through the collection of information and data.
Examples of community dialogue include organizing a series of
town meetings, conducting focus groups, participating in other state
organizations’ community meetings (e.g., state injury prevention
association meetings, state public health association meetings. etc.),
conducting open forums, and conducting group discussions with
specific populations (e.g., teenagers, young mothers, residents of a
specific area, etc.).
Documentation could be, for example, reports of data and their analysis,
findings from a focus group, meeting minutes where health issues or
needs were discussed, reports of open forums, etc. Documentation
of attendance at a meeting is not sufficient; documentation of the
information gathered and analyzed is required.
24
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 24
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.1: Participate in or lead a collaborative process resulting in a
comprehensive community health assessment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.1.2 T/L
A Tribal/local community health
assessment
The purpose of this measure is to assess
the Tribal or local health department’s
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, policy changes,
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
the health of the population and the broad range of factors
that impact health on the population level as well as 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 that
includes:
1. The health department must document the identification and
description of the Tribe’s or community’s health 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 include all
of the following:
DOMAIN 1
PHABStandardsMeasures4-30-14.indd 25
DOMAIN 3
1 community
health
assessment
5 years
Documentation
must include the
month and year.
Qualitative data as well as quantitative data must be utilized.
Qualitative data may address, for example, the community’s
perception of health, factors that contribute to higher health risks and
poorer health outcomes, or attitudes about health promotion and
health improvement. Data collection methods include, for example,
surveys, asset mapping, focus groups, town forums, and community
listening sessions.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
DATED
WITHIN
a. Evidence that comprehensive, broad-based data and information from
a variety of sources were used to create health assessment.
a. Data and information
from various sources
contributed to the community health assessment and how the data
were obtained
25
NUMBER OF
EXAMPLES
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 T/L, continued
REQUIRED DOCUMENTATION
NUMBER OF
EXAMPLES
GUIDANCE
DATED
WITHIN
Quantitative data may, for example, include vital statistics; graduation
rates; morbidity and mortality numbers and rates; and rates of
behavioral risks, such as tobacco use.
The assessment must also include both primary data and
secondary data.
Examples of sources of secondary data include: federal, Tribal,
state, and local data; hospitals and health care providers; local
schools; academic institutions; other departments of government (for
example, recreation, public safety, etc.); community not-for-profits.
Data sources also include, for example, the County Health Rankings,
Community Health Needs Assessment Toolkit, CDC Community
Health Status Indicators, County Health Rankings, CDC Disability
and Health Data System, US Census American Factfinder,
Dartmouth Atlas of Health Care, National Health Indicators
Warehouse, CDC Wonder, and Tribal Epidemiology Centers.
Non-traditional and non-narrative data collection techniques are
encouraged. 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.
Examples of primary data include local surveys (for example,
surveys of high school students and/or parents), focus groups (for
example, to discuss community health issues), or other data that the
health department collects to better understand contributing factors
or elements of secondary data sets.
b. A description of the demographics of the population of the
jurisdiction served by the Tribal/local health department, for example,
gender, race, age, socioeconomic factors, income, disabilities,
mobility (travel time to work or to health care), educational
attainment, home ownership, employment status, immigration status,
sexual orientation, etc.
b. Demographics of the
population
26
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 26
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 T/L, continued
REQUIRED DOCUMENTATION
c. Description of health
issues and specific
descriptions of
population groups with
particular health issues
and inequities.
c. A description of the health issues of the population and their
distribution, based on the analysis of data listed in a) above. The
description must address the existence and extent of health disparities
between and among specific populations in the community or areas in
the community: populations with an inequitable share of poorer health
outcomes must be identified.
d. Description of factors
that contribute to
specific populations’
health challenges.
d. A discussion of the contributing causes of the health challenges, for
example, behavioral risk factors, environmental factors (including
the built environment), socioeconomic factors, policies (e.g.,
zoning, taxation, education, transportation, insurance status, etc.),
injury, maternal and child health issues, infectious and chronic
disease, resource distribution (e.g., grocery stores), and the unique
characteristics of the community that impact on health status. Multiple
determinants of health, especially social determinants, must be
included. Health disparities and high health-risk populations must
be addressed. Community factors that contribute to higher health
risks and poorer health outcomes of specific populations must be
considered.
e. Description of existing
Tribal or community or
assets or resources to
address health issues
e. A listing or description of the assets and resources that can be
mobilized and employed to address health issues. These must include
other sectors. For example, a local park or recreation center 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.
2. Opportunity for
the Tribal or local
community at large to
review and contribute
to the assessment
27
DOMAIN 1
GUIDANCE
2. The health department must document that the preliminary
findings of the assessment were distributed to the community
at large and that the community’s input was sought. Examples
of methods to seek community input include: publication of a summary
of the findings in the Tribal/local press with feedback or comment
forms, publication on the health department’s website and website
comment form, community/town forums, listening sessions, newsletters,
presentations and discussions at other organizations’ local meetings, etc.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 27
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.1.2 T/L, continued
REQUIRED DOCUMENTATION
GUIDANCE
3. The ongoing monitoring,
refreshing, and adding of
data and data analysis
3. The health department must document the gathering of
information, collection of data, conduct of community
dialogues, and/or identification of community assets specific
to populations and/or geographic areas in the community
where health inequities and poorer health indicators were
identified in the community health assessment. Additional
data analysis is expected to be neighborhood/community specific in
order to understand health inequities and the factors that create them.
Geographic information analysis of socioeconomic conditions would be
appropriate information to include in an annual update or supplement.
A complete revision or overhaul of the community health assessment, is
not required, but for a continuous effort to better understand the health of
the population through the collection of information and data.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
from
different
years
14 months –
If the CHA is
two years or
more old, then
the examples
must be from
two different
years.
or, if the CHA
is 2 years old
or older, 1
example within
the last 14
months and 1
example from
another year
since the CHA
was adopted.
Examples of community dialogue include organizing town meetings,
conducting focus groups, participating in other local organizations’
community meetings (e.g., church community meetings, school public
meetings, community association meetings or assemblies, etc.),
conducting open forums, and conducting group discussions with specific
populations (e.g., teenagers, young mothers, residents of a specific
neighborhood, etc.).
Documentation could be, for example, reports of data and their analysis,
findings from a focus group, meeting minutes where health issues or
needs were discussed, reports of open forums, etc. Documentation
of attendance at a meeting is not sufficient; documentation of the
information gathered and analyzed is required.
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Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 1.1: Participate in or lead a collaborative process resulting in a
29
comprehensive community health assessment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.1.3 A
Accessibility of community
health assessment to agencies,
organizations, and the general
public
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 and for 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 not-for-profits will use the community
health assessment in their planning, program development,
and development of funding applications.
REQUIRED DOCUMENTATION
GUIDANCE
1. Information provided to
partner organizations
concerning the
availability of the
community health
assessment
1. Health departments must document how it inform partners,
stakeholders, other agencies, associations, and organizations
of the availability of the community health assessment.
2. The availability of the
community health
assessment findings to
the public
2. Health departments must document how it communicates the
community health assessment findings to the public.
DOMAIN 1
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DOMAIN 3
DATED
WITHIN
2 examples
5 years
2 examples
5 years
Documentation could be, for example, emails to partners and
stakeholders providing information of how to access the assessment;
announcements in department newsletters; articles in newspapers;
digital media, health department tweet or Facebook; public service
announcements, and local news announcement.
Documentation could be, for example, evidence of distribution of the
assessment to libraries or the publication of the community health
assessment on the department’s website. Summaries of the findings
could be, for example, published in newspapers, outlined in the
department’s newsletter, linked to from the department’s Facebook page,
or published on the department’s website.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
NUMBER OF
EXAMPLES
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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DOMAIN 11
DOMAIN 12
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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.
Reliable data are key building blocks of public health. Health departments must gather timely and
accurate data to identify health needs, understand factors that contribute to higher health risks or
poorer health outcomes among populations, 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. Additionally, it is important that health departments share data with other organizations and
access others’ data.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.2.1 A
The purpose of this measure is to assess the
health department’s process for collecting
and managing health data for public health
surveillance.
Public health surveillance is the continuous, systematic
collection, analysis, and interpretation of health-related data
needed for the planning, implementation, and evaluation
of public health practice. Such surveillance can: serve
as an early warning system for impending public health
emergencies; document the impact of an intervention or track
progress towards specified goals; and monitor and clarify
the epidemiology of health problems, to allow priorities to be
set and to inform public health policy and strategies. (World
Health Organization)
24/7 surveillance system or set
of program surveillance systems
31
REQUIRED DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
1. Process(es) and/
or protocol(s) for
the collection,
review, and analysis
of comprehensive
surveillance data
on multiple health
conditions from
multiple sources
1. The health department must provide written process(es) and/
or protocol(s) used to collect surveillance data from multiple
sources and to review and analyze those data. Process(es) and
protocol(s) must include how data are collected, (e.g., fax, emails,
web reports, electronic data, phone calls to the health department or
to another site, for example, emergency management or a 9-1-1 call
center). The health department defines from whom reports are received.
1
departmentwide process
or protocol,
or a set of
processes or
protocols
DOMAIN 1
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DOMAIN 3
5 years
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 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
responsibilities, confidentiality protection (2 below) and reporting.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
DATED
WITHIN
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.2.1 A, continued
32
NUMBER OF
EXAMPLES
DATED
WITHIN
2. The health department must provide written processes and/
or protocols that (1) specify which surveillance data are,
and which are not, considered to be confidential and (2)
assure that confidential data are maintained and handled in
a secure and confidential manner.
1
departmentwide process
or protocols,
or a set of
processes or
protocols
5 years
3. 24/7 contact capacity
3. The health department must document a 24/7 contact
system or protocol to collect data from those who report
data to the health department. This may be, for example, 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), via regional or state agreements, or other
arrangement. 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.
1
departmentwide contact
system or
protocol
or a set
of contact
systems
14 months
4. 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 is
expected to 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.
2 examples
5 years
REQUIRED DOCUMENTATION
GUIDANCE
2. Processes and/or
protocols to assure that
confidential data are
maintained in a secure
and confidential manner
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
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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
PURPOSE
SIGNIFICANCE
Measure 1.2.2 A
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 about their surveillance responsibilities.
Communication with
surveillance sites
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The health department must provide a list of the individuals
or organizations that provide surveillance data to the health
department. Examples of surveillance sites include, for example,
health care providers, schools, laboratories, veterinarians, Tribal
epidemiology centers, etc.
1 list
14 months
2. The health department must document trainings or
meetings held with surveillance site members regarding
relevant reporting requirements, reportable diseases/
conditions, and timeframes.
2 examples
of trainings/
meetings
14 months
REQUIRED DOCUMENTATION
GUIDANCE
1. The identification of
providers and public
health system partners
who are surveillance
sites reporting to the
surveillance system
2. Trainings/meetings held
with surveillance sites
regarding reporting
requirements including
reportable diseases/
conditions, and
reporting timeframes
Trainings may address general requirements or topic issue requirements.
Training need not be in-person but may be provided online, via
webinars, etc.
Documentation must include when the training or meeting was held,
who attended the training, and what topics were covered.
Documentation could be, for example, sign-in sheets and agendas,
reports, or minutes of the meeting.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.2.2 A, continued
3. Surveillance data
received concerning
two different topics
3. The health department must provide received surveillance
data that address two different topics (for example, reports of
flu cases, animals with confirmed rabies, a case of antibiotic
resistant infection, or environmental public health monitoring
data) itemized by reporting site.
2 examples
of data
received
14 months
2 different
topics
2 different
occasions
4. The distribution of
surveillance data
4. The health department must document the distribution of
surveillance data to others.
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DOMAIN 3
2 examples
14 months
Documentation could be, for example, copies of emails, documented
phone calls, newsletters, presentations, and meetings.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.2.3 A
The purpose of this measure is to assess
the health department’s capacity to collect
primary data concerning health; health
inequities; contributing factors or causes
of health challenges; or potential policy,
public health and/ or community solutions.
This measure addresses data other than
surveillance data.
Primary data are required to better understand specific
situations, issues, and potential solutions. While secondary
data can provide a wealth of information concerning the
population’s health, it is not possible to understand how
the reality of those data impact on the population, what
the population’s perspectives and priorities are or what
community resources or resilience can be mobilized to
address situations that cause poor health.
Primary data
35
REQUIRED DOCUMENTATION
GUIDANCE
1. Collection of primary
quantitative health data
1. The health department must provide the results of the collection
of quantitative primary data from the population (in addition to
its surveillance data). Primary data are data that did not exist before
the health department gathered it.
DOMAIN 1
The collection of primary quantitative data need not be complicated or
costly. The data collection is intended to enhance the knowledge and
understanding of the population the health department serves.
Data can be obtained from surveys of target groups (e.g., teenagers,
the jobless, residents of a neighborhood with higher risks of poor health
outcomes). Vital records are considered primary data for state health
departments, if the state health department collects them.
Documentation could be reports, presentations made, minutes of
briefings given, or other communications of the data results and
conclusions.
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
3 years
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.2.3 A, continued
2. Collection of primary
qualitative health data
2. The health department must provide the results of the collection
of qualitative primary data from the population. Data must be
collected directly from groups or individuals who are at higher health risk.
2 examples
2 years
2 examples
2 years
The collection of primary qualitative data need not be complicated or
costly. The data collection is intended to enhance the knowledge and
understanding of the population the health department serves.
These data may address social conditions that have an impact on the
health of the population served, for example, unemployment, poverty, lack
of accessible facilities for physical activity, housing, transportation, and lack
of access to fresh foods.
Examples of data collection methods include open ended survey questions,
forums, listening sessions, focus groups, storytelling, group interviews,
stakeholder interviews, key informant interviews, etc.
Documentation could be, for example, reports, presentations made,
minutes of briefings given, or other communications of the data results and
conclusions.
3. The use of data
collection instruments
3. The health department must provide standardized data collection
instruments that they have used.
Standardized instruments include those that are recognized as national,
state-wide, or local data collection tools. They may also be standardized
from the standpoint that the same tool was used with all respondents,
for example, a local survey developed and distributed to a representative
sample of potential respondents. The tool may collect quantitative or
qualitative data.
Tribes often use qualitative data collection methods, e.g., focus groups,
interviews and other methodologies with elders, traditional healers, or
ceremonial/cultural leaders. Documentation of qualitative data collection
using indigenous methodologies of this type is 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 will be
accepted.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
The health
department
can provide the
tools used for
the required
documentation
listed under the
Required Documentation 1 or 2
for this measure,
or they can be
examples from
different data
collection activities, showcasing
different data
collection efforts.
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 1.2.4 S
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 pertain 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.
Data provided to Tribal and local
health departments located in
the state
REQUIRED DOCUMENTATION
GUIDANCE
1. The provision of
data to local health
departments
1. The state health department must document the provision of
primary and secondary data to local health departments located
in the state.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
14 months
Data can be aggregate for the local health department, or for a region of
the state.
Data could be, for example, collected at the 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 could be from registries, (e.g., cancer registries or immunization
registries); vital records reports; environmental public health data; or data
in web-based infectious disease reporting systems.
Data may address social conditions that affect the health of the population
served, for example, unemployment, poverty, or lack of accessible
facilities for physical activity, housing, transportation, or lack of access to
fresh foods.
Data may be distributed in an electronic or hard copy format.
Documentation could be, for example, distribution lists, distribution
protocols, email confirmation of receipt of reports, screen shots of web
pages or portals, etc.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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DOMAIN 11
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5/9/14 10:43 AM
MEASURE 1.2.4 S, continued
2. The provision of
data to Tribal health
departments in the
state (if one or more is
located in the state)
2. If one or more Tribal health departments is located in the state,
the state health department must document the provision of
primary and secondary data to the Tribal health department
located in the state.
2 examples
14 months
Data can be aggregate for the Tribal health department, or for a region of
the state.
Data could be collected at the Tribal 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 could be, for example, from registries, (e.g., cancer registries or
immunization registries); vital records reports; environmental public health
data; or data in web-based infectious disease reporting systems.
Data may address social conditions that affect the health of the population
served, for example, unemployment, poverty, or lack of accessible facilities
for physical activity, housing, transportation, or lack of access to fresh foods.
Data may be distributed in an electronic or hard copy format.
Documentation could be, for example, distribution lists, distribution
protocols, email confirmation of receipt of reports, screen shots of web
pages or portals, etc.
38
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.2.4 L
The purpose of this measure is to assess the
local health department’s role and process
for sharing data with their state health
department and Tribal health departments.
State health departments should have access to local data
that pertain to health of the state’s population. Likewise,
Tribal health departments should have access to local data
that pertain to the health 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
Tribes (if applicable).
Data provided to the state health
department and Tribal health
departments in the jurisdiction
the local health department is
authorized to serve
REQUIRED DOCUMENTATION
GUIDANCE
1. The provision of data
to the state health
department and
to a Tribal health
department (if one or
more is located in the
jurisdiction the local
health department is
authorized to serve)
1. The local health department must document the provision of
primary or secondary data to the state health departments and
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.
Date could be, for example, data submitted for registries (e.g., cancer
registries or immunization registries); vital records data; environmental
public health data; or data in web-based infectious disease reporting
systems.
Data may address social conditions that affect the health of the population
served, for example, unemployment, poverty, lack of accessible facilities
for physical activity, and lack of access to healthy foods.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
if a Tribal
health
department
is located
within the
health
department’s
jurisdiction,
one example
must be of
data provided
to a Tribal
health
department
14 months
Data may be distributed electronically or via hard copy format.
Documentation could be, for example, distribution lists, distribution
protocols, email confirmation of receipt of reports, screen shots of web
pages or portal, etc.
39
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.2.4 T
The purpose of this measure is to assess
Tribal health department’s role and process for
sharing data with the state health department
and nearby local health departments.
State and local health departments should have access to
Tribal data that pertain to the health 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 local health
departments.
Data provided to the state health
department and to local health
departments
REQUIRED DOCUMENTATION
GUIDANCE
1. The provision of data
to the state health
department and to a
local health department
1. The Tribal health department must document the provision of
primary and secondary data to the state health department and
to a local health department.
Data could be, for example, data submitted for registries (e.g., cancer
registries or immunization registries); vital records data; environmental
public health data; or data in web-based infectious disease reporting
systems. The data may address social conditions that have an impact on
the health of the population served, for example unemployment, poverty,
lack of accessible facilities for physical activity and lack of access to
healthy foods.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
14 months
one example
of data to the
state and one
example of
data provided
to a local health
department
Data may be distributed electronically or via hard copy format.
Documentation could be, for example, distribution lists, entries in
registries, faxed paper reports, distribution protocols, email confirmation
of receipt of reports, screen shots of web page or portal, etc.
40
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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, evaluation, and quality improvement. The
purpose of data analysis is to identify and understand current, emerging, or potential health problems, the
contributing causes of health challenges, or environmental public health hazards. Data can identify trends
in behaviors, disease incidence, opinions, socioeconomic status, the environment (natural and built), and
other factors that aid in understanding health issues and their causes and in designing and evaluating
programs and interventions.
41
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.3.1 A
The purpose of this measure is to assess the
health department’s capacity to analyze and
utilize data to identify trends over time, identify
clusters, understand health problems, assess
behavioral risk factors, detect environmental
public health hazards, and recognize 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. Data analysis is critical for problem
identification, program design, and evaluation of programs for
continuous quality improvement.
Data analyzed and public
health conclusions drawn
REQUIRED DOCUMENTATION
GUIDANCE
1. Analysis of data and
conclusions drawn
with the following
characteristics:
1. The health department must document the analysis of data with
conclusions drawn from the data. The provision of data used in the
analysis is not required, but evidence of the health department’s analysis
and conclusions is required.
Data to be analyzed can include qualitative and/or quantitative, primary
and/or secondary data, or combinations of data.
Examples include: epidemiologic data, vital statistics, workplace fatality or
disease investigation results, cluster identification or investigation results,
outbreak investigation results, environmental and occupational public health
hazard data, population health or key health indicator data, community
survey/focus group results and conclusions, outbreak after action reports,
analysis of hospital data, analysis of not-for-profit organizations’ data (for
example, poison control center data or child health chart book), health
disparities data, environmental data, socioeconomic data, stratified racial
and ethnic health disparities data, and community health indicator data.
Other examples include results of an investigation of a food borne disease
outbreak, environmental hazard trends with arsenic in well water, or trends
of reported infectious diseases over the past five years.
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Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
Analysis
conducted within
14 months
(data may be
older)
one example
must be the
analysis of
qualitative
data and
one must be
quantitative
data
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.3.1 A, continued
The data may point out social conditions that have an impact on the health
of particular or specific populations served, for example, unemployment,
poor housing, lack of transportation, high crime residential areas, poor
education, poverty, or lack of accessible facilities for physical activity.
a. The inclusion of
defined timelines
a. Data used in the report must be distinct to a specific time period, for
example, fiscal year 12-13, calendar year 2014, years 2012-2014.
b. A description of the
analytic process used
to analyze the data or
a citation of another’s
analysis
b. The type of analytic process used must be stated and/or be evidencebased with the citation available. The intent is to have conclusions based
on solid analysis, not just collection of data.
c. The inclusion of the
comparison of data to
other agencies and/
or the state or nation,
and/or other Tribes,
and/or similar data
over time to provide
trend analysis
c. The analysis and conclusions must have the quality of comparability.
That is, the data can be compared with (1) other similar sociogeographic areas, sub-state areas, the state, or nation, or (2) similar data
for the same population gathered at an earlier time to establish trends.
2. Review and discussion
of data analysis
2. The health department must document the review of data analysis
selected for Measure 1.3.1, Required Documentation 1, above.
Examples of trend analysis include conclusions based on rates of
sexually transmitted diseases over the past five years, childhood
immunization rates over the past eight quarters, unemployment rates
over the past five years, or crime rate over the past two years, etc.
2 examples
14 months
The intent is to document the sharing of data and their analysis with others.
The discussions may be internal, with governing entities, with community
groups, with other health or social service organizations, or provided to
elected bodies.
Documentation could be, for example, minutes or documentation of
meetings to show the presentation, review, and discussion of data analysis.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.3.1 A, continued
3. Analysis of data that
demonstrates the use
of information and data
from multiple databases
or data sources
3. The health department must document the analysis of data that
combines data from multiple databases of different data topics,
(e.g., the housing department’s data and the prevalence of
asthma) or data sources to support its conclusion. The analysis
of data from multiple data sources demonstrates an understanding of
how multiple factors affect health issues.
4. Aggregated primary and
secondary data and the
sources of each
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5 years
2 examples
14 months
Other data sources include, for example, education, transportation,
and housing.
4. The health department must document the aggregation of
primary and secondary data. Data must be compiled, analyzed, and
conclusions drawn. The sources of the data used must also be provided.
1 example
Documentation could be reports, memos, GIS maps, or other written
documents.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.3.2 S
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.
Statewide public health data
and their analysis provided
to various audiences on a
variety of public health issues
REQUIRED DOCUMENTATION
GUIDANCE
1. The distribution of data
analysis and findings
that address public
health issues to specific
audiences
1. The state health department must document the distribution of
analytical public health findings to specific audiences in the state.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
1 example
dated
within 14
months;
the other
dated older
than 14
months but
within 5
years.
Two examples
must be from
two different
years; one
from one
year and the
other from a
different year.
Examples must include data on one or more specific public health issue, for
example, health behaviors; public health laboratory reports; environmental
public health hazards reports; disease clusters or trends; vital records and
health statistics; or health indicators (e.g., infant mortality rate).
Distribution of the data analysis and findings may be targeted to a variety of
audiences, for example, public health and health care providers, employers,
labor unions and other public health stakeholders, partners, and the public.
A range of methods of distribution could be used including: mailing lists, email
lists, presentations, workshops, web postings, meeting minutes, published
editorials, and press releases.
The data or written report of the analysis itself does not have to be distributed,
but the contents and findings must be communicated. Thus, while distribution
of a hard copy of a report would meet the requirement of the measure, so
would a verbal presentation to an audience of the contents of the report.
The analysis 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,
data analysis developed by others must have a connection to the state and the
state’s population and contain information of public health significance.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.3.2 L
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.
Public health data provided
to various audiences on a
variety of public health issues
REQUIRED DOCUMENTATION
GUIDANCE
1. The distribution of data
analysis and findings
to address community
public health issues, to
specific audiences
1. The local health department must document distribution of
analytical public health findings to specific audiences in the
community.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
1 example
dated
within 14
months;
the other
dated older
than 14
months but
within 5
years.
Two examples
must be from
two different
years; one
from one
year and the
other from a
different year.
Examples must include data on one or more specific public health issues,
for example, health behaviors; disease clusters or trends; public health
laboratory reports; environmental public health hazards reports; or health
indicators (e.g. infant mortality rate).
Distribution of the reports may be targeted to a variety of audiences,
including: public health organizations, health care providers, employers,
veterinarians, community service groups, local schools, labor unions, other
public health stakeholders, partners, and the public.
A range of distribution methods could be used including, for example, mailing
lists, email lists, presentations, workshops, web postings, meeting minutes,
published editorials, and press releases.
The data or written report of the analysis 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.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
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MEASURE 1.3.2 L, continued
47
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DOMAIN 3
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,
data analysis 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.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 1.3.2 T
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.
Public health data provided
to the Tribal community on a
variety of public health issues
REQUIRED DOCUMENTATION
GUIDANCE
1. The distribution of data
analysis and findings
that address community
public health issues, to
specific audiences
1. The Tribal health department must document distribution of
analytical public health findings to specific audiences in the Tribe.
Examples must include data on one or more specific public health issues,
for example, health behaviors; disease clusters or trends; public health
laboratory reports; environmental public health hazards reports; or health
indicators (e.g., infant mortality rate).
Distribution of the data analysis and findings may be targeted to a variety
of audiences, including: public health organizations, health care providers,
veterinarians, community service groups, local schools, other stakeholders
and partners, and the public.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
1 example
dated
within 14
months;
the other
dated older
than 14
months but
within 5
years.
Two examples
must be from
two different
years; one
from one
year and the
other from a
different year.
A range of distribution methods could be used, including, for example,
mailing lists, email lists, presentations, workshops, web postings, meeting
minutes, published editorials, and press releases.
The data or written report of the analysis itself does not have to be
distributed, but the contents and findings 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 data analysis and findings.
48
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 1.3.2 T, continued
49
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DOMAIN 3
The analysis 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, data analysis developed by others
must have a connection to the Tribal health department and to the
populations served by the Tribal health department and contain
information of public health significance.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.4: Provide and use the results of health data analysis to develop
recommendations regarding public health policies,
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.
50
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 50
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.4: Provide and use the results of health data analysis to develop
recommendations regarding public health policies, processes,
programs, or interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.4.1 A
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, processes priorities, program design,
and interventions should be based on the most current and
relevant data available.
Data used to recommend and
inform public health policy,
processes, programs, and/or
interventions
REQUIRED DOCUMENTATION
GUIDANCE
1. The use of data to inform
public health policy,
processes, programs,
and/or interventions
1. The health department must document that public health
data have been used to impact the development of policies,
processes, programs, or interventions or the revision or
expansion of an existing policies, processes, programs, or
interventions. The data used to inform the policy, process, program,
or intervention must also be included. The data alone will not serve as
evidence for this measure. The health department must demonstrate
the use of the data.
Documentation could be, for example, documented program
improvements, or a revised or new policy and procedure.
Documentation could also be Tribal Council resolutions and Health
Oversight Committee meeting minutes, which demonstrate that data
was used to inform policy, processes, programs and/or interventions.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
14 months
One of the
two examples
must
demonstrate
the use of
data across
multiple
data sets,
databases, or
data source.
VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 1.4: Provide and use the results of health data analysis to develop
recommendations regarding public health policies, processes,
programs, or interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.4.2 S
The purpose of this measure is to assess the
state health department’s development and
distribution of statewide health data 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 specific or program
specific data summaries. These will be summaries of
data that focus on a particular issue, for example, health
behaviors, health equity factors, or the incidence of infectious
diseases. It is important that others have access to health
data to inform their program planning and activities at the
state level. Health data summaries 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 summaries or fact
sheets of data to support
health improvement planning
processes at the state level
REQUIRED DOCUMENTATION
GUIDANCE
1. State health data
summaries or fact sheets
1. The state health department must provide summaries or fact
sheets that condense the state’s public health data. Data
summaries may address a combination of public health issues or may
focus on a particular health issue regarding the population served.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
of data
summaries
5 years
Statewide health data summaries are not the same as a community
health assessment. A data summary can take several forms. It can
be an overview, summary, or synopsis of a particular health issue,
such as cancer or obesity. Or it can address a set of issues, such as
health equity or the health issues of the state’s 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.
Health data summaries produced by national or federal sources are
insufficient documentation of the measure, unless the state health
department demonstrates how the data summary was supplemented
with additional data collected and analyzed by the state health
department.
52
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.4.2 S, continued
2. Distribution of
summaries of state data
to public health system
partners, community
groups and key
stakeholders
2. The state health department must document the distribution
of summaries of health data to public health system partners,
community groups, Tribal health departments, local health
departments, elected officials, or key stakeholders, such as
governing entities or community advisory groups. This may
include partners, including community-based organizations, civic groups,
and any others who receive services, help in the delivery of services, or
support public health services.
53
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DOMAIN 3
Documentation could be, for example, a summary, fact sheet, brief,
overview, a single document of comprehensive data, or a dynamic
website with comprehensive state data that is updated as data are
available (i.e., web-based dashboard).
Documentation could be, for example, a mailing list, email list-serve,
posting on the website, press releases, meeting minutes documenting
distribution of the profile, presentations, inserts or flyers, or a website of
data that is updated as data are available.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
2 examples
of distribution of issue
specific
data summaries or 1
example of
provision of
comprehensive data
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.4: Provide and use the results of health data analysis to develop
recommendations regarding public health policies, processes,
programs, or interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.4.2 T/L
The purpose of this measure is to assess
the Tribal and local health department’s
development and distribution of health data to
inform and support others’ health improvement
efforts at the Tribal and local level.
In addition to the Tribal/local health assessment, Tribal
and local health departments should provide health-issue
specific or program specific data summaries. These will
be summaries of data that focus on a particular issue, for
example, health behaviors, health equity factors, or the
incidence of infectious diseases. It is important that others
have access to health data to inform their program planning
and activities at the local or Tribal community level. Health
data summaries are used to inform stakeholders and
partners about the health of the community health issue and
to advocate for the health of the Tribe or locality and for the
needs identified in the profile.
Tribal/community summaries
or fact sheets of data
to support public health
improvement planning
processes at the Tribal or
local level
REQUIRED DOCUMENTATION
GUIDANCE
1. Tribal or community
health data summaries or
fact sheets
1. The Tribal or local health department must provide summaries
or fact sheets of Tribal/community health data that condense
public health data. Data summaries may address a combination of
public health issues or may focus on a particular health issue regarding
the population served.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
of data
summaries
5 years
Tribal or local health data summaries are not the same as a community
health assessment. A data summary can be an in several forms. It can
be an overview, summary, or synopsis of a particular health issue, such
as cancer or obesity. Or, it can address a set of issues, such as health
equity or health issues of adolescents. It may also focus on select key
indicators of the health of the community, such as health behaviors like
tobacco use or healthful eating.
Documentation could be, for example, a summary, fact sheet, brief,
overview, a single document of comprehensive data, or a dynamic
website with comprehensive data that is updated as data are available
(i.e., web-based dashboard).
54
DOMAIN 1
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 54
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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5/9/14 10:43 AM
MEASURE 1.4.2 T/L, continued
2. Distribution of health
data summaries to
public health system
partners, community
groups, and key
stakeholders
2. The Tribal or local health department must document the
distribution of summaries of health data to public health
system partners, community groups, other Tribal and local
health departments, elected officials, or key stakeholders, such
as governing entities or community advisory groups. This may
include partners, including elected/appointed officials, community based
organizations, civic groups and any others who receive services, help in
the delivery of service, or support public health services.
55
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DOMAIN 3
Community health data summaries produced by national,
federal including Tribal Epidemiologic Centers), or state health
department sources for the local health departments are insufficient
documentation of the measure, unless the local health department
demonstrates how the data summary was supplemented with
additional data collected and analyzed by the local health department.
Documentation could be, for example, a mailing list, email list-serve,
posting on the website, press releases, meeting minutes documenting
distribution of the profile, presentations, and inserts or flyers, or a
dynamic website of data that is updated as data are available.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
2 examples
of distribution of issue
specific
data summaries or 1
example of
provision of
comprehensive data
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 1.4: Provide and use the results of health data analysis to develop
recommendations regarding public health policies, processes,
programs, or interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 1.4.3 S
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 summaries of data.
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 community health data or
summaries of data.
Support provided to Tribal
and local health departments
in the state concerning the
development and use of
summaries of community data
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The state health department must document 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 and local profile development.
2 examples
5 years
2. The state health department must provide summaries of data
of the Tribal and local community.
2 examples
5 years
2 examples;
5 years
REQUIRED DOCUMENTATION
GUIDANCE
1. Tools and guidance
2. Summaries of
community data
These must be summaries of data specific to the Tribe or local area
and may include data collected by other state agencies, for example,
educational attainment, unemployment, types of employment, or crime
statistics.
3. Determination of
support or assistance
in the analysis and
understanding of data
appropriate for Tribal and
local health departments
decision making
56
DOMAIN 1
3. The state health department must document that it has asked
Tribal and local health departments about what support or
technical assistance is needed or requested.
Documentation could be, for example, phone call minutes, faxes,
newsletters, memos, meeting minutes.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 56
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
1 example is
a Tribal health
department if
one exists in
the state.
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 1.4.3 S, continued
4. Technical assistance
provided to Tribal and
local health departments
in the analysis and
understanding of data
appropriate for public
health decision making
57
DOMAIN 1
4. The state health department must document the assistance
that it provided to Tribal and local health departments
concerning the use of summaries of data.
Documentation could be, for example, faxes, newsletters, memos,
meeting minutes, phone call minutes.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
PHABStandardsMeasures4-30-14.indd 57
DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
2 examples;
5 years
1 example is
a Tribal health
department if
one exists in
the state.
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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:
58
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:
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
Standard 2.4:
Maintain a Plan with Policies and Procedures for Urgent and Non-Urgent Communications
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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 spread of
disease or illness.
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.1 A
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 thorough investigation into the
cause of a public health problem or environmental public health
hazard and timely response so that further disease and illness
can be prevented.
Protocols for investigation
process
REQUIRED DOCUMENTATION
GUIDANCE
1. Protocols that include:
1. The health department must provide written protocols
that include a procedure for conducting investigations of
suspected or identified health problems and environmental and
occupational public health hazards.
Examples of health problems that require investigation include infectious
disease, sexually transmitted disease/infection, injury, chronic disease,
chemical emissions, and drinking water contamination, etc.
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
(for example, all environmental public health sanitarians, epi-diagnostic
teams, and/or community health outreach staff in the health department)
or may be assigned to a named individual. Documentation must include
specific responsibilities shown in a procedure, protocol, or flow chart.
a. Assignment of
responsibilities for
investigations of
health problems,
environmental, and/
or occupational public
health hazards
NUMBER OF
EXAMPLES
DATED
WITHIN
1 comprehensive
protocol or a
set of
protocols
that covers
diseases and
environmental health
issues
24 months
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.
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MEASURE 2.1.1 A, continued
b. Health problem or
hazard specific protocol
steps including case
investigation steps and
timelines, and reporting
requirements
61
b. The protocol must contain protocol steps or procedures for the health
problems or hazards that will be investigated, case investigation steps,
and timelines related to those problems or hazards, and reporting
requirements.
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The protocols may be in separate documents, may be contained in a
manual format, or may be in a single compiled document.
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.2 S
The purpose of this measure is to assess the
state health department’s capacity to engage
in more than one investigation of infectious
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 disease at the same time.
The focus of this measure is on investigation of infectious
diseases such as influenza, measles, food borne illnesses, or
Lyme disease.
Capacity to conduct and/
or support investigations
of infectious diseases
simultaneously
REQUIRED DOCUMENTATION
GUIDANCE
1. Procedures for the
conduct of simultaneous
investigations
1. The state health department must provide written procedures
that describe how it conducts multiple, simultaneous
investigations of infectious diseases.
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
state governmental departments to show the capacity to conduct
simultaneous investigations.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 comprehensive
procedure or
2 examples
of
procedures
5 years
The state health department does not have to perform all functions of
an investigation, but must have the capacity to respond when needed.
Documentation could be, for example, response plans, internal plans,
staff capacity and expertise, and resources available to the health
department from other state governmental departments (for example,
the Department of Agriculture or the Department of Environmental
Resources).
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MEASURE 2.1.2 S, continued
2. Reviews of investigation
reports against
procedures
63
2. The state health department must provide program audits
(internal or external), programmatic evaluations, case reviews,
or peer reviews of investigation reports (as compared to
written procedures) developed as a result of an investigation
of infectious diseases. The documentation must reference the state
health department’s capacity to respond to outbreaks of infectious or
communicable disease. The documentation could be a completed After
Action Report (AAR).
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2 examples of
simultaneous
investigations
5 years
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.2 T/L
The purpose of this measure is to assess the
Tribal/local health department’s capacity to
implement its protocols for an investigation of
infectious disease.
Investigations of infectious 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 diseases, such as influenza, measles, food borne
illnesses, or Lyme disease.
Capacity to conduct an
investigation of an infectious
disease
64
REQUIRED DOCUMENTATION
GUIDANCE
1. Reviews of investigation
reports against
procedures
1. The Tribal/local health department must provide audits
(internal or external), programmatic evaluations, case reviews,
or peer reviews of investigation reports (as compared to
written procedures). The documentation must reference the health
department’s capacity to respond to outbreaks of infectious disease.
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 disease, but must have formal arrangements
with others who will participate and support the Tribal/local health
department in its investigations.
The documentation could be a completed After Action Report (AAR).
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NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.3 A
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
department to learn how to prevent or mitigate health problems
caused by non-infectious health problems and environmental
public health hazards.
Capacity to conduct
investigations of non-infectious
health problems, environmental,
and/or occupational public
health hazards
65
REQUIRED DOCUMENTATION
GUIDANCE
1. Completed investigation
of a non-infectious health
problem or hazard
1. The health department must provide written reports of a
completed investigation of a non-infectious health problem or
hazard. There is no specified format.
Non-infectious health problems include: morbidity and mortality
associated with emergent and non-emergent health problems that are not
infectious, for example, chronic disease, injuries, and environmental public
health hazards, as well as their risk factors, including socioeconomic
issues. 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.
If this activity is provided through a contract/MOA/MOU, then written
assurance that the investigation was completed must be provided.
Documentation could be, for example, reports of the investigation,
executive summary, presentation or investigation records, including logs
and notes.
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NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.4 A
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 investigation.
Collaborative work through
established governmental and
community partnerships on
investigations of reportable
diseases, disease outbreaks,
and environmental public
health issues
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The department must provide contracts/MOAs/MOUs/
agreements/funding agreements that document established
partnerships for the investigation of outbreaks of disease, health
care associated infections, 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 examples
5 years
2. The department must document work with partners to conduct
investigations.
2 examples
5 years
REQUIRED DOCUMENTATION
GUIDANCE
1. Partnerships with other
governmental agencies/
departments and/or key
community stakeholders
that play a role in
investigations or have
direct jurisdiction over
investigations
2. Working with partners to
conduct investigations
Documentation could be investigation reports and records, AARs,
meeting minutes, presentations, and news articles
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The examples
must be from
two different
investigations
of reportable
diseases or
environmental
public health
investigations
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MEASURE 2.1.4 A, continued
3. Laboratory testing for
notifiable/reportable
diseases
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3. The department must provide a list of public health laboratory
services presently provided that includes testing for notifiable/
reportable diseases.
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1 list of public
health
laboratory
services
5 years
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.5 A
The purpose of this measure is to assess
the health department’s assurance of timely
investigations including reporting of notifiable/
reportable diseases, laboratory test results,
and reporting investigation results.
A component of assuring timely investigations is the monitoring
of reporting notifiable/reportable diseases, laboratory testing,
and investigation of results as appropriate and required by law.
When all steps are timely, partners can work together to stop
the spread of disease.
Monitored timely reporting of
notifiable/reportable
diseases, lab test results, and
investigation results
REQUIRED DOCUMENTATION
GUIDANCE
1. 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 or audit
on investigations that includes reporting lab test results and
investigation results. The log is used to track various elements of
investigations.
2. Applicable laws
2. The department must provide a copy of laws relating to the
reporting of notifiable/reportable diseases.
Documentation could be a log or a report. The log or report must include
timelines.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 tracking
log or audit
of investigations
conducted
5 years
1 set of laws
The law may
be older than
5 years, but
the health
department
should
document
that the law
has been
reviewed
within 5
years
State health departments must include laws for local health
departments to report to the state, as well as for states reporting to
CDC.
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Documentation could be, for example, a screen shot of a posting on a
website or a department intranet or a pdf copy.
Standards & Measures
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STANDARD 2.1: Conduct timely investigations of health problems and
environmental public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.1.6 S
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 the
management of disease outbreaks and
public health hazards.
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 to environmental and
occupational public health hazards.
Consultation, technical
assistance, and/or information
provided to Tribal and
local health departments
in the state regarding the
management of disease
outbreaks and environmental
public health hazards
REQUIRED DOCUMENTATION
GUIDANCE
1. The provision of
consultation, technical
assistance, and/or
information
1. The state health department must document how it provides
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 list-serves.
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NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
State health department assistance can be for example, onsite, phone
consultation, conference calls, webinars, presentations, training sessions,
written guidelines, and investigation protocols and manuals.
Standards & Measures
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DOMAIN 8
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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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STANDARD 2.2: Contain/mitigate health problems and environmental
public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.2.1 A
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.
Protocols for containment/
mitigation of public health
problems and environmental
public health hazards
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. Protocol(s) that address
containment/mitigation
of public health problems
and environmental public
health hazards
1. The health department must provide written protocols or a set
of protocols for the containment/mitigation of health problems
and hazards. This includes disease-specific procedures (for example,
pertussis, TB) for follow-up and reporting during outbreaks.
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.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 comprehensive
protocol or
a set of
protocols
2 years
These protocols may be in a single document or be comprised of many
separate documents.
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DOMAIN 8
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STANDARD 2.2: Contain/mitigate health problems and environmental
public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.2.2 A
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 in order
to address a natural disaster, terrorist event,
disease outbreak or cluster, environmental
public health hazard, or other emergency that
threatens the population’s health.
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 and that it is not put into action when it is not needed.
A process for determining when
the All Hazards Emergency
Operations Plan (EOP) will be
implemented
72
REQUIRED DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. Protocols that address
infectious disease
outbreaks 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 all 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.
1 comprehensive
protocol or
a set of
protocols
5 years
2. Protocols that address
environmental public
health issues 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.
1 comprehensive
protocol or
a set of
protocols
5 years
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DOMAIN 5
DOMAIN 6
DOMAIN 7
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MEASURE 2.2.2 A, continued
3. Cluster evaluation
protocols that describe
the processes for the
review of specific
situations that involve
a closely grouped
series of events or
cases of disease or
other health-related
phenomenon with welldefined distribution
patterns in relation to
time or place or both,
and for determining
initiation of the All
Hazards Emergency
Operations Plan
73
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, for example, SARS, influenza, food
poisoning, health care associated infections (e.g., MRSA), or unusual
symptoms in a group, together in time and location.
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1 comprehensive
protocol or
a set of
protocols
5 years
A cluster evaluation is differentiated from an outbreak in that a single case
of some infectious diseases may trigger the use of an outbreak protocol
(e.g., small pox or polio).
Standards & Measures
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 12
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STANDARD 2.2: Contain/mitigate health problems and environmental
public health hazards.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.2.3 A
The purpose of this measure is to assess the
department’s development of descriptions and
analysis of performance after an emergency
operation or exercise. This measure assesses
the existence of After Action Reports.
A process for After Action Reports provides a way for the health
department to assess its performance during an emergency
operation for quality improvement. It identifies issues that need
to be addressed and includes recommendations for corrective
actions for future emergencies and disasters.
Complete After Action Reports
(AAR)
An AAR is to be completed when an infectious disease
outbreak occurs, an environmental public health risk has been
identified, a natural disaster occurs, and 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 focus of this measure is concerning the determination
of when AAR methodology is applied to actual events that
threaten the health of the people living in the jurisdiction of the
health department.
74
REQUIRED DOCUMENTATION
GUIDANCE
1. Protocol describing
the processes used to
determine when events
rise to significance for
the development and
review of an AAR
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 infectious disease outbreaks, environmental public health
hazards, natural disasters, and other threats.
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
1 protocol
5 years
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MEASURE 2.2.3 A, continued
75
2. A list of all 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. The list must
include all events that met and did not meet the level of significance
to require an AAR. The list must include, at minimum, the event name,
dates of the event, and type of event (e.g., natural disasters, such as
floods or hurricanes; manmade disasters, such as a toxic chemical
release or pollution; and terrorism, such as anthrax or explosions). The
list must include all outbreaks, environmental public health risks, natural
disasters, or other events that threaten the public’s health.
1 list
5 years
3. Completed AAR for two
events
3. The health department must provide completed AARs.
2 examples
of separate
events
5 years
An AAR documents successes, issues, and recommended changes in
investigation and response procedures or other process improvements.
The AARs must report what worked well, what issues arose,
what improvement in protocols are indicated, and recommended
improvements.
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Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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 on 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.
76
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 2.3.1 A
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 need the capacity to respond to public
health emergencies. The department needs to have access to
epidemiological and environmental public health resources that
can support the rapid detection, investigation, and mitigation
of problems and hazards. This access must be available to the
department 24/7.
Provisions for the health
department’s 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
77
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
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.
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
1 comprehensive
policies and
procedures
document
or a set of
policies and
procedures
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
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MEASURE 2.3.1 A, continued
78
2. Process to contact
epidemiological and
environmental public
health resources
2. The health department must provide the call down list that
is used to contact epidemiological and environmental public
health resources.
1 call down
list
5 years
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.
1 list
5 years
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 2.3.2 A
The purpose of this measure is to assess
the department’s access to needed
laboratory services to provide rapid detection,
investigation, and containment/mitigation of
public health problems and environmental
public health hazards.
Emergency laboratory services are critical to recognize agents
for the development of an appropriate public health rapid
response. The department must 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.
24/7 access to laboratory
resources capable of providing
rapid detection, investigation
and containment of health
problems and environmental
public health hazards
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.
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DOMAIN 3
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.)
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
Accreditation
documentation,
certification,
and/or
licensure
appropriate
for all the
testing that
is performed
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 2.3.2 A, continued
2. Policies and procedures
ensuring 24/7 coverage
2. The health department must provide policies and procedures
that assure 24/7 laboratory coverage. 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. These policies and procedures may be contained in the
All Hazards Emergency Operations Plan or may be separate policies
and procedures.
3. Protocols for the health
department’s handling
and submitting of
specimens
80
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DOMAIN 3
5 years
1 comprehensive protocol
or a set of
protocols
5 years
Documentation could be contracts, MOAs/MOUs, or mutual assistance
agreements that the department has with other public and private
laboratories to provide support services.
3. The department must provide protocols for the health
department’s handling and submitting of specimens.
PUBLIC HEALTH ACCREDITATION BOARD
1 set of
policies and
procedures or
policies and
procedures,
MOUs, or
agreements
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 2.3.3 A
The purpose of this measure is to assess
the department’s support personnel and
infrastructure capacity for providing 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.
Access to laboratory and
other support personnel and
infrastructure capable of
providing surge capacity
81
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The health department must provide the 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. The
protocol must include access to public health laboratory services.
1 protocol
5 years
2. The health department must provide the staffing list(s) for
surge capacity that refers to both the staffing needed for a
surge response and how department staff will fill those needs.
Included with this documentation must be a description of how staff
will access this information. Access could be through various methods,
including: web or intranet, central location in the facility, or distributed to
those positions that have surge capacity assignments.
1 list or lists
5 years
REQUIRED DOCUMENTATION
GUIDANCE
1. Surge capacity protocol
that pre-identifies
support personnel to
provide surge capacity
2. Access to surge capacity
staffing list
The HD must also demonstrate that staff on the list have access to the list.
Positions on the list may include, for example, nursing, health education
specialist, communications, IT, logistics, veterinarian and animal caretaker,
environmental health specialist, laboratory, and administrative personnel.
This could be a part of an All Hazards/ERP or a separate protocol.
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 2.3.3 A, continued
82
3. Availability of equipment
3. The health department must provide a document detailing
the availability of equipment to support a surge in order to
demonstrate the availability of additional infrastructure for a
response. For example, equipment may be used for transportation,
field communications, Personal Protective Equipment (PPE), etc.
1 document
5 years
4. Training/exercise
schedule for surge
personnel
4. The health department must provide a schedule for training
or exercises to 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.
1 schedule
2 years
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.
1 list
5 years
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
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
PURPOSE
SIGNIFICANCE
Measure 2.3.4 A
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.
Collaboration among Tribal,
state, and local health
departments to build capacity
and share resources to address
Tribal, state, and local efforts
to provide for rapid detection,
investigation, and containment/
mitigation of public health
problems and environmental
public health hazards
REQUIRED DOCUMENTATION
GUIDANCE
1. Shared resources and/or
additional capacity
1. The health department must document Tribal, state, and local
health departments working together to build capacity and
share resources.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Documentation could be policies and procedures, MOUs, or other
written agreement that demonstrate plans to communicate and
collaborate in addressing public health problems and environmental
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.
83
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 2.3.4 A, continued
2. Joint exercises for rapid
detection, investigation,
and containment/
mitigation of public
health problems and
environmental public
health hazards
84
2. The health department must document joint exercises that
show the Tribal, state, and local levels work together to test
or implement shared resources and build capacity during the
exercise.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
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DOMAIN 3
Documentation could be AARs or other records.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
2 examples;
one example
must include
a Tribe, if
one exists
in the health
department’s
jurisdiction.
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 2.4: Maintain a plan with policies and procedures for urgent
and non-urgent communications.
Reliable and timely communication with partners and the public is important to ensure informed and
appropriate responses to public health problems and environmental public health hazards.
85
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 2.4: Maintain a plan with policies and procedures for urgent and
non-urgent communications.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.4.1 A
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.
Written protocols for urgent 24/7
communications
86
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The health department must provide a communication
protocol that provides 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 (for
example, phone numbers, email addresses, and website addresses
for relevant partners). The health department must have duplicative
means to get in touch with partners.
1 protocol
14 months
2. The health department must document the provision 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 may include: law enforcement, schools, hospitals,
veterinarians, and government agencies.
1 example
5 years
REQUIRED DOCUMENTATION
GUIDANCE
1. Protocol for urgent 24/7
communications
2. Availability of
information 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
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Documentation could be a screen shot of a web page with contact
information.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
MEASURE 2.4.1 A, continued
3. The method for partners
and the public to contact
the health department
24/7
87
3. The health department must document how partners and
the public contact the health department 24/7. An after-hour
answering service or pager service could provide this capacity.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
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DOMAIN 3
1 example
5 years
Documentation could be, for example, a script or transcript of an
answering service.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 2.4: Maintain a plan with policies and procedures for urgent and
non-urgent communications.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.4.2 A
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.
A system to receive and
provide urgent and nonurgent health alerts and to
coordinate an appropriate
public health response
REQUIRED DOCUMENTATION
GUIDANCE
1. A tracking system for the
receipt and issuance of
urgent and non-urgent
health alerts
1. The health department must document 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.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 tracking
system or
health alert
network
5 years
2 examples
5 years
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 jurisdictions
have established a Joint Information Center (JIC) with a public
information officer for the health department; health departments may
provide evidence of this as documentation.
2. Reports of testing 24/7
contact and phone line(s)
88
2. The health department must provide reports of testing the
24/7 contact procedure. 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.
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 2.4: Maintain a plan with policies and procedures for urgent and
non-urgent communications.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.4.3 A
The purpose of this measure is to
assess the health department’s
ability to provide information to
the public during a public health
emergency.
During a public health emergency, the health department functions
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
and spread. 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.
Timely communication
provided to the general
public during public health
emergencies
REQUIRED DOCUMENTATION
GUIDANCE
1. Communications
plan, procedure,
or process to
provide emergency
information to the
public
1. The department must demonstrate how it communicates with
and provides information to the public.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Documentation must provide evidence of outreach and communication
methods designed specifically to communicate with the disabled,
linguistically challenged, and other members of the public that require
particular communication considerations.
The measure deals with public health emergencies (for example, an
outbreak of an infectious disease, a release of toxic chemicals, or the
need to boil water during a flood or water main break); documentation
must demonstrate processes to ensure timely communication with the
public during an emergency.
89
General public health educational materials are not relevant for this
measure.
The process must include a variety of means to communicate
information to the public, including, for example, posting on a website,
distribution of printed materials (brochures, flyers, factsheets, inserts),
fax broadcast to all providers and other responders, automated call
systems, digital media (e.g., Twitter) and email list-serves.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
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MEASURE 2.4.3 A, continued
2. Communications through
the media to provide
information during a
public health emergency
90
2. The department must demonstrate the use of the media to
communicate information to the public during a public health
emergency.
PHABStandardsMeasures4-30-14.indd 90
DOMAIN 3
5 years
Documentation must provide evidence of relationships with media,
organizations, and outlets for reaching the disabled, the non-English
speaking public, and other members of the public that require particular
communication considerations.
The measure deals with public health emergencies and the
documentation must demonstrate timely communication with the media
during an emergency.
General public health educational information is not relevant for this
measure.
Documentation could be, for example, a press conference, media
packets, press release, public service announcement, or video of a
televised interview.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 2
2 examples
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 2.4: Maintain a plan with policies and procedures for urgent and
non-urgent communications.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 2.4.4 S
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.
Consultation and technical
assistance provided to Tribal
and local health departments
on the accuracy and clarity
of public health information
associated with a public
health emergency
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.
REQUIRED DOCUMENTATION
GUIDANCE
1. Consultation, technical
assistance, or
guidance provided to
Tribal and local health
departments
1. The state health department must document the provision of
consultation, technical assistance, or guidance provided to
Tribal and local health departments. The state health department
does not have to demonstrate that the Tribal and local health
departments use the services from the state, but consultation and
technical assistance must be available if requested.
Documentation could be, for example, minutes of meetings or
conference calls. 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 list-serves sent to
Tribal and local health departments.
2. Guidelines for
accurate and clear
communication to
the public
91
2. The state health department must provide communication
guidelines, protocols, or written assistance for Tribal and
local departments. Guidelines must include information about
developing clear and accurate public health information during an
outbreak, crisis, or emergency to prepare Tribes and local health
departments for such an occurrence.
PUBLIC HEALTH ACCREDITATION BOARD
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DOMAIN 3
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
one example
must include
a Tribe, if
one exists
in the health
department’s
jurisdiction.
5 years
1 set of
guidelines
5 years
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
Domain 3: Inform and Educate about Public Health Issues and Functions
Domain 3 focuses on informing and educating the public. This domain assesses the health department’s processes for continuing two-way
communication with the public as standard operating procedure.
A role of the health department is to provide accurate and reliable information about how to protect and promote individual and family health. Health
departments provide information about healthy behaviors, such as good nutrition, hand washing, and seat belt use. The public needs access to
accurate and timely information in the case of particular health risks like H1N1, a food borne disease outbreak, or an anthrax attack. For information
to be actionable, it must be communicated in a language and format that the population can access and understand. Messages need to be culturally
appropriate and trusted. Public health departments also have a responsibility to educate the public about the mission, value, roles, and responsibilities
of the health department and the meaning and importance of public health. Building and maintaining a positive, trustworthy reputation in all of its
diverse communities is essential.
These educational responsibilities require a continuing flow of information. To be effective, information cannot be one-way. 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 local health departments. To facilitate communication, it needs to have a relationship with community partners and the population and subgroups 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. Communication methods are changing rapidly through digital media such as Twitter and Facebook. Selected
communication methods must be appropriate for the target audience, the urgency of the communication, and the type of information. In addition, the
science of public health branding is developing rapidly. Branding is important for the department’s image, reputation, and perceived value.
DOMAIN 3 INCLUDES TWO STANDARDS:
92
Standard 3.1:
Provide Health Education and Health Promotion Policies, Programs, Processes, and
Interventions to Support Prevention and Wellness
Standard 3.2:
Provide Information on Public Health Issues and Public Health Functions Through
Multiple Methods to a Variety of Audiences
PUBLIC HEALTH ACCREDITATION BOARD
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Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
5/9/14 10:43 AM
STANDARD 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support
prevention and wellness.
Health promotion involves a wide range of social and environmental changes that allow and encourage
the population to be healthy. Health promotion policies, programs, processes, and interventions are
the mainstay of public health improvement efforts. Health promotion can involve health education,
communication, working with the media and other stakeholders, social marketing, health equity, behavior
change, environmental changes, community mobilization, community development, and policy changes.
Health education is an important component of encouraging the adoption of healthy behaviors. Health
education provides the information needed 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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VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support prevention
and wellness.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 3.1.1 A
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, health
behaviors, disease prevention,
and wellness approaches.
A key activity in promoting population health is providing public health information
that encourages the adoption of healthful behaviors and activities. To be effective,
information should be appropriate for the target audience. It must be accurate,
timely, and provided in a manner that can be understood and used effectively by
the target population.
Information provided to
the public on protecting
their health
Public health information can address a broad range of public health promotion
messages:
• Health risks, for example, high blood pressure or high cholesterol.
• Health risk behaviors, for example, tobacco use or unprotected sexual activity.
• Disease, illness, or injury prevention, for example, seat belt use or immunizations.
• Wellness, for example, health nutrition or physical activity.
Health information could address a combination of these targets and messages.
For example, unprotected sex, needle sharing, and HIV transmission could
combine aspects of health risks, health behaviors, and prevention.
For the information to be trusted and understood, health education messaging
must not be contradictory or confusing. Ideally, messaging needs to be coordinated
with others who are providing public health information to the public.
94
REQUIRED
DOCUMENTATION
GUIDANCE
1. The provision of
information to the
public on health
risks, health
behaviors, disease
prevention, or
wellness
1. The health department must document the provision of
information to the public to address health risks, health
behaviors, disease prevention, and/or wellness. Information
must be accurate, accessible, and actionable. The need for cultural
competence and consideration of health literacy must be taken into
account. Information is expected to be provided in plain language with
everyday examples.
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NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
(See details on
following page.)
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MEASURE 3.1.1 A, continued
Documentation must note the target group or audience, the program area,
the date the information was shared or distributed, and the purpose for the
information.
Documentation could be, for example, a public presentation, distribution of
a press release, media communications, brochures, flyer, or public service
announcement.
95
2. Consultation with
the community
and target
group during the
development of
the educational
material/
messages
2. The health department must document steps taken to solicit
input from the target audience during the development of
messages and materials. Input is intended to help shape the final
content, cultural competence, language, and real life situations of the
target audience. The role of social and environmental factors must be
addressed (rather than focusing primarily on the individual).
3. Health education
messages that are
coordinated with
Tribal, state, and/
or local health
departments; and/
or community
partners
3. The health department must document communication with
other health departments (Tribal, state, or local) or community
partners to promote unified messaging.
5 years
One example must
come from one of the
two program areas
from which documentation was provided in
1, above
2 examples
5 years
Documentation could be, for example, a fact sheet, an email or
memorandum, meeting minutes where messaging was discussed, or
documented phone conversation discussing the message.
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2 examples
Documentation could be, for example, a report of findings from a focus
group, key informant interviews, or pull-aside testing. Documentation
could also be minutes from a town meeting with the target population or a
meeting of an advisory group representing the target population.
DOMAIN 3
The two examples
can relate to the
same message area,
such as two items
addressing disease
prevention issues.
The two examples
must, however,
be from different
program areas,
one of which must
address a chronic
disease program, for
example, diabetes,
obesity, heart
disease, HIV, or
cancer.
Standards & Measures
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DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support prevention
and wellness.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 3.1.2 A
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 encourages positive health behaviors.
Health promotion is a combination of health education, community change,
environmental change (including the built environment) and organizational and
social supports that provide conditions conducive to the good health of individuals,
groups, and communities. Health promotion combines educational, political,
regulatory, social, and organizational efforts.
Health promotion
strategies to mitigate
preventable health
conditions
REQUIRED
DOCUMENTATION
GUIDANCE
1. A planned
approach for
developing and
implementing
health promotion
programs
1. The health department must document a planned approach for
developing and implementing health promotion materials and
activities.
2. Development and
implementation of
health promotion
strategies
2. The health department must document the development and
implementation of health promotion strategies. The documentation must
show how the strategies:
• Are evidence-based, rooted in sound theory, practice-based evidence, and/
or promising practice.
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DATED
WITHIN
1 example
5 years
2 examples
5 years
A planned approach could be documented through, for example, policies
and procedures, a health promotion communications plan, the use of a
communications model or methodology (for example, CDCynergy), or other
documentation that describes how health promotion programs are developed
(including the use of data and community input).
• Were developed with engagement of the community, including input, review,
and feedback from the target audience.
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NUMBER OF
EXAMPLES
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The examples
must come from
two different
program areas,
one of which
must address
the prevention
of a chronic
disease.
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MEASURE 3.1.2 A, continued
• Focus on social and environmental factors (such as air quality or the built
environment) that create poor health, discourage good health, or encourage
individual behavioral factors that impact negatively on health.
• Use various marketing or change methods including, for example, digital
media and social marketing, as appropriate.
• Were implemented in collaboration with stakeholders, partners, and the
community.
Examples of health promotion efforts include biking pathways, farmers markets,
public meeting places (to encourage social interaction), distribution of child
safety devices, walking clubs, and smoke free zones.
Documentation could be, for example, a portion of a 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, evaluation report of the
program, 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.
3. Engagement of
the community
during the
development
of a health
promotion
strategy
97
3. The health department must document that it solicited review, input,
and/or feedback from the target audience during the development of
the health promotion strategy.
Documentation must include a description of the process and the results.
Documentation could be, for example, findings from a focus group, key
informant interviews or pull-aside testing. It could also include minutes from a
town meeting or planning meeting with the target population or a meeting of an
advisory group representing the target population.
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5 years
2 examples
One of the
examples must
be from one of
the two program
areas from which
documentation
was provided
in Required
Documentation
2, above.
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MEASURE 3.1.2 A, continued
4. Implementation
of strategies in
collaboration
with
stakeholders,
partners, and/or
the community
98
4. The health department must document that implementation of the
strategies was in collaboration with stakeholders, partners, and/or
the community. The stakeholders and partners associated with the strategy
must be listed or community described. The documentation must define the
stakeholders’, partners’, and/or community’s relationship to and role in the
strategy.
Documentation could 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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2 examples
5 years
One of the
examples must
be from one of
the two program
areas from which
documentation
was provided in
2, above.
VERSION 1.5 APPROVED DECEMBER 2013
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STANDARD 3.1: Provide health education and health promotion policies,
programs, processes, and interventions to support prevention
and wellness.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 3.1.3 A
The purpose of this measure
is to assess the health
department’s assessment,
identification, and efforts to
address factors that contribute
to specific populations’ higher
health risks and poorer health
outcomes, or health inequities.
Differences in populations’ health outcomes are well documented. Factors that
contribute to these differences are many and varied and include the lack of
opportunities and resources, economic and political policies, discrimination,
and other aspects of a community that impact on individuals’ and population’s
resilience. These differences in health outcomes cannot be effectively addressed
with programs and interventions; they require engagement of the community in
strategies that develop community resources, capacity, and strength.
Efforts to specifically
address factors that
contribute to specific
populations’ higher health
risks and poorer health
outcomes
REQUIRED
DOCUMENTATION
1. Identification and
implementation
of strategies to
address factors
that contribute to
specific populations’
higher health risks
and poorer health
outcomes, or health
inequity, including:
a. Analysis of factors
that contribute to
higher health risks
and poorer health
outcomes of specific
populations and
the development
of health equity
indicators
99
GUIDANCE
1. The health department must document efforts to address
health equity among the populations in the health department’s
jurisdiction. The health department must provide:
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DATED
WITHIN
2 examples
5 years
a. The analysis of health inequity, factors that cause or contribute to it,
and health equity indicators across communities or neighborhoods.
Health equity indicators must be specific to the factors analyzed.
Factors could be, for example, tax policies, community zoning, public
education, transportation policy, and resource allocation.
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NUMBER OF
EXAMPLES
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 3.1.3 A, continued
Indicators identified could be, for example, living standards, foreclosure
rates, housing stock, transportation, safety, air quality, infrastructure
(sewage, sidewalks, street design, etc.), employment and income
levels, parks, and food access. Documentation of indicators would be
the list of indicators identified.
Documentation could be, for example, the results of an analysis in a
report, white paper, briefing paper, or a memo.
b. Public health efforts
to address identified
community factors
that contribute to
specific populations’
higher health risks
and poorer health
outcomes and to
impact health equity
indicators
b. Plans and/or of efforts to address social change, social customs,
community policy, level of community resilience, or the community
environment to impact on health inequities.
For example, the question “How do we motivate people to stop
smoking?” can be rephrased as “What are the community conditions
(e.g., stress, convenience stores, social norms) that encourage
smoking?” Plans address the issue as defined as a community issue
that impacts on higher health risks and poorer health outcomes of
specific populations. Plans and/or reports will address efforts to work
with those who set policy and make other decisions that impact the
community’s health inequities.
Documentation could be, for example, program plans, program goals
and objectives, reports, or other written commitment to address the
factors in 1a, above. Reports could be, for example, press releases,
formal reports to governance and/or the community, or other written
document that outlines efforts to be made or achievements.
c. Internal policies and
procedures to ensure
programs address
specific populations
at higher risk for poor
health outcomes
100
c. Internal policies and procedures for the inclusion of health equity
considerations of specific populations (for example, racial/ethnic
minorities, those who live in poverty, and people with disabilities), in
program development (e.g., RFPs or program proposals or plans).
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DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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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 communicating with external audiences.
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 communicate with the public about
their products and services, regulatory and policy activities, role in the community, and the value the
departments deliver to the community. Also included are plans to communicate information to the public
in times of calm and crisis, disasters, outbreaks, or other threats to the public’s health.
101
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.1 A
The purpose of this measure is to
assess the health department’s efforts to
inform the public and stakeholders 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. Conveying the value, mission, roles, processes, programs, and
interventions of the health department is a necessary step in building
effective public health programs and ensuring sustained funding levels.
Information on public health
mission, roles, processes,
programs, and interventions
to improve the public’s health
provided to the public
REQUIRED
DOCUMENTATION
1. The provision of
information provided
to the public about
what public health
is, its value, and/
or on the health
department’s roles,
processes, programs,
and interventions
GUIDANCE
1. The health department must document the distribution of
information 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. The documentation must
describe how the information was distributed, dates of distribution (or
range of dates), and the purpose of the information.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Documentation could be, for example, 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 Tribal attorney may need to be included when crafting messages for
the public and 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.
102
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 3.2.1 A, continued
2. Relationship with
the media to ensure
their understanding
of public health and
to ensure that they
cover important
public health issues
103
2. The health department must document communication with the
media.
The media include print media, radio, television, bloggers, web reporters,
and diverse media outlets (for example, urban radio stations; free
community newspapers; migrant worker newspapers; immigrant, ethnically
targeted, and non-English language newspapers or radio stations, etc.)
Documentation could be, for example, a log of media contacts, a published
editorial concerning a public health issue (written by a department staff
person or member of the governing entity), an appearance on a television
show (of a department staff person or member of the governing entity), or
a radio interview (of a department staff person or member of the governing
entity), minutes or other documentation of a meeting or phone call with
editorial staff, and emails or other communications with bloggers.
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
2 examples
2 years
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.2 A
The purpose of this measure is to
assess the health department’s
strategy to communicate the value of
its products, services, and practices to
external audiences.
Branding is a standard business practice to raise the visibility,
perceived value, and reputation of an organization. Branding
communicates what the health department stands for and what it
provides that is unique and differentiated from other agencies and
organizations. Branding can help to position the health department as
a valued, effective, trusted leader in the community.
Organizational branding
strategy
REQUIRED
DOCUMENTATION
GUIDANCE
1. A department brand
strategy
1. The health department must provide a brand strategy that includes
provisions or steps to:
a. ensure that department staff have a clear understanding and commitment to
the brand of the health department,
NUMBER OF
EXAMPLES
DATED
WITHIN
1 policy,
plan, or set
of policies
or strategies
5 years
b. communicate the health department’s brand in a targeted manner (customized
to different stakeholders) to convey the presence of the health department and
the essential products and services that it delivers to its community,
c. integrate brand messaging into organizational communication strategies
and external communications (e.g., website, media releases, public service
announcements, social media activities, speeches, grant applications, and
promotional materials),
d. use a common visual identity (logo) to communicate the health department’s
brand,
e. display appropriate signage inside and outside the health department facility,
and
f. link the branding strategy to the department’s strategic plan.
Documentation could be, for example, written health department policies, plan,
or strategies or could be a separate branding strategic document.
104
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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MEASURE 3.2.2 A, continued
2. Implementation of
the department’s
branding strategy
105
2. The health department must document its implementation of
elements of its branding strategy.
PHABStandardsMeasures4-30-14.indd 105
5 years
Examples must implement plans, policies, or strategies as presented above.
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2 examples
Standards & Measures
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DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.3 A
The purpose of this measure
is to assess the health
department’s written procedures
for communication to the public,
partners, and stakeholders.
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.
Communication procedures
to provide information
outside the health
department
106
REQUIRED
DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. Procedures for
communications
that include:
1. The health department must provide a copy of communication
procedures. There is no required format for the procedures. The
procedures must:
1 procedure
or one set of
procedures
2 years
a. Dissemination of
accurate, timely,
and appropriate
information for
different audiences
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. Coordination
with community
partners for the
communication
of targeted and
unified public
health messages
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.
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
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MEASURE 3.2.3 A, continued
c. A contact list of
media and key
stakeholders
c. Include a 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. A designated staff
position as the
public information
officer
d. Identify which department staff position is designated as the public information
officer. The protocol must define this position’s responsibilities, which must
include: maintaining media relationships; creating appropriate, effective public
health messages; and managing other communications activities.
e. 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. Implementation of
communications
procedures
PHABStandardsMeasures4-30-14.indd 107
2 examples
2 years
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
positions, such as the director, public information officer, and representatives
of the governing entity.
2. The health department must document the department’s
implementation of the communications procedures listed in 1, above.
The health department must provide public health messages disseminated
outside the health department.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 3
5 years
Documentation could be, for example, a job description or other description
of responsibilities.
Documentation could be a press release, email between the public information
officer and the media, or other written communication to the media.
107
1 policy,
plan, or set
of policies
or strategies
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
Examples
must come
from two
different
program
areas, one
of which is
a chronic
disease
program.
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.4 A
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 is to
ensure an accurate understanding of the
actual and perceived public health risks,
the possible solutions, and related issues
and concerns voiced by experts and nonexperts.
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, effective response. The plan will detail public
relations processes and give guidance on anticipating a crisis and
responding effectively. It should also address how to prevent public
alarm by dealing appropriately with misconceptions or misinformation.
Risk communication plan
REQUIRED
DOCUMENTATION
GUIDANCE
1. Risk communication
plan
1. The health department must provide a copy of the risk communication
plan, protocol, or procedures.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 plan
5 years
The plan must provide protocols that address how information is provided for
a given situation; address how information is provided 24/7; delineate roles,
responsibilities and chain of command; describe how information will be
disseminated in the case of communication technology disruption; address how
message clearance will be expedited; and describe how the health department
will work with the media. The plan must also address preventing public alarm by
dealing with misconceptions or misinformation.
There is no required format for the plan; that is, it may be a part of a larger
communications plan or part of an overall department emergency operations plan.
A risk communication plan may be identified, for example, as an emergency
communication plan, crisis communication policies, risk communication plan,
or media communication plan..
108
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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MEASURE 3.2.4 A, continued
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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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.5 A
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 need the ability to present information to
different audiences through a variety of methods, including
information technology.
Information available to the
public through a variety of
methods
REQUIRED
DOCUMENTATION
1. A website or web
page that contains
information on:
110
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The health department must document that its website provides:
1 website
2 years
a. 24/7 contact number
for reporting health
emergencies
a. A 24/7 contact number for reporting health emergencies;
b. Notifiable/reportable
conditions link or
contact number
b. Notifiable/reportable conditions line or contact number;
c. Health data
c. Health data, for example, morbidity and mortality data;
d. Links to public
health-related laws
d. Links to public health related laws or public health code;
e. Information and
materials from
program activities
e. Information and materials from program activities, for example, infectious
disease, chronic diseases, environmental public health, prevention, and health
promotion;
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
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MEASURE 3.2.5 A, continued
f. Links to CDC
and other public
health-related
federal, state, or
local agencies, as
appropriate
f. Links to CDC and other public health-related federal, state, or local agencies,
as appropriate; and
g. The names of the
health department’s
leadership
g. The names of the health department director and the leadership team.
The health department may have its own website or be part of another
governmental website or internet domain.
Documentation could be screen shots of the pages that contain the information
required in each of the elements listed.
2. Other
communication
strategies for
informing the
public about public
health issues or
functions
111
1. The health department must document the use of other methods
used to make information available to the general public about
public health issues and/or functions.
PHABStandardsMeasures4-30-14.indd 111
5 years
Methods could include, for example, radio or television programs or
interviews, brochures, flyers, newsletters, or digital media, Facebook or Twitter.
PUBLIC HEALTH ACCREDITATION BOARD
DOMAIN 3
2 examples
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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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
PURPOSE
SIGNIFICANCE
Measure 3.2.6 A
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 must be understandable and
usable by the target audience. Information should be
accessible to all audiences in the jurisdiction served,
whether they are non-English speaking, are hearing
impaired, or have low literacy.
Accessible, accurate,
actionable, and current
information provided in
culturally sensitive and
linguistically appropriate formats
for target populations served by
the health department
REQUIRED
DOCUMENTATION
GUIDANCE
DATED
WITHIN
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.
1 data
report or
multiple
data sets
2 years
2. Interpretation,
translation, or other
specific communication
services
2. The health department must provide a list of staff or contractors
who provide interpretation, translation, or specific communication
services. Specific communication services may mean non-English speaking
or 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.
1 list
5 years
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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.
Standards & Measures
DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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MEASURE 3.2.6 A, continued
113
3. Assistive staff or
technology devices
3. The health department must document assistance for the
hearing and the visually impaired, or other assistive staff or
technology devices.
1 example
of assistive
staff or
devices
5 years
4. Public health 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 materials that are
appropriate for a population who may have difficulty with the
receipt or understanding of public health communications.
2 examples
are required;
two examples
must be
from different
program
areas.
2 years
Methods that target low-literacy individuals could include, for example, audiovisual formats and/or written materials that include images to support text.
Documentation could be, for example, materials that are culturally or
linguistically appropriate, or communicated for the hearing impaired.
National Standards for Culturally and Linguistically Appropriate Services in
Health and Healthcare is a resource for these efforts
(http://thinkculturalhealth.hhs.gov/content/CLAS.asp)
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DOMAIN 4
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 11
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Domain 4: Engage with the Community to Identify and Address
Health Problems
Domain 4 focuses on community engagement. Members of the community possess unique perspectives on how issues are manifested in the
community, what and how community assets can be mobilized, and what interventions will be effective. Community members are important partners
in identifying and defining public health issues, developing solutions or improvements, advocating for policy changes, communicating important
information, and implementing public health initiatives. Public health can broaden its leverage and impact by doing things with the community rather
than doing things to the community. Aligning and coordinating efforts towards health promotion, disease prevention, and health equity across a wide
range of partners is essential to the success of health improvement. This domain addresses health departments’ establishment and maintenance of
community partnerships and collaborations that will facilitate public health goals being accomplished, promote community resilience, and advance the
improvement of the public’s health.
DOMAIN 4 INCLUDES TWO STANDARDS:
114
Standard 4.1:
Engage with the Public Health System and the Community in Identifying and Addressing
Health Problems through Collaborative Processes
Standard 4.2:
Promote the Community’s Understanding of and Support for Policies and Strategies that will
Improve the Public’s Health
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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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 when the health department works with the community
that it serves. Ongoing dialogue about community issues, discussions about options and alternatives, and
community ownership increase the effectiveness of health improvement efforts. Collaboration with other
members of the public health system and with members of the community develops 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, coordinated, and used in creative ways for increased community efficacy in addressing public
health issues and concerns.
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
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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.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 4.1.1 A
The purpose of this measure is to
assess the health department’s
engagement with partners
in the public health system,
representatives of various sectors
of the community, and community
members to address public health
issues and concerns.
Community engagement is an ongoing process of dialogue and
discussion, collective decisions, and shared ownership. Public health
improvement requires social change; social change takes place when the
population affected by the problem is involved in the solution. Collaborative
partnerships to address public health issues and concerns provide various
perspectives, additional expertise, and assets and resources. Partnerships
provide the opportunity to leverage resources, coordinate activities,
and employ community assets in new and effective ways. Collaborative
partnerships include engagement with community members so that they
are involved in the process and participate in the decisions made and
actions taken. Community engagement also has benefits of strengthening
social engagement, building social capital, establishing trust, ensuring
accountability, and building community resilience.
Establishment and/
or engagement and
active participation in a
comprehensive community
health partnership and/
or coalition; or active
participation in several
partnerships or coalitions
to address specific
public health issues or
populations
REQUIRED
DOCUMENTATION
1. Collaborative
partnerships with
others to address
public health issues
GUIDANCE
1. The health department must document a current, ongoing
comprehensive community partnership or coalition in which
it is an active member. The purpose of the partnership or coalition
must be to improve the health of the community and, therefore, must
be engaged in various issues and initiatives.
A comprehensive community partnership, in this context, is a
partnership that is not topic or issue specific. It is a community
partnership that addresses a wide range of community health issues.
The comprehensive partnership or coalition may be organized into
several committees or task forces to address specific issues, for
example, teenage pregnancy, social determinants of health, health
equity, or increased opportunities for physical activities. This partnership
or coalition may be the same group that developed the community
health assessment and community health improvement plan.
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DATED
WITHIN
1 broad community
partnership
or coalition
addressing at least
4 health issues; or
4 examples of issue
specific partnership
or coalitions; or a
mix of a partnership
addressing 1 to 4
issues and single
issue partnerships
addressing the
remaining number,
for a total of four
issues.
2 years
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NUMBER OF
EXAMPLES
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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MEASURE 4.1.1 A, continued
This partnership or coalition may work on various issues addressed in the Standards
and Measure, such as access to care (Domain 7).
Alternatively, the health departments must document their involvement in several
current ongoing partnerships or coalitions that address specific public health issues.
In this case, each collaboration must address a particular public health issue or
population. Examples of collaborative partnerships 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, integrated chronic disease prevention coalition,
and a partnership to decrease childhood obesity. Partnerships addressing issues that
impact on health, for example, housing, transportation, or parks and recreation are
acceptable.
Tribal public health departments may partner with other Tribal or local partners,
for example, Head Start, emergency management, and social services to address
specific Tribal health issues.
These partnerships and coalitions, whether a broad multi-issue partnership or a
group of single issue partnerships or coalitions, may address an already established
program area; newly identified issues; issues identified by the health assessment;
strategies or actions included in a health improvement plan; a potential public
health threat or hazard; populations with particular health needs; and/or goals of the
community, health department, community, region, or state. They may address broad
public health issues, for example, health equity or access to community resources.
The partnerships or coalitions may also address issues that impact health, for
example, smart growth and the built environment, education and training, employment
rates, or transportation.
These partnerships or coalitions 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, active partnerships and not partnerships
that have completed their tasks and disbanded. Partnerships must include
representation of the community impacted.
Documentation could be a summary or report of the partnership(s) or coalition(s),
indicating on-going activities; meeting minutes and agendas: progress reports;
evaluations, etc.
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DOMAIN 6
DOMAIN 7
DOMAIN 8
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MEASURE 4.1.1 A, continued
118
2. Partner
organizations or
representation
2. The health department must provide a list of the participating partner
organizations for the partnerships(s) or coalitions referenced above.
Organizational and representational membership must be listed; individuals’
names are not required. For example, names of: the hospitals; school systems; and
specific businesses, social service organizations, not-for-profit organizations, faith
institutions, private citizen groups, or particular population groups. The membership
must be broad and include various sectors of the community. Community members
must be included.
1
membership
list of the
broad
community
partnership
or coalition;
or lists of
members
of the 4
examples
provided
above in
4.1.1 RD 1
2 years
3. Community,
policy, or
program
change
implemented
through the
partnership(s)
or coalition(s)
3. The health department must document a change in the community, a
change in policy, or a new or revised program that was implemented
through the work of the partnership(s) or coalition(s) identified in
Required Documentation 1, above.
2 examples
5 years
Examples could be an increase in the number and types of locations where tobacco
use is not permitted, an increase in the number of miles of bike paths, a local zoning
change, the removal of soda vending machines from public schools, an increase in
the frequency of restaurant inspections, an increase in the number of community
police stations, policies that address social determinants of health, etc.
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 11
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STANDARD 4.1: Engage with the public health system and the community in
MEASURE
PURPOSE
SIGNIFICANCE
Measure 4.1.2 S
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
methods 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.
Technical assistance
provided to Tribal and
local health departments
and/or public health
system partners regarding
methods for engaging with
the community
REQUIRED
DOCUMENTATION
1. The provisions
of consultation,
technical
assistance, and/
or information
concerning the
use of models
of community
organizing or
methods of
community
engagement
provided to Tribal
and local health
departments and/or
public health system
partners
119
identifying and addressing health problems through
collaborative processes.
GUIDANCE
1. The state health department must document the provision of
consultation, technical assistance, and/or information to Tribal
and local health departments or to public health system partners
on use of methods 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.
Established methods of community engagement include but are not
limited to: Healthy Cities/Communities methods; Asset Based Community
Development; and deliberative processes, for example, regular town
forums, community advisory groups, and participatory decision processes.
Tools include the National Public Health Performance Standards Program
(NPHPSP), asset mapping, community indicator projects, and Mobilizing
for Action Through Planning and Partnership (MAPP). Other community
organizing models and methods are acceptable.
Documentation could be, for example, emails, newsletters, meeting minutes,
web based assistance, agenda of meetings, documented phone calls,
presentations, and training sessions.
PUBLIC HEALTH ACCREDITATION BOARD
DATED
WITHIN
2 examples
5 years
If the state has
a Tribal health
department
located in its
jurisdiction, one
of the examples
must be related
to a Tribal health
department.
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NUMBER OF
EXAMPLES
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
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DOMAIN 11
DOMAIN 12
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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.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 4.1.2 T/L
The purpose of this measure is to assess
the Tribal or local health department’s
provision of sources of information about
principles, processes, and methods 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 methods for engaging
with the community.
Stakeholders and partners
linked to technical
assistance regarding
methods of engaging with
the community
REQUIRED
DOCUMENTATION
1. The provision
of consultation,
technical
assistance, or
information
concerning methods
of community
engagement
GUIDANCE
1. Tribal health departments and local health departments must
document that consultation, technical assistance, or information
is provided to community partners or stakeholders concerning
methods for collaborative community engagement.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Tribal health departments may provide supporting documentation that they
forward technical assistance requests to the state or a federal agency, for
example, 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.
Established methods of community engagement include but are not
limited to: Healthy Cities/Communities methods; Asset Based Community
Development; Mobilizing Action Toward Community Health (MATCH),
and deliberative processes for example, regular town forums, community
advisory groups, and participatory decision processes. Tools include asset
mapping, community indicator projects, and Mobilizing for Action Through
Planning and Partnership (MAPP).
Documentation could be, for example, 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.
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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 11
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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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DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
DOMAIN 12
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STANDARD 4.2: Promote the community’s understanding of and support for
MEASURE
PURPOSE
SIGNIFICANCE
Measure 4.2.1 A
The purpose of this measure is to assess
the health department’s engagement 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,
discussed 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.
Engagement with the
community about policies
and/or strategies that
will promote the public’s
health
REQUIRED
DOCUMENTATION
1. Engagement of
members of the
specific community
or group that will
be affected by
a policy and/or
strategy to promote
the public’s health
122
policies and strategies that will improve the public’s health.
GUIDANCE
1. The health department must document engagement with the
specific population in the community 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 it can target a specific group
that will be most affected by a policy or strategy. Listening sessions, open
forums, and other methods of dialogue can be used to develop engagement
and community ownership.
DATED
WITHIN
2 examples
from different
policy areas
2 years
Documentation could be, for example, an announcement or minutes of a
town meeting or public hearing, or a call for review and input posted through
groups’ customary communication channels such as newspapers and
newsletters. Other examples include meetings with a particular geographic
community served by the health department or a particular group of people,
for example, adolescents, single mothers, or seniors.
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NUMBER OF
EXAMPLES
DOMAIN 5
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
VERSION 1.5 APPROVED DECEMBER 2013
DOMAIN 10
DOMAIN 11
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STANDARD 4.2: Promote the community’s understanding of and support for
MEASURE
PURPOSE
SIGNIFICANCE
Measure 4.2.2 A
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 decision-making process.
Engagement with
governing entities,
advisory boards, and
elected officials about
policies and/or strategies
that will promote the
public’s health
REQUIRED
DOCUMENTATION
1. Engagement with
the governing
entity, advisory
boards, and/or
elected officials
about policies and/
or strategies that
will promote the
public’s health
123
policies and strategies that will improve the public’s health.
GUIDANCE
1. The health department must document that it communicates and
collaborates with the governing entity, an advisory board, and/or
elected officials concerning public health policy or strategy.
Documentation could be, for example, a copy of a presentation, meeting
packet, meeting agenda, meeting minutes, press story, event summary,
briefing paper, or written public comments.
DATED
WITHIN
2 examples;
examples must
address two
separate public
health issues
2 years
Tribal documentation could be, for example, 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
DOMAIN 6
DOMAIN 7
DOMAIN 8
DOMAIN 9
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DOMAIN 11
DOMAIN 12
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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 to
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. The development of policies and plans can be a vehicle for community engagement and shared
responsibility for addressing population health improvement.
Policies and plans that are not public health specific may also impact the public’s health, for example, zoning, transportation, and education. 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 access to sound, science-based, current public health information when policies are being considered or adopted.
DOMAIN 5 INCLUDES FOUR STANDARDS:
124
Standard 5.1:
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, evidencebased interventions, and promising practices that are required to develop sound public health policies,
practices, and capacities. Health departments also have access to community and population data and
information that provide knowledge concerning the potential or current impact of policies, practices,
and capacities. For these reasons, health departments should play a central and active role in the
establishment of policies and practices, whenever governing entities, elected officials, governmental
departments, and others set policies and practices that have 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
PURPOSE
SIGNIFICANCE
Measure 5.1.1 A
The purpose of this measure is to assess the
health department’s ability to maintain knowledge
about what policies are being considered in
order to ensure that the health department is in
a position to influence the development of those
policies and their impact on public health.
An important role for health departments is influencing the
adoption of effective public health policies and practices by
being a resource for science-based public health information.
Health departments need to be constantly aware of what
issues are being discussed by those who set policies and
practices so that they can exert influence.
The monitoring and
tracking of public health
issues that are being
discussed by individuals
and entities that set
policies and practices that
impact on public health
REQUIRED
DOCUMENTATION
1. Monitoring/tracking
of policies under
consideration by the
governing entity,
elected officials,
government
officials, and/
or other entities
that set policies
and practices that
impact public health
GUIDANCE
1. The health department must document that the department stays
informed of the public issues that are being discussed by the health
department’s governing entity, and by elected officials, individuals,
and/or other entities that set policies and practices that impact on
the health department or public health.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
2 years
Local elected officials include county (for example, county manager, board
of commissioners, or supervisors) or city officials (for example, mayor, city
council, board of commissioners, or supervisors). State elected officials
include the governor, council of state, or state legislators. Tribal elected or
appointed officials vary depending on the Tribal Nation’s governance. Some
examples include: Principal Chief, Chief, President, Chairman/woman/person,
Governor, Tribal Council Member, or Health Oversight Committees.
Government officials include elected or appointed positions or other staff of
government departments (e.g., education, labor, insurance, etc.).
Policies being discussed could be Tribal. State, or local policies.
Documentation could be, for example, meeting minutes and agendas; a log
of legislation impacting on health and environmental public health; health
department membership on a list-serve that discusses public health issues;
or newsletters, reports, or summaries showing health department review and
tracking of issues discussed by elected officials or governing entities.
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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
PURPOSE
SIGNIFICANCE
Measure 5.1.2 A
The purpose of this measure is to assess the
Tribal, state, or local health department’s efforts
to contribute to and influence the development
and/or modification of Tribal, state, or local
policies that impact public health.
To ensure that public health policies and practices are
effective, health departments must be actively engaged in
the development and/or modification of policies. The health
department can provide policy makers with sound, sciencebased, current public health information that should be
considered in setting policies and practice.
Engagement in activities
that contribute to the
development and/or
modification of policy that
impacts public health
REQUIRED
DOCUMENTATION
1. Contribution to
deliberations
concerning
public policy
GUIDANCE
1. The health department must document that it has contributed to
deliberations concerning public policy and practice and its impact
on public health. 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 related policy.
The two examples must address two different items of the items listed below:
• Informational materials, for example, issue briefs, media statements, talking
points, fact sheets, white papers, and other official written documents.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
2 years
Each example
must address
one item
listed in the
guidance. The
two examples
must address
different items.
• 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 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.
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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
PURPOSE
SIGNIFICANCE
Measure 5.1.3 A
The purpose of this measure is to assess the
health department’s provision of 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.
Informed governing
entities, elected officials,
and/or the public of
potential intended or
unintended public health
impacts from current and/
or proposed policies
REQUIRED
DOCUMENTATION
1. Information
provided to
policy makers
and/or the public
about potential
public health
impacts of
policies that are
being considered
or are in place
GUIDANCE
1. The health department must document that it has informed policy
makers and/or 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 sectors, for
example, land use, housing, employment, transportation, and education.
The health department may address both intended and unintended impact.
Documentation can address policies either in effect or proposed.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
2 years
Examples
must address
different items
listed in the
Guidance.
Each example must address one of the items listed below must be addressed:
• 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.
• 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 follow- up 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.
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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 community, stakeholders, and partners can use a solid community health improvement plan to set
priorities, direct the use of resources, and develop and implement projects, programs, and policies.
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 community stakeholders and
partners. The planning and implementation process is community-driven. The plan reflects the results of
a collaborative planning process that includes significant involvement by a variety of community sectors.
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
PURPOSE
SIGNIFICANCE
Measure 5.2.1 S
The purpose of this measure
is to assess the state health
department’s collaborative
community health improvement
planning 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.
Other sectors of the state and stakeholders have access to additional data
and bring different perspectives that will enhance planning. A collaborative
planning process fosters shared 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.
A process to develop
a state health
improvement plan
REQUIRED
DOCUMENTATION
1. State health
improvement
planning process
that included:
GUIDANCE
1. The state health department must document the collaborative state
health improvement planning process. The process may be a national
model; state-based model; a model from the public, private, or business sector;
or other participatory process model. When a specific model is not used, the
key steps undertaken that outline the process used should be described.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 process
5 years
National models include, for example, State Health Improvement Plan
(SHIP) Guidance and Resources (http://www.astho.org/accreditation/SHIP/),
Mobilizing for Action through Planning and Partnerships (MAPP) (developed
for local health departments but can be used in state health departments),
Association for Community Health Improvement (ACHI) Assessment Toolkit,
Assessing and Addressing Community Health Needs (Catholic Hospital
Association of the US) (http://www.chausa.org/docs/default-source/generalfiles/cb_assessingaddressing-pdf.pdf?sfvrsn=4), and the University of Kansas
Community Toolbox (http://ctb.ku.edu/en/node/9).
Examples of tools or resources that can be adapted or used include
Community Indicators process project, Asset Based Community Development
model, National Public Health Performance Standards Program (NPHPSP),
Assessment Protocol for Excellence in Public Health (APEX/PH), Guide to
Community Preventive Services, and Healthy People 2020.
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The state health department must document that the state health improvement
planning process included all of the following:
a. Broad participation
of community
partners
a. Participation by a wide range of community partners representing
various sectors of the community. Partners are organizations that work
with the state health department on health issues and could include
other governmental agencies, statewide not-for-profit groups, statewide
associations, veterinarian organizations, and others, including organizations
that are not health-specific, for example, education advocates, businesses,
recreation organizations, faith-based organizations, etc. Members of this
group may or may not be the same as members of the community health
assessment partnership.
Documentation could be, for example, participant lists, attendance rosters,
minutes, or membership lists of work groups or subcommittees.
131
b. Information from
community health
assessments
b. Data and information from the community health assessment provided
to participants in the state health improvement planning process to use
in their deliberations. This may include a list of data sets or evidence that
participants used for the community health assessment.
c. Issues and themes
identified by
stakeholders in the
community
c. Evidence that stakeholder discussions were held and that they identified
issues and themes. The list of issues must be provided as documentation.
d. Identification of
assets and resource
d. Assets and resources identified and considered in the state health
improvement planning process. Community assets and resources could be
anything that the state could utilize to improve the health of the community.
Community assets and resources could include, for example, skills of
residents, the power of state associations (e.g., service associations,
professional associations) and institutions (e.g., faith based organizations,
foundations, institutions of higher learning), as well as other state factors for
example, state recreational facilities, social capital, community resilience, a
strong business community, etc. Assets and resources can be documented
in a list, chart, narrative description, etc.
e. A process to set
health priorities
e. A description of the process used by participants to develop a set of priority
state health issues
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Standard 5.2: Conduct a comprehensive planning process resulting in a
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.1 L
The purpose of this measure
is to assess the local health
department’s collaborative
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 shared 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.
A process to develop
a community health
improvement plan
REQUIRED
DOCUMENTATION
1. Community
health
improvement
planning process
that included:
132
Tribal/state/community health improvement plan.
GUIDANCE
1. The local health department must document the collaborative
community health improvement planning process. The process used may
be an accepted national model; state-based model; a model from the public,
private, or business sector; or other participatory process model. When a specific
model is not used, the key steps undertaken that outline the process used
should be described.
National models include, for example, Mobilizing for Action through Planning
and Partnerships (MAPP), Association for Community Health Improvement
(ACHI) Assessment Toolkit, Assessing and Addressing Community Health
Needs (Catholic Hospital Association of the US) (http://www.chausa.org/docs/
default-source/general-files/cb_assessingaddressing-pdf.pdf?sfvrsn=4), and the
University of Kansas Community Toolbox (http://ctb.ku.edu/en/node/9).
Examples of tools or resources that can be adapted or used include NACCHO’s
Resource Center for Community Health Assessments and Community Health
Improvement Plans, Community Indicators process project, Asset Based
Community Development model, National Public Health Performance Standards
Program (NPHPSP), Assessment Protocol for Excellence in Public Health
(APEX/PH), Guide to Community Preventive Services, and Healthy People 2020.
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EXAMPLES
DATED
WITHIN
1 process
5 years
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MEASURE 5.2.1 L, continued
a. Broad participation
of community
partners
The local health department must document that the community health improvement
planning process included all of the following:
a. Participation by a wide range of community partners representing various sectors
of the community. Community partners could include, as appropriate for the
specific community: hospitals and healthcare providers, the faith community,
veterinarians, military installations, academic institutions, local schools, other
departments of government (e.g., parks and recreation, planning and zoning,
housing and community development, etc.), economic development, community
not-for-profits, civic groups, elected officials, the chamber of commerce and
local businesses, police, housing, foundations and philanthropists, planning
organizations, and the state health department. Members of this group may or may
not be the same as members of the community health assessment partnership.
Documentation could be, for example, participant lists, attendance rosters, minutes,
or membership lists for work groups or subcommittees.
b. Information from
community health
assessments
b. Data and information from the community health assessment 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. Issues and themes
identified by
stakeholders in the
community
c. Evidence that community and stakeholder discussions were held and that they
identified issues and themes. Community members’ definition of health and of a
healthy community must be included. The list of issues identified by the community
and stakeholders must be provided as documentation.
d. Identification of
community assets
and resources
d. Community assets and resources identified and considered in the community
health improvement process. Community assets and resources could be anything
in the community that could be utilized to improve the health of the community.
Community assets and resources could include, for example, skills of residents, the
power of local associations (e.g., service associations, professional associations)
and local institutions (e.g., faith based organizations, local foundations, institutions
of higher learning), as well as other community factors for example, parks, social
capital, community resilience, a strong business community, etc.
e. A process to set
health priorities
133
Community assets and resources can be documented in a list, chart, narrative
description, etc.
e. A description of the process used by participants to develop a set of priority state
health issues.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
Tribal/state/community health improvement plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.1 T
The purpose of this measure
is to assess the Tribal health
department’s collaborative
community health improvement
planning 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 shared 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.
A process to develop a
Tribal community health
improvement plan
REQUIRED
DOCUMENTATION
GUIDANCE
1. Tribal community
health
improvement
planning process
that included:
1. The Tribal health department must document the collaborative community
health improvement process. The process used may be an accepted national
model; state-based model; a model from the public, private, or business sector; or
other participatory process model. When a specific model is not used, the key steps
undertaken that outline the process used should be described.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 process
5 years
National models include, for example, Mobilizing for Action through Planning and
Partnerships (MAPP) (developed for local health departments but can be used in
Tribal health departments), Association for Community Health Improvement (ACHI)
Assessment Toolkit, Assessing and Addressing Community Health Needs (Catholic
Hospital Association of the US) (http://www.chausa.org/docs/default-source/generalfiles/cb_assessingaddressing-pdf.pdf?sfvrsn=4), and the University of Kansas
Community Toolbox (http://ctb.ku.edu/en/node/9).
Examples of tools or resources that can be adapted or used as part of the
community health improvement planning process include NACCHO’s Resource
Center for Community Health Assessments and Community Health Improvement
Plans, Community Indicators process project, Asset Based Community Development
model, Tribal Accreditation Readiness Guidebook and Roadmap, Inter Tribal Council
of Arizona’s Tribal CHA Toolkit, National Public Health Performance Standards
Program (NPHPSP), Assessment Protocol for Excellence in Public Health (APEX/
PH), Guide to Community Preventive Services, and Healthy People 2020.
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MEASURE 5.2.1 T, continued
a. Broad participation
of public health
system partners
The Tribal health department must document that the Tribal health improvement
planning process included all of the following:
a. Participation by a wide range of community partners. Community partners could
include, for example, organizations that work with the Tribal health department
to address health issues and may include other governmental agencies, not-forprofit groups, associations, and others, including organizations that are not healthspecific, for example, education advocates, businesses, recreation organizations,
faith-based organizations, veterinarians, military installations, etc. Members of
this group may or may not be the same as members of the community health
assessment partnership.
Documentation could be, for example, participant lists, attendance rosters, minutes,
or membership lists of work groups or subcommittees.
b. Information from
Tribal health
assessments
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.
Documentation may include a list of data sets or evidence that participants used
the community health assessment.
c. Issues and themes
identified by the
stakeholders
c. Evidence that stakeholder discussions were held and that they identified issues
and themes. Community members’ definition of health and healthy community must
be included. The list of issues must be provided as documentation.
d. Identification of
Tribal assets and
resources
d. Assets and resources identified and considered in Tribal community health
improvement planning process. Tribal community assets and resources could
be anything in the community that could be utilized to improve the health of the
community. Community assets and resources could include skills of residents,
the power of community groups (e.g., council of elders, youth councils, health
promotion coalitions of Tribal program) and local community partners (e.g., faith
based organizations, schools, institutions of higher learning), as well as recreation
centers, cultural celebrations and activities, other community factors for example,
parks, social capital, community resilience, etc.
e. A process to set
Tribal health priorities
135
Community assets and resources can be documented in a list, chart, narrative
description, etc.
e. A description of the process used by participants to develop a set of priority
Tribal health issues.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
Tribal/state/community health improvement plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.2 S
The purpose of this measure is to assess
the state health department’s 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 and across the state.
The state 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 collaborative planning process that includes
significant involvement by key sectors. Partners can use a state health
improvement plan to prioritize existing activities and set new priorities.
The plan can serve as the basis for taking collective action and can
facilitate collaborations.
State health
improvement plan
adopted as a result of
the health improvement
planning process
REQUIRED
DOCUMENTATION
1. State health
improvement
plan that
includes:
a. Desired measurable
outcomes or
indicators of health
improvement and
priorities for action
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The state health department must provide a state health improvement
plan that includes all of the following:
1 completed
plan
5 years
a. The desired measurable outcomes or indicators of the health improvement effort
and the priorities for action, from the perspective of the population of the state. The
plan must include statewide health priorities, measurable objectives, improvement
strategies, and activities with time-framed targets that were determined in the
planning process. In establishing priorities, the plan must include consideration of
addressing social determinants of health, causes of higher health risks and poorer
health outcomes of specific populations, and health inequities.
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 may be evidence-based, practice-based, or promising practices or may
be innovative to meet the needs of the population. National state-of-the-art guidance
(for example, the National Prevention Strategy, Guide to Community Preventive
Services, and Healthy People 2020) should be referenced, as appropriate.
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137
b. Policy changes
needed to
accomplish health
objectives
b. Policy changes needed to accomplish the identified health objectives must be
included in the plan. Policy changes must include those that are adopted to
alleviate the identified causes of health inequity. Policy changes may address the
social and economic conditions that influence health equity including housing,
transportation, education, job availability, neighborhood safety, and zoning, for
example.
c. Individuals and
organizations that
have accepted
responsibility for
implementing
strategies
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. Consideration of
Tribal, local, and
national priorities
d. States must demonstrate that they considered both Tribal and local health
department health improvement priorities. Consideration of national priority
alignment could include using the National Prevention Strategy and Healthy
People 2020.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
Tribal/state/community health improvement plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.2 L
The purpose of this measure is to assess
the local health department’s 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 across
programs and across the community.
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 collaborative planning process that
includes significant involvement by key sectors. Partners can use a
community health improvement plan to prioritize existing activities and
set new priorities. The plan can serve as the basis for taking collective
action and can facilitate collaboration.
Community health
improvement plan
adopted as a result of
the community health
improvement planning
process
REQUIRED
DOCUMENTATION
1. Community health
improvement plan
that includes:
a. Desired measurable
outcomes or
indicators of health
improvement and
priorities for action
GUIDANCE
1. The local health department must provide a community health
improvement plan that includes all of the following:
NUMBER OF
EXAMPLES
DATED
WITHIN
1 plan
5 years
a. The desired measurable outcomes or indicators of the health improvement effort
and priorities for action, from the perspective of community members. The plan must
include community health priorities, measurable objectives, improvement strategies
and activities with time-framed targets that were determined in the community
planning process. In establishing priorities, the plan must include consideration of
addressing social determinants of health, causes of higher health risks and poorer
health outcomes of specific populations, and health inequities.
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 may be evidence-based, practice-based, or promising practices or may
be innovative to meet the needs of the community. National state-of-the-art guidance
(for example, the National Prevention Strategy, Guide to Community Preventive
Services, and Healthy People 2020) should be referenced, as appropriate.
138
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139
b. Policy changes
needed to
accomplish health
objectives
b. Policy changes needed to accomplish the identified health objectives must be
included in the plan. Policy changes must include those that are adopted to
alleviate the identified causes of health inequity. Policy changes may address
social and economic conditions that influence health equity including housing,
transportation, education, job availability, neighborhood safety, access to
recreational opportunities, and zoning, for example.
c. Individuals and
organizations that
have accepted
responsibility for
implementing
strategies
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, health care providers (community benefit), other local governmental
agencies, or other community organizations. For this measure, agreements do not
need to be formal, such as an MOA/MOU.
d. Consideration of
state and national
priorities
d. Local health departments must demonstrate that they considered both national
and state health improvement priorities where they have been established.
National priority alignment could include the National Prevention Strategy and
Healthy People 2020.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.2 T
The purpose of this measure is to assess the
Tribal health department’s 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 and throughout the
Tribal jurisdiction or service area.
The Tribal 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 collaborative planning process that includes
significant involvement by key sectors. Partners can use a health
improvement plan to prioritize existing activities and set new
priorities. The plan can serve as the basis for taking collective
action and can facilitate collaboration.
Tribal community health
improvement plan
adopted as a result of
the health improvement
planning process
REQUIRED
DOCUMENTATION
1. Tribal health
community
improvement plan
that includes:
a. Desired outcomes
of health
improvement and
priorities for action
140
Tribal/state/community health improvement plan.
GUIDANCE
1. The Tribal health department must provide a Tribal community health
improvement plan that includes all of the following:
DATED
WITHIN
1 plan
5 years
a. The desired measurable outcomes or indicators of the community health
improvement effort and priorities for action, from the perspective of the population
of the Tribe. The plan must include Tribal health priorities, measurable objectives,
improvement strategies, and activities with time-framed targets that were determined
in the planning process. In establishing priorities, the plan must include consideration
of addressing social determinants of health, causes of higher health risks and poorer
health outcomes of specific populations, and health inequities.
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 may be evidence-based, practice-based, promising practices, or may
be innovative to meet the needs of the Tribe’s population. Guidance (for example,
National Prevention Strategy, Guide to Community Preventive Services, and Healthy
People 2020) should be referenced, as appropriate.
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b. Policy changes
needed to
accomplish health
objectives
b. Policy changes needed to accomplish the identified health objectives must be
included in the plan. Policy changes must include those that are adopted to
alleviate the identified causes of health inequity. Policy changes may address the
social and economic conditions that influence health equity including housing,
transportation, education, job availability, neighborhood safety, access to
recreational activities, and zoning, for example.
c. Individuals and
organizations that
have accepted
responsibility for
implementing
strategies
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 governmental agencies, or other Tribal organizations. For
this measure, agreements do not need to be formal and do not require compacts,
contracts or an MOA/MOU.
d. Consideration of
local, state, and
national priorities
d. Tribes must demonstrate that they considered state, local and national health
improvement priorities. This could include the National Prevention Strategy and
Healthy People 2020.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.3 A
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 activities and resource allocation.
Elements and
strategies of the
health improvement
plan implemented in
partnership with others
REQUIRED
DOCUMENTATION
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Tribal/state/community health improvement plan.
GUIDANCE
1. A process to track
actions taken
to implement
strategies in the
community health
improvement plan
1. The health department must provide a tracking process of actions taken
toward the implementation of the community health improvement plan.
2. Implementation of
the plan
2. The health department must document areas of the plan that were
implemented by the health department and/or its partners. Examples
must identify a specific achievement and describe how it was accomplished.
The tracking process must specify the strategies being used, the responsible
partners involved, and the status of the effort or results of the actions taken.
DATED
WITHIN
1 report or
a group of
reports
5 years
2 examples
5 years
Documentation could be, for example, a narrative, table, spread sheet, or a
combination. This may look like a work plan that includes the status of the
implementation of the work plan.
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Standard 5.2: Conduct a comprehensive planning process resulting in a
Tribal/state/community health improvement plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.2.4 A
The purpose of this measure is to
assess the health department’s
efforts to ensure that the
strategies of the community health
improvement plan are assessed
for feasibility and effectiveness and
that they are revised as indicated by
those assessments.
Effective, community health improvement plans are dynamic. While goals,
objectives, and priorities are meant to be long range, strategies may
need to be adjusted. Strategies may need revision based on a completed
objective, an emerging health issue, a change in responsibilities, or a
change in resources and assets. All identified tasks and timelines, should
be monitored and assessed 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.
Monitor and revise as
needed, the strategies
in the community health
improvement plan
in collaboration with
broad participation from
stakeholders and partners
REQUIRED
DOCUMENTATION
1. Report on
progress made
in implementing
strategies in the
community health
improvement plan
GUIDANCE
1. The health department must provide an annual report on the
progress made in implementing strategies in the community health
improvement plan.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 example
14
months
1 example
14
months
The report will consider the feasibility and the effectiveness of the strategies and/
or changing priorities, resources, or community assets.
If the plan was adopted within the year, a report of a previous plan may be
provided or detailed plans for assessment and reporting may be submitted.
2. Review and
revision, as
necessary,
of the health
improvement plan
strategies based
on results of the
assessment
2. The health department must document that the health improvement plan
has been reviewed and revised as necessary based on the report required
in 1 above.
The revisions may be in the improvement strategies, planned activities, time-frames,
targets, or assigned responsibilities listed in the plan. Revisions may be based on,
for example, achieved activities, implemented strategies, changing health status
indicators, newly developing or identified health issues, and changing level of
resources.
143
If the plan was adopted less than a year before it was uploaded to PHAB, the health
department may provide (1) revisions of an earlier plan or (2) detailed plans for a
revision process.
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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; this standard addresses the health department’s
organizational strategic plan.
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Standard 5.3: Develop and implement a health department organizational
strategic plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.3.1 A
The purpose of this measure is to
assess the health department’s
strategic planning process.
A functional and useful organizational 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.
Department strategic
planning process
REQUIRED
DOCUMENTATION
1. Use a planning
process to
develop the
organization’s
strategic plan:
a. Membership of the
strategic planning
group
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
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 consultant.
1 strategic
planning
process
5 years
If the health department is part of a super health agency or umbrella agency (see
PHAB Acronyms and Glossary of Terms), the health 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 must include various levels of staff as
well as representatives of the health department’s governing entity.
Documentation could be, for example, meeting minutes, a report that presents the
members of a strategic planning committee, or other formal listing of participants.
b. Strategic planning
process steps
145
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, for example, opportunities and threats
analysis or environmental scanning process, stakeholder analysis, story-boarding,
strengths and weaknesses analysis, and scenario development.
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Standard 5.3: Develop and implement a health department organizational
strategic plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.3.2 A
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.
Adopted department
strategic plan
REQUIRED
DOCUMENTATION
1. Health
department
strategic plan
that includes:
GUIDANCE
1. The health department must provide a strategic plan.
If the health department is part of a super health agency or umbrella agency (see
PHAB Acronyms and Glossary of Terms), 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 document that it has conducted an internal health department
planning process and adopted a health department specific strategic plan.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 strategic
plan
5 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.
There is no required or suggested format for the strategic plan. There is no required
or suggested length of the strategic plan.
The health department may call the plan something other than a “strategic plan,”
but it must include the items listed in a through g.
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The strategic plan must include all of the following:
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a. Mission, vision,
guiding principles/
values
a. The health department’s mission, vision, and guiding principles/values for the
health department.
b. Strategic priorities
b. The health department’s strategic priorities.
c. Goals and objectives
with measurable and
time-framed targets
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. Consideration
of key support
functions required
for efficiency and
effectiveness
d. The strategic plan must consider capacity for and enhancement of information
management, workforce development, communication (including branding), and
financial sustainability.
e. Identification of
external trends,
events, or factors
that may impact
community health
or the health
department
e. The identification of external trends, events, or other factors that may impact
community health or the health department.
f. Assessment of
health department
strengths and
weaknesses
f. The analysis of the department’s strengths and challenges.
g. Link to the health
improvement
plan and quality
improvement plan
g. Linkages with the health improvement plan and 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
PURPOSE
SIGNIFICANCE
Measure 5.3.3 A
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.
Implemented department
strategic plan
REQUIRED
DOCUMENTATION
1. Progress towards
achievement of the
goals and objectives
contained in the
plan
GUIDANCE
1. The health department must provide reports developed since the
plan’s adoption showing that it has reviewed the strategic plan and
has monitored and 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. Reports must be completed no
less frequently than annually. The plan may be revised based on work completed,
adjustments to timelines, or changes in available resources.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 reports
1 report
dated
within 14
months;
second
report may
be older
If the plan has been adopted within the year, progress reports of a previous plan
may be provided or detailed evaluation plans may be submitted.
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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 terrorism, chemical terrorism, radiological/nuclear terrorism, or bombings). Plans
for responding to emergencies are critical to being prepared for effective public health action during
disasters and similar emergency events and for building community resilience over time.
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Standard 5.4: Maintain an all hazards emergency operations plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.4.1 A
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,
managing the many response and recovery activities, and building
community resilience.
Process for the
development and
maintenance of an All
Hazards Emergency
Operations Plan (EOP)
REQUIRED
DOCUMENTATION
GUIDANCE
1. Collaborative
planning with
other government
agencies
1. The health department must document that it participates in
preparedness meetings with other government agencies and other
levels of health departments (Tribal, state, and local).
2. Collaborative testing
of the All Hazards
EOP:
2. The health department must document that it participates in drills,
exercises, or actual implementation of the All Hazards Emergency
Operations Plan in order to test its implementation.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
2 examples
5 years
Documentation could be, for example, meeting agenda and minutes, meeting
rosters, calendar of meetings, email exchanges, and phone calls, as shown on a
log or other record.
a. Description of a
real emergency or
exercise
a. The documentation may 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 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. Debriefing or AfterAction Report (AAR)
b. Documentation must include debriefing or evaluation reports from the
emergency or drill/exercise.
Examples could be an evaluation report, minutes from a debriefing session, or
the AAR produced by the health department or a partner health department.
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3. Collaborative
revision of the All
Hazards EOP that
includes:
a. A collaborative
review meeting
3. The health department must document collaboration in revising
emergency plans including:
Documentation could be, for example, meeting agendas and minutes or
attendance rosters or other written report or record.
b. Updated contact
information
b. A contact list of responders.
c. Coordination
with emergency
response partners
c. 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. Revised All
Hazards/EOP
d. A copy of the revised emergency operations plan 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. Updates must be indicated in some way (e.g.,
underlined) and the date of the change must be noted.
Documentation could be the most current contact list or previous listings that
have been updated.
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5 years
a. A collaborative review of the All Hazards Emergency Operations Plan by
those responsible for its implementation.
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1 example
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Standard 5.4: Maintain an all hazards emergency operations plan.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.4.2 A
The purpose of this
measure is to assess
the health department’s
development and
maintenance of the
emergency operations
plan.
An emergency operations plan outlines core roles and responsibilities for all-hazard
responses, as well as plans for scenario- specific events, such as hurricanes. Health
departments must engage in basic activities to prepare for 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
to work with the community in an emergency for the community’s sustained ability to
withstand and recover from an emergency event.
Public health emergency
operations plan (EOP)
REQUIRED
DOCUMENTATION
1. EOP, as defined
by Tribal, state, or
national guidelines
that includes:
GUIDANCE
1. The health department must provide 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 local health departments
by the state health department or may be defined for both state and locals by a
Federal or another state agency, such as an office of emergency management.
Project Public Health Ready (PPHR) is a national model that could be
used. Tribes may use guidelines that are most appropriate for their unique
emergency management needs.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 EOP
5 years
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.
The plan must address emergency operations for the entire population
(including special needs and vulnerable populations, e.g., those with
disabilities and non-English speaking people).
The public health EOP must include all of the following:
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a. Designation of the
health department
staff position
that is assigned
the emergency
operations
coordinator
responsibilities
a. The health department staff position responsible for coordinating a response
within the department in an emergency. This position may have various job titles.
b. Roles and
responsibilities
of the health
department and its
partners
b. The roles and responsibilities of the health department and its partners.
c. Communication
networks or
communication plan
c. A health department communication network that addresses communication
with other members of emergency networks or organizations that are also
responders; or an emergency communication plan.
The 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. Continuity of
operations
2. Testing of the public
health EOP, through
the use of drills and
exercises
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d. Description of how the health department will manage continuity of operations
during an emergency.
a. Process for
exercising and
evaluating the public
health EOP
a. A description of the process for testing and evaluating the Emergency
Operations Plan.
b. After-Action Report
(AAR)
b. An After-Action Report (AAR) developed after an emergency or exercise/drill.
5 years
Documentation could be, for example, a written procedure, a memo stating the
process, meeting minutes that document the procedure, or other written report
or record.
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2 examples
2. The health department must document that the plan has been
reviewed or tested through the use of exercises and drills, and
revised as needed and must include:
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3. Revision of the
public health EOP
including:
a. A review meeting
b. Revised public
health EOP, as
needed
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3. The health department must document that the public health
emergency operations plan has been revised as indicated by review
of the AAR.
2 years
a. Documentation of a review meeting.
Documentation could be, for example, meeting minutes, a list of items
discussed, a memo documenting review and decisions, or other written
report or record.
b. A public health EOP that has been revised as indicated through review,
evaluation, and/or drills.
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MEASURE
PURPOSE
SIGNIFICANCE
Measure 5.4.3 S
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.
Consultation and/or
technical assistance
provided to Tribal and local
health departments in the
state regarding evidencebased and/or promising
practices/templates in EOP
development and testing
REQUIRED
DOCUMENTATION
1. The provision of
consultation and/or
technical assistance
GUIDANCE
1. The state health department must document the provision of expert
consultation, advice, and /or information provided to Tribal or local
health departments concerning the development and testing of
emergency operations plans.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Documentation could be, for example, 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, wastewater disposal, and animal and vector control), infectious disease (outbreak investigation, required newborn screenings, immunizations, infectious
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.
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Domain 6: Enforce Public Health Laws
DOMAIN 6 INCLUDES THREE STANDARDS:
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Standard 6.1:
Review Existing Laws and Work with Governing Entities and Elected/Appointed Officials to
Update as Needed
Standard 6.2:
Educate Individuals and Organizations on the Meaning, Purpose, and Benefit of Public Health
Laws and How to Comply
Standard 6.3:
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 need to be revised to also 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 recommended 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
PURPOSE
SIGNIFICANCE
Measure 6.1.1 A
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, impact on systemic health
inequities, and regulatory alternatives and
sanctions, in addition to the public health
program benefits of the law.
Health departments need to be aware of current public health laws
and of laws that are not specific to public health but have public health
implications, for example, zoning, recreation related, animal related, or
transportation laws. These types of laws can have significant impact on
health equity. The laws that the health department reviews need not be
only laws that the health department enforces. They may also be laws
that others enforce but that impact public health, for example, helmet
use laws, school nutrition requirements, sale of tobacco products to
minors, animal rabies vaccination laws, or school requirements for
proof of childhood vaccinations. Program staff of the health department
reviews these laws to ensure that they are consistent with evidencebased public health practices and emerging public health issues.
Laws reviewed in order
to determine the need for
revisions
REQUIRED
DOCUMENTATION
1. Reviews of public
health laws or
laws with public
health implications
that include the
following:
GUIDANCE
1. The health department must document its evaluation of laws for their
public health implications.
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. This is a program review and does not require
the review by a lawyer.
Documentation could be, for example, meeting minutes, reports, presentations,
memos, or some other record of the discussion of the review and findings. They
could also be in the form of policy agendas, position papers, white papers, and
legislative briefs, including recommendations for amendments.
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Health departments must document that the review of the law included:
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EXAMPLES
DATED
WITHIN
2 examples
that are
from
different
programs
Reviews
completed
within 3
years
1 example
must
demonstrate
collaboration
with other
levels of
health
departments
(Tribal, state,
and/or local)
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MEASURE 6.1.1 A, continued
a. Evaluations of laws
for consistency
with public health
evidence-based
and/or promising
practices; and
consideration of the
impact on health
equity
a. Consideration of evidence-based practices, promising practices, or practicebased evidence. The impact of the law on health equity in the health
department’s jurisdiction, if any, must also be considered.
b. Use of model
public health
laws, checklists,
templates, and/
or exercises in
reviewing law
b. The use of model public laws, check lists, templates, or some other standard
outline or guide. The standard outline or guide could be developed by the
health department or by others.
c. Input solicited from
key stakeholders
on proposed and/or
reviewed laws
c. Input from key partners and stakeholders. Input may be sought through, for
example, public notice, town forums, meetings, hearings, or request for input
on the health department’s web page.
d. Collaboration with
other levels of
health departments
when the laws
impact on them
d. Collaboration with other levels of government health departments.
Due to the limited availability of evidenced-based practices or promising
practices in Tribal communities, Tribes may provide examples of practicebased evidence used to adapt models or create models based on a cultural
framework or traditional forms of governance.
State health departments must document that it has collaborated with Tribal or
local health departments in reviewing laws that may impact those Tribal or local
health departments. This collaboration may involve state health departments
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.
Documentation of state collaboration could be minutes or summaries of
meetings held by the state with Tribal and/or local public health officials;
agenda, minutes, and any resulting documents from meetings with
stakeholders; summaries of comments from town meetings, hearings, or
comments received through a website.
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MEASURE 6.1.1 A, continued
Local health departments must document how they consult with Tribes when
reviewing laws that impact multiple jurisdictions, for example, disease reporting,
isolation and quarantine, and immunizations.
Tribal health departments must document work 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 could be, for example, reports of working with local Tribal
community stakeholders, for example, elected Tribal District Chairpersons,
elected Tribal council committees, Tribal Community Colleges, school districts,
and boards. Tribal health documentation may also include work completed with
Tribal Legislative Counsel or Tribal Elected/Appointed officials, for example,
District Chairpersons, Tribal Oversight Committees, and governing entities.
2. Access to legal
counsel
2. The health department must document that it has access to legal
counsel review and advice for use, as needed.
1 example
3 years
Documentation could be, for example, an MOU, a contract, a letter of
agreement, or statement that a governmental attorney’s office has the
responsibility to provide legal counsel to the health department.
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Standard 6.1: Review existing laws and work with governing entities and
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.1.2 A
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 an expert on the impact of 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, for example, helmet use laws, school
nutrition requirements, sale of tobacco products to minors, texting while driving
law, animal rabies vaccination laws, 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.
Information provided to
the governing entity and/
or elected/appointed
officials concerning
needed updates/
amendments to current
laws and/or proposed
new laws
REQUIRED
DOCUMENTATION
1. The provision
of written
recommendations
to governing entity
and/or elected/
appointed officials
concerning
amendments or
updates to current
laws and/or
proposed new laws
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elected/appointed officials to update as needed.
GUIDANCE
1. The health department must document that it has submitted written
reviews of current laws or proposals for new laws to the governing
entity and/or elected/appointed officials.
Documentation could be, for example, 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.
DATED
WITHIN
2 examples
5 years
The examples
can be, but
do not have
to be, related
to the two
examples
provided for
measure 6.1.1.
Documentation for Tribal health departments could be, for example, work
completed with Tribal Legislative Council or Tribal Elected/Appointed officials,
for example, District Chairpersons, Tribal Oversight Committees, and other
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. Education efforts need to be culturally and linguistically
appropriate to the audience.
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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
PURPOSE
SIGNIFICANCE
Measure 6.2.1 A
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.
Department knowledge
maintained and public
health laws applied in a
consistent manner
REQUIRED
DOCUMENTATION
NOTE:
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.
NUMBER OF
EXAMPLES
GUIDANCE
DATED
WITHIN
Public health law enforcement, for example, 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 must provide documentation of
how it maintains knowledge of the laws and their consistent application.
1. Provisions of
training for staff
in laws to support
public health
interventions and
practice
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, an infectious
disease nurse should be trained on the law that addresses infectious disease
reporting; he or she would not be required to know specific elements on public
water laws.
2 examples
2 years
Documentation could be, for example, training agendas, minutes of training
meetings, HR lists of personnel trained and the date of the training, or
screenshots of links to online training required for staff completion and
documentation that it was completed. Orientation for new staff is not sufficient.
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MEASURE 6.2.1 A, continued
2. Efforts to ensure
the consistent
application of
public health laws
2. The health department must document efforts to ensure the
consistent application of public health laws. Documentation may
be a review of either health department staff’s application of laws or other
organizations’ application of public health laws for which the health department
is not responsible for enforcement. Coordination with other organizations that
apply laws must be evidenced. Examples include enforcement of seat belt use,
environmental public health laws, sale of tobacco products to minors, clean
indoor air laws, quarantine laws, food safety, etc.
2 examples
5 years
Documentation could be, for example, 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,
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.2.2 A
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 the 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.
Laws and permit/
license application
requirements are
accessible to the public
REQUIRED
DOCUMENTATION
1. Public access to
information about
laws and permit/
license application
processes
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and benefit of public health laws and how to comply.
GUIDANCE
1. The health department must document how it makes information
concerning public health related laws and permits/license
applications available to members of the public who request it. This
information can be made available through the health department’s website
or provided to the public in a paper document (e.g., flyer, brochure, etc.). 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. Information will direct
the public to the appropriate agency, if the responsibility does not legally reside
with the health department.
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NUMBER OF
EXAMPLES
DATED
WITHIN
1 example
5 years
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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
PURPOSE
SIGNIFICANCE
Measure 6.2.3 A
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.
Information or education
provided to regulated entities
regarding their responsibilities
and methods to achieve full
compliance with public health
related laws
REQUIRED
DOCUMENTATION
1. Provision of
information or
education to regulated
entities concerning
their responsibilities
for compliance with
public health laws
GUIDANCE
1. The health department must provide a written record of the
provision of information to regulated individuals or entities about
their responsibilities related to public health laws. Documentation
must include both the information provided and evidence of its distribution.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 written
record
5 years
The information could be provided to a targeted group, such as public schools
that are responsible for, for example, 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, for example, 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 or
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
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.3.1 A
The purpose of this
measure is to assess
the health department’s
standard and consistent
enforcement actions.
Enforcement actions require 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.
Written procedures and
protocols for conducting
enforcement actions
REQUIRED
DOCUMENTATION
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coordinate notification of violations among appropriate agencies.
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. Authority
to conduct
enforcement
activities
1. The health department must document its authority to conduct
enforcement activities. 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
must 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.
2 examples
no date
restriction
2. Procedures
and protocols
for achieving
compliance
with laws or
enforcement
actions
2. The health department must provide copies of procedures, protocols
or processes (for example, decision trees) for enforcement program
areas.
2 examples;
one of the
examples
must address
infectious
disease.
2 years
Where the health department does not conduct public health enforcement
actions, the protocols used by the enforcement agency must be provided and
must demonstrate cooperation between the enforcement agency and the health
department.
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Standard 6.3: Conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.3.2 A
The purpose of this measure is to assess the
health department’s adherence to guidelines on
the frequency of inspection activities.
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.
Inspection activities
of regulated entities
conducted and monitored
according to mandated
frequency and/or a risk
analysis method that
guides the frequency and
scheduling of inspections of
regulated entities
REQUIRED
DOCUMENTATION
1. Protocol/algorithm
for scheduling
inspections of
regulated entities
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.
.
GUIDANCE
1. The health department must provide schedules for inspections. The
health department may select the areas or programs. The selected
schedules must be in programs where the health department has authority to
conduct an inspection of the regulated entity, unless the health department has
no such authority.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
from 2
different
programs
5 years
In some cases, schedules for inspections 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
2. Inspections that
meet defined
frequencies with
reports of actions,
status, follow-up,
re-inspections, and
final disposition
171
2. The health department must document a database or provide a log
of inspection reports with actions taken, current status, follow-up,
return inspections and final disposition.
Documentation could be screen shots, if the data are kept electronically.
In some cases, the health department may have little or no authority to conduct
enforcement actions. In those cases, the department must coordinate and
share 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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2 examples
5 years
This
documentation
of inspections
must relate
to the same
programs
for which
schedules
were provided
in 1 above.
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Standard 6.3: Conduct and monitor public health enforcement activities and
coordinate notification of violations among appropriate agencies.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.3.3 A
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, and
complaint follow-up should be conducted according to
standard procedures and protocols to ensure that they are
conducted appropriately.
Procedures and protocols
followed for both routine
and emergency situations
requiring enforcement
activities and complaint
follow-up
REQUIRED
DOCUMENTATION
GUIDANCE
1. Actions taken
in response to
complaints
1. The health department must document actions taken as a result of
investigations or follow-up of complaints, as well as analysis of the
situation and standards for follow-up.
Documentation could be, for example, a database or log with analysis and
standards for follow-up at each level. The standards for follow-up may be within
the procedure and protocols. 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 document hearings, meetings, or other
official communications with regulated entities regarding a complaint
and any resulting compliance plans. The compliance plan has no specific
format and will be determined by law or department protocol. The regulated
entity, based on the law, could be an organization, business, or individual.
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DATED
WITHIN
2 examples
from 2
different
programs
5 years
2 examples
5 years
In some cases, the health department may have little or no authority to conduct
enforcement actions. In those cases, the department must coordinate and
share 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
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.3.4 A
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 non- compliance, 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.
Patterns or trends identified
in compliance from
enforcement activities and
complaints
REQUIRED
DOCUMENTATION
1. Enforcement
programs’ annual
reports summarizing
complaints,
enforcement
activities, or
compliance
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coordinate notification of violations among appropriate agencies.
GUIDANCE
1. The health department must provide annual reports that
summarize complaints, enforcement activities, or compliance.
Reports must include patterns, trends, and compliance.
Documentation from an enforcement program that is out of compliance with
state law or is under sanctions or a performance improvement plan must be
labeled as being out of compliance with state law or under sanctions or a
performance improvement plan.
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EXAMPLES
DATED
WITHIN
2 examples
from different
enforcement
programs. If
the department
operates an
enforcement
program
that is out of
compliance with
state law or is
under sanctions
or a performance
improvement
plan, then one
of the examples
must be from
that program.
14 months
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2. Debriefings or
other evaluations
on enforcement
for process
improvements
2. The health department must document 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.
2 examples
5 years
In some cases, the health department may have little or no authority
to conduct enforcement actions. In those cases, the department must
coordinate and share 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
MEASURE
PURPOSE
SIGNIFICANCE
Measure 6.3.5 A
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 so that the public may make
decisions or alter their behavior, based on the information.
For example, many members of the public want to know what
local restaurants have failed inspection and why.
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.
It is important that the health department shares information
concerning enforcement actions and/or any resulting followup 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.
Coordinated notification
of violations to the
public, when required,
and coordinated sharing
of information among
appropriate agencies about
enforcement activities,
follow-up activities, and
trends or patterns
REQUIRED
DOCUMENTATION
175
coordinate notification of violations among appropriate agencies.
GUIDANCE
1. Communication
protocol for
interagency
notifications
1. The health department must provide a communication protocol
for interagency notifications.
2. Protocol for
notification of the
public of enforcement
activities
2. The health department must provide a protocol for notifying the
public of enforcement activities. 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,
provide a copy of the relevant protocol. Examples include notifications
of the public of restaurant inspection violations, emission violations, and
inspections of public facilities (for example, public swimming pools).
DATED
WITHIN
1 protocol
5 years
1 departmentwide protocol
or 2 examples
5 years
The protocol may be in parts to address multiple communication protocols
or it may be a single comprehensive protocol for notifying other agencies
concerning enforcement actions.
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MEASURE 6.3.5 A, continued
3. Notifications of
enforcement actions
and other sharing
of information
concerning
enforcement
activities
3. The health department must document the notification of
enforcement actions.
Required Documentation 1 and 2 requires written protocols. Required
Documentation 3 requires documentation of the implementation of a
protocol. Documentation must demonstrate that protocols were followed.
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.
2 examples are
required.
5 years
The two
examples
must be from
two different
enforcement
programs.
When other agencies have enforcement authority, 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
Domain 7 focuses on the population’s access to needed health care services. An important role of public health is the assessment of the population’s
access to health care services and the capacity of the health care system to meet the health care needs of the population. Public health also has a role
in efforts to increase access to needed health care services, particularly primary care. The focus of this Domain is not on health care or clinical services
that the health department may provide directly, though those services are part of the analysis of access to health care.
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
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STANDARD 7.1: Assess health care service capacity and access to
health care services.
Health departments should work with the health care system to (1) understand the availability of
health care services to the population, (2) identify populations who experience barriers to health care
services, and (3) identify gaps in access to health care and barriers to the receipt of care.
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Standard 7.1: Assess health care service capacity and access to health care services.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 7.1.1 A
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 needed health care
services.
Collaborative efforts are required 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
primary care and chronic disease management.
Process to assess the
availability of health care
services
Health care services, for access planning purposes, include:
clinical preventive services, emergency services, urgent
care, occupational medicine, ambulatory care (primary and
specialty), and dental treatment.
REQUIRED
DOCUMENTATION
1. A collaborative
process to assess
availability of health
care services
GUIDANCE
1. The health department must document its participation in a
collaborative process to assess the availability of health care
services to the population.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 collaborative
process
5 years
The collaborative process must include the involvement of the health
care system. Other partners may include, for example, representatives
of social service organizations, employers, health insurance companies,
communities of color, Tribes, low income workers, military installations,
correctional agencies, specific populations who may lack health care and/
or experience barriers to service (e.g., disabled, non-English speaking, or
otherwise disenfranchised residents), and other stakeholders.
For Tribal health departments it may include clinic and hospital
representatives, Indian Health Service, other Tribal programs and
departments, and individuals representing communities that experience
barriers to services (e.g., distance from service, transportation barriers).
Information on the partnerships developed to assess health care must
include rosters of coalition/network/council members.
Documentation could be, for example, charters or meeting agendas, or
meeting minutes.
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MEASURE 7.1.1 A, continued
2. The sharing of
comprehensive data
for the purposes
of assessing the
availability of health
care services and for
planning
3. Consideration of
emerging issues in
public health, the
health care system,
and health care
reimbursement
2. The health department must document the sharing of public
health Tribal, state, and/or local data for assessment and planning
purposes.
Sharing mechanisms can include regional health information organizations
(RHIOs) and health information exchanges (HIEs), or less formal data sharing
efforts, for example, MOUs or contracts.
Documentation could be examples of data sharing through reports, emails, etc.
3. The health department must document consideration of emerging
issues that may impact access to care. These might include changes
in the structure of the health care system; types and numbers of health care
professionals being trained; changes in reimbursement structure, rates, or
payment mechanisms such as accountable care organizations; developing care
models, for example, coordinated care organizations or convenient care clinics;
and electronic medical records.
2 examples
5 years
2 examples
5 years
Documentation could be, for example, meeting minutes, reports, or white
papers.
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Standard 7.1: Assess health care service capacity and access to health care services.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 7.1.2 A
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. Assessing capacity and access to health
care includes the identification of those who are not receiving services and understanding
the reasons that they are not receiving needed care or experiencing barriers to care. Barriers
may be experienced, for example by populations who are uninsured or under-insured, have
no transportation to health care, are non-English speaking, 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 the health care system or do not understand why certain routine
medical services or screenings are necessary for their health. The importance of access to
health care services includes, for example: pregnant women who use tobacco (who 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 (who are at risk for cancer).
Identification of
populations who
experience barriers to
health care services
identified
REQUIRED
DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. A process for the
identification of
un-served or underserved populations
1. The health department must document 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.
1 process
5 years
2. A report that
identifies
populations who
are un-served or
under-served
2. The health department must provide a report that identifies
populations who experience barriers to health care services.
Populations may be identified by a variety of characteristics, for example,
age (e.g., teenagers, elderly, etc.), ethnicity, geographic location, health
insurance status, educational level obtained, mental or physical disabilities,
discrimination (e.g., marriage inequality), or special health service needs
(women who are pregnant, individuals with diabetes, etc.).
1 report
5 years
This report could be a section of a larger report that includes other topic, a
separate report, or part of the community health improvement plan.
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Standard 7.1: Assess health care service capacity and access to health care services.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 7.1.3 A
The purpose of this measure
is to assess the health
department’s knowledge of
gaps in access and barriers to
health care services among the
population it serves.
It is important for health departments to understand the gaps in access to health
care and the barriers to care so that effective strategies can be put in place to
address the lack of access to health care. Barriers to health care services can
range from financial (e.g., lack of affordable services), health care system capacity
(e.g., lack of dental providers), cultural (e.g., lack of interpreters), geographic (e.g.,
lack of transportation), and lack of health insurance, among others. Shared data
among the members of the partnership can evidence an effort to capture and
understand all possible gaps that exist.
Identification of gaps in
access to health care
services and barriers to
the receipt of health care
services identified
REQUIRED
DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The process or
set of processes
used for the
identification
of service gaps
and barriers to
accessing health
care services
1. The health department must document the process used to identify
gaps in health care services and barriers to care. The documentation
must identify who was involved in the identification process. Processes
may include sector maps, analysis of hospital admissions or emergency
department data, analysis of health insurance data, or other tools.
1 process or
set processes
5 years
2. Reporting the
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, or barriers
to care.
2. The health department must provide reports of analysis of data
from various partnership sources that identify and describe gaps
in access and barriers to health care services. Reports must include
analysis of data and conclusions that can help develop effective strategies
to address gaps in access. At a minimum, data sources must 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:
2 examples
5 years
Reports must
include:
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a. Assessment of
capacity and
distribution
of health care
providers
a. Assessment of capacity and distribution of health care providers. These data
will show geographic gaps in the availability of health care providers.
b. Availability of health
care services
b. Assessment of the availability of health care services, for example,
clinical preventive services, EMS, emergency departments, urgent care,
occupational medicine, ambulatory care (primary and specialty), inpatient
care, chronic disease care (e.g., diabetic care, HIV health services), dental,
and other health care services. These data can be useful in seeking support
for a particular service.
c. Identification of
causes of gaps
in services and
barriers to receipt
of care
c. Assessment of cause(s) for lack of access to services and barriers to
access to care. Causes may include: a population that is uninsured/underinsured, 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
data gathered
periodically
concerning access
d. Results of data or information gathered concerning access, for example,
focus groups, studies of eligible groups receiving services, and other
assessment information, can provide perspectives from the population that
lacks access. These data collection efforts do not have to be administered
by the health department, but the results must be considered in the
assessment of gaps in access and barriers to care.
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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
PURPOSE
SIGNIFICANCE
Measure 7.2.1 A
The purpose of this measure is to assess
the health department’s collaborative
efforts 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 collaborative process, but it must have
participated in the process.
Process to develop
strategies to improve
access to health care
services
REQUIRED
DOCUMENTATION
1. A coalition/
network/
council working
collaboratively to
reduce barriers
to health care
access or gaps in
access
GUIDANCE
1. The health department must document its involvement in a collaborative
process for developing strategies to improve access to health care.
The example must demonstrate involvement of representatives of providers of
health care services, for example, hospitals, clinics, primary care physicians, etc.
Other partners may include, for example: community service providers, schools,
correctional agencies, migrant health, social service organizations, transportation
providers, military installations, and employers.
NUMBER OF
EXAMPLES
DATED
WITHIN
1
collaborative
process
5 years
The documentation must demonstrate that the group is actively working to identify
strategies.
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.
Documentation could be, for example, a charter for the group; membership rosters
or participant/attendance lists; meeting agendas and minutes; or workgroup reports,
work plans, and white papers.
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MEASURE 7.2.1 A, continued
2. Strategies
developed by
the coalition/
network/council
working through
a collaborative
process to
improve access
to health care
services
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2. The health department must provide strategies that the coalition/
network/council developed to improve access to health care services
and reduce barriers to care. Examples include: linking individuals with needed
and convenient services; establishing systems of care in partnership with other
members of the community; addressing transportation barriers; addressing cuts in
budgets and clinic hours; expanding roles of care givers (e.g., mid-level providers)
to provide screenings and referrals; working with employers to increase the number
of insured workers; or other strategies to address particular barriers.
5 years
Documentation could be, for example, reports, meeting minutes, or MOUs.
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Standard 7.2: Identify and implement strategies to improve access to
health care services.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 7.2.2 A
The purpose of this measure is to assess
the health department’s involvement in the
implementation of strategies to increase
access to health care services.
Improved access to care will provide continuity of health promotion and
disease prevention to members of the population and ensure access to
needed preventive services.
Implemented
strategies to
increase access to
health care services
REQUIRED
DOCUMENTATION
1. Collaborative
implementation
of mechanisms
or strategies
to assist the
population in
obtaining health
care services
GUIDANCE
1. The health department must document collaborative implementation
of strategies to improve access to services for those who experience
barriers. Documentation could be, for example:
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
• A signed Memoranda of Understanding (MOU) between partners to list
activities, responsibilities, scope of work, and timelines.
• 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.
• Documentation of transportation programs.
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Standard 7.2: Identify and implement strategies to improve access to
MEASURE
PURPOSE
SIGNIFICANCE
Measure 7.2.3 A
The purpose of this measure is to assess
the health department’s involvement in
the 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. Cultural differences must be addressed in strategies to improve
access to health care services, if those strategies are to be successful.
For example, some cultures discourage women from talking about
personal issues with people outside of their families, discourage men
from seeking care, may not trust health care providers, or may rely on
community providers who are not trained in medical care. Language and
low literacy can also limit access to care.
Implemented culturally
competent initiatives
to increase access to
health care services
for those who may
experience barriers to
care due to cultural,
language, or literacy
differences
REQUIRED
DOCUMENTATION
1. Initiatives to
ensure that
access and
barriers are
addressed in
a culturally
competent
manner
188
health care services.
GUIDANCE
1. The health department must document that initiatives to ensure
access and address barriers are culturally competent, and take into
account cultural, language, or low literacy barriers. The initiatives may
be developed by the health department or in collaboration with others.
DATED
WITHIN
2 examples
5 years
Examples of initiatives include the 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 strategically approach the development of a 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 health equity and 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. A strategic workforce includes the alignment of workforce development with the health department’s overall mission and goals and the
development of strategies for acquiring, developing, and retaining staff.
DOMAIN 8 INCLUDES TWO STANDARDS:
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Standard 8.1:
Encourage the Development of a Sufficient Number of Qualified Public Health Workers
Standard 8.2:
Ensure a Competent Workforce through Assessment of Staff Competencies, the Provision of
Individual Training and Professional Development, and the Provision of a Supportive Work
Environment
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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 qualified public health workers
sufficient to meet public health needs. As public health workers retire or seek other employment
opportunities, newly trained public health workers must enter the field. Trained and competent
workers are needed in such diverse 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 a responsibility to collaborate
with others to encourage the development of a sufficient number of public health students and to
encourage qualified individuals to enter the field of public health to meet the staffing needs of public
health departments and other public health related organizations.
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Standard 8.1: Encourage the development of a sufficient number of qualified
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.1.1 S
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 and educational
programs (for example, public health nursing, public health laboratory services,
health promotion, environmental public health, public policy, colleges of veterinary
medicine) is a means to promote public health as an attractive career choice.
Collaborative efforts promote the health department as an employer of choice and
open new pathways for recruitment. Collaboration with academic programs can
create opportunities for internships, guest lecturers, and other ways to expose
students or new graduates to public health practice.
Relationship and
collaboration with
educational programs
that promote the
development of future
public health workers
REQUIRED
DOCUMENTATION
1. Partnership
or ongoing
collaboration
with educational
programs to
promote public
health as a
career or to
provide training
in public health
fields
191
public health workers.
GUIDANCE
1. The state health department must document 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
enhancing training in public health.
DATED
WITHIN
1 partnership
or ongoing
collaboration
5 years
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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Standard 8.1: Encourage the development of a sufficient number of qualified
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.1.1 T/L
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.
Relationships and/
or collaborations
that promote the
development of future
public health workers
REQUIRED
DOCUMENTATION
1. Relationship or
collaboration that
promotes public
health as a career
192
public health workers.
GUIDANCE
1. The health department must document a partnership or collaboration
that promotes public health as a career choice.
DATED
WITHIN
1 example
5 years
Examples of partnerships or collaborations include collaboration with a school
or college of public health, working with organizations such as AmeriCorps,
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.
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STANDARD 8.2: Ensure a competent workforce through the assessment of staff
competencies, the provision of individual training and
professional development, and the provision of a supportive
work environment.
A health department workforce development plan ensures 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 point out gaps
in competencies and skills for the health department and provide workforce development guidance for
individual staff members.
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Standard 8.2: Ensure a competent workforce through the assessment of staff
competencies, the provision of individual training and professional
development, and the provision of a supportive work environment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.2.1 A
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.
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. Workforce development strategies support the
health department, individual staff members, staff development, and
the overall workplace environment. Employee training and core staff
competencies assure a competent workforce.
Workforce development
strategies
REQUIRED
DOCUMENTATION
GUIDANCE
1. Workforce
development plan
1. The health department must provide a health department-specific
workforce development plan. The workforce development plan must:
NUMBER OF
EXAMPLES
DATED
WITHIN
1 plan
2 years
• Address the collective capacity and capability of the department workforce and
its units.
• Address gaps in capacity and capabilities and include strategies to address them.
• Be responsive to the changing environment and include consideration of areas
where the technology advances quickly such as information management and
(digital) communication science.
• Be responsive to the changing environment and include considerations of areas
where the field is advancing, for example, emergency preparedness training,
health equity, and cultural competence.
The plan must include:
• An assessment of current staff competencies against the adopted core
competencies. An example of nationally adopted core competencies is the
“Core Competencies for Public Health Professionals” from the Council on
Linkages Between Academia and Public Health Practice. The plan may
also use state developed or specialty focused sets of competencies, for
example, nursing, public health preparedness, informatics, and health equity
competencies.
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MEASURE 8.2.1 A, continued
• Training schedules and a description of the material or topics to be
addressed in the training curricula to address gaps in staff competencies.
• A description of barriers/inhibitors to the achievement of closing gaps or
addressing future needs in capacity and capabilities and strategies to
address those barriers/inhibitors.
2. Implemented workforce
development strategies
195
2. The health department must document implementation of its
workforce development strategies. Examples must demonstrate how
the health department addresses gaps in capacity and capabilities.
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2 years
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Standard 8.2: Ensure a competent workforce through the assessment of staff
competencies, the provision of individual training and professional
development, and the provision of a supportive work environment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.2.2 A
The purpose of this measure is to assess
the health department’s execution of
its workforce development plan related
to recruitment, retention, and staff
qualifications.
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 a health department to
function at a high level.
A competent health
department workforce
REQUIRED
DOCUMENTATION
1. Recruitment
of qualified
individuals for
specific positions
2. Recruitment
of individuals
who reflect the
population served
GUIDANCE
1. The health department must document the recruitment of individuals
who are qualified for their public health specific specialty position.
Examples of the evidence of the efforts of the health department to achieve the
desired applicant pool are required.
Documentation could be, for example, a competency-based job description and
requirement for specific certification posting that specifies the level of skills,
training, experience, and education that the applicant needs to possess to qualify
for the position.
2. The health department must document the recruitment of individuals
who reflect the demographics (e.g., race, ethnicity, language, etc.) of
the population that the health department serves.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
2 examples
5 years
2 examples
5 years
Examples of the evidence of the efforts of the health department are required, not
the success or failure to achieve the desired applicant pool.
Tribal health departments may use Indian Preference hiring policies.
3. Retention
activities
196
3. The health department must document 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.
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MEASURE 8.2.2 A, continued
4. Position
descriptions,
available to staff
4. The health department must provide position descriptions or job
descriptions. Position or job descriptions must include the competencies that are
required for the position and must address both public health specialty needs (e.g.,
epidemiologist, public health laboratory technician, etc.) and generalist needs.
2 examples
3 years
The health department must also document how the descriptions are made
available to staff. They may be made available for example, through the internet/
intranet, a policy procedures manual, or through the human resources department.
5. A process to verify
staff qualifications
5. The health department must document 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 Tribal/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. Tribal health departments may include
using the Indian Preference hiring policies and/or proof of enrollment.
1 process
2 years
6. Verified
qualifications for
all staff hired
6. The health department must document that qualifications have been
verified for all staff hired in the past two years. Reviews include tracking
required recertification.
2 examples
2 years
Documentation could be, for example, personnel files, a log or spreadsheet,
or a template or form used by the health department; civil service commission
certification; or evidence from a county or state personnel office demonstrating
that the person is qualified for the position.
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 8.2: Ensure a competent workforce through the assessment of staff
competencies, the provision of individual training and professional
development, and the provision of a supportive work environment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.2.3 A
The purpose of this measure
is to assess the health
department’s comprehensive
approach to the provision of
opportunities for professional
career development for all
staff and the department’s
implementation of staff
development activities.
All staff should have opportunities for professional development. All employees
need to have a basic understanding of public health in order to coordinate
program efforts, especially in the case of working with the public and in the case
of emergency situations. All staff should have opportunities to learn and to grow in
their positions both to improve their own skills and also to address the changing
needs of the health department.
Professional and career
development for all staff
REQUIRED
DOCUMENTATION
1. Participation
in personal
professional
development
activities by staff
of the department
(other than
management
and leadership
staff, who are
addressed below)
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 to employ state-of-the-art theory, management
processes, public health knowledge, and management techniques.
GUIDANCE
1. The health department must document staff’s completion of their
annual personal professional development plan.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
2 years
Professional development activities could include: education assistance (e.g., time
off for classes, tuition reimbursement, bringing classes to the health department),
continuing education, training opportunities, mentoring, job shadowing,
certification in public health, etc.
Topics could be, for example, HIPAA, emergency response, methods for the
presentation of data, health equity, communications, and courses required for
Certified Public Health continuing education.
Documentation could be, for example, a training completion certificate, an
attendance record for a class, or a report written by the staff person documenting
the activities and learnings.
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MEASURE 8.2.3 A, continued
199
2. Development
activities for
leadership and
management staff
2. The health department must document the provision of department
training and development programs for department leaders and
managers.
3. Participation
of department
leaders and
managers in
training provided
by others, outside
of the health
department
3. The health department must document leaders’ and/or managers’
attendance at a leadership and/or management development training.
Online courses are acceptable.
2 years
2 examples
2 years
Activities could include, for example, education assistance, continuing education,
support for membership in professional organizations, and training opportunities.
Examples of providers include National Public Health Leadership Institutes;
Public Health Training Centers Network, Environmental Public Health Leadership
Institute; executive management seminars or programs; graduate programs in
leadership/management; and related meetings and conferences.
Examples of course topics include negotiation skills, CQI, systems thinking,
change management, intercultural or intergenerational management, collaborative
intelligence, handling conflict, coaching and mentoring skills, communications
skills for managers, leadership styles, effective networks, concepts of public health
informatics, leading teams and collaborations, health equity, community resilience,
relationship building, marketing/branding, business process improvement, digital
media, and crisis/risk communication.
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Standard 8.2: Ensure a competent workforce through the assessment of staff
competencies, the provision of individual training and professional
development, and the provision of a supportive work environment.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.2.4 A
The purpose of this measure is to
assess the health department’s efforts
to create an organizational culture and
work environment that is supportive of
the staff and their maximum productivity.
A positive work environment is vital to the success of any organization.
The work environment impacts job satisfaction, employee retention, and
employee creativity and productivity. The work environment should support
and foster each employee’s ability to contribute to the achievement of the
department’s mission, goals, and objectives.
Work environment that
is supportive to the
workforce
REQUIRED
DOCUMENTATION
1. Policies that
provide an
environment in
which employees
are supported in
their jobs
GUIDANCE
1. The health department must provide policies that provide a supportive
work environment. Policies could include, for example:
• A work/life balance, for example, telecommuting, flex time, and breastfeeding/
lactation support;
• Diversity (especially for staffing to match the diversity of the population);
NUMBER OF
EXAMPLES
DATED
WITHIN
1 policy
or set of
policies,
plans, or
program
descriptions
5 years
• Leadership attributes, for example, setting a professional tone; fair and equitable
management decisions; focus on the department’s vision and mission;
• Regular assessments of the organizational climate, for example, regular staff
surveys and 360 reviews of the management team;
• The provision of the tools, information, and freedom to allow staff to perform
their responsibilities;
• The maintenance of institutional memory, the transfer of knowledge, and the
celebration of past and current accomplishments, for example, partnerships
with retirees, sharing of stories, celebration events, etc.
• Supervisors’ encouragement of systems thinking, change management, data
use for decisions, and a culture of quality improvement; and
• Collaborative learning, for example participation of staff on boards, committees,
and task forces in community, collaborative planning sessions, shared reviews
of program evaluations, etc.
200
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MEASURE 8.2.4 A, continued
2. A process
for employee
recognition
2. The health department must provide employee recognition policies.
Examples can address both team and individual recognition and
recognition for employee improvement.
Examples of employee recognition include a call out in a newsletter, employee of
the month program, posting an employee honor roll, recognition letters, regularly
organized recognition lunch, etc.
3. Employee
wellness activities
3. The health department must provide a policy, plan, or description of
opportunities provided to staff to promote health and wellness and
prevent disease.
Activities may include, for example, health screenings and risk assessments,
flu shots, exercise programs, nutrition information, stress reduction methods,
breastfeeding and lactation support, and tobacco use cessation. Examples may
also include healthy food policies and efforts to create a culture of health and
wellness.
201
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1 set of
policies,
plans, or
program
descriptions
5 years
1 policy,
plan, or
program
description
5 years
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Standard 8.2: Ensure a competent workforce through the assessment of staff
MEASURE
PURPOSE
SIGNIFICANCE
Measure 8.2.5 S
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 has knowledge and experience to
share about workforce capacity, workforce training, and continuing
education to address organizational gaps in the public health
workforce. A trained and competent Tribal or local health department
workforce enhances the capacity of the state health department.
Consultation and/or technical
assistance provided to Tribal
and local health departments
regarding evidence-based
and/or promising practices
in the development of
workforce capacity, training,
and continuing education
REQUIRED
DOCUMENTATION
1. The provision of
consultation and/or
technical assistance
to Tribal or local
health departments
202
competencies, the provision of individual training and professional
development, and the provision of a supportive work environment.
GUIDANCE
1. The state health department must document consultation
or technical assistance provided to Tribal or local health
departments.
Documentation could include, for example, emails, phone calls,
webinars, documents/materials, site-visits, meetings, training
sessions, and web postings.
PUBLIC HEALTH ACCREDITATION BOARD
DATED
WITHIN
2 examples
5 years
The state health
department must
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 must
be from local health
departments.
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Domain 9: Evaluate and Continuously Improve Processes, Programs,
and Interventions
Domain 9 focuses on the use and integration of performance management and quality improvement practices and processes for the
continuous improvement of the public health department’s practices, programs, and interventions.
Performance management identifies actual results against planned or intended results. Performance management systems ensure that
progress is being made toward department goals by systematically collecting and analyzing data to track results to identify opportunities and
targets for improvement.
Quality improvement is an element of performance management that uses processes to address specific targets for effectiveness and
efficiency. “Quality improvement in public health is the use of a deliberate and defined improvement process that is focused on activities that
are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable
improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes
which achieve equity and improve the health of the community.” (Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. Defining Quality
Improvement in Public Health. Journal of Public Health Management and Practice. January/February 2010).
DOMAIN 9 INCLUDES TWO STANDARDS:
203
Standard 9.1:
Use a Performance Management System to Monitor Achievement of Organizational Objectives
Standard 9.2:
Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice,
Programs, Processes, and Interventions
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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 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, 4) identifying areas where
achieving objectives requires focused quality improvement processes, and 5) visible leadership for
ongoing performance management. Department information systems and public health data support
performance management.
204
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Standard 9.1: Use a performance management system to monitor achievement of
organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.1 A
The purpose of this
measure is to assess
the health department’s
engagement of leadership
and staff in developing,
establishing, using, and
updating a performance
management system for
the organization.
To continuously improve public health practice, the health department leadership and
staff need to commit to establishing and using a performance management system.
The performance management process 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 and completely integrated
performance management system.
Staff at all organizational
levels engaged in
establishing and/or
updating a performance
management system
REQUIRED
DOCUMENTATION
GUIDANCE
1. Health department
leadership and
management
supportive and
engaged in
establishing and/
or updating a
performance
management system
1. The health department must document the health department leadership’s
engagement in setting a policy for and/or establishing a performance
management system for the department.
2. Health department
staff at all other
levels engaged
in establishing
and/or updating
a performance
management system
2. The health department must document engagement of staff at all levels of
the department in determining the nature of a performance management
system for the department and implementing the system.
205
DATED
WITHIN
2 examples
5 years
2 examples
5 years
Documentation could be, for example, 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.
Documentation could be, for example, meeting agendas, packets, materials, and
minutes; orientation presentations/programs for new personnel; health department
meeting materials and operational plans.
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Standard 9.1: Use a performance management system to monitor achievement of
organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.2 A
The purpose of this
measure is to assess
the health department’s
adoption of a departmentwide performance
management system.
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. An adopted performance management system
communicates across the department how the department will (1) ensure that goals are
being met consistently in an effective and efficient manner and (2) identify the need to
improve organizational results.
Performance
management policy/
system
REQUIRED
DOCUMENTATION
1. An adopted
performance
management
system
GUIDANCE
1. The health department must provide a written description of the
department’s adopted performance management system that includes:
a. Performance standards, including goals, targets and indicators, and the
communication of expectations;
NUMBER OF
EXAMPLES
DATED
WITHIN
1
performance
management
system
5 years
b. Performance measurement including data systems and collection;
c. Progress reporting including analysis of data, communication of analysis
results, and a regular reporting cycle; and
d. A process to use data analysis and manage change for quality improvement
and towards creating a learning organization.
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Standard 9.1: Use a performance management system to monitor achievement of
organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.3 A
The purpose of this
measure is to assess
the health department’s
management practices for
assessing performance
and identifying and
managing opportunities
for improvement.
A performance management system ensures that progress is being made toward
department goals and allows the department to identify areas for quality improvement.
Implemented performance
management system
REQUIRED
DOCUMENTATION
1. A functioning
performance
management
committee or team
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.
GUIDANCE
1. 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. This
does not have to be a separate group that deals only with performance management
but may be a function of a standing department committee.
207
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.
DATED
WITHIN
1 example
5 years
Documentation could be, for example, a charter, agendas, minutes, reports, or
protocols of the subsidiary body responsible.
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MEASURE 9.1.3 A, continued
2. Goals and
objectives
2. The health department must document setting of goals and objectives
with the identified time frames for measurement.
Examples of administrative areas where performance management might be
appropriate include contract management (e.g., looking at the contract approval
process or how contracts are tracked for compliance), vital records (e.g., processing
birth and death certificates or evaluating their accuracy), human resources functions
(e.g., the performance appraisal system), staff professional development (e.g.,
effectiveness of the professional development process), workforce development (e.g.,
appropriateness of employee wellness program), or financial management system
(e.g., the financial data development, analysis, and communication process).
2 examples;
one example
must be from a
programmatic
area and the
other from an
administrative
area.
5 years
2 examples
5 years
Documentation could be provided in narrative, table, or graphic form, depending on
the chosen reporting method.
208
3. Implementation
of the process for
monitoring the
performance of
goals and objectives
3. The health department must document the monitoring of performance
towards the two objectives cited above.
4. Analysis of progress
toward achieving
goals and objectives
and identification
of areas in
need of focused
improvement
processes
4. The health department must document that performance of the two
objectives identified in 2) above was analyzed according to the time
frames. Evidence for determining opportunities for improvement can be shown
through the use of tools and techniques, for example, root cause analysis, cause and
effect/Fishbone; or interrelationship digraphs or other analytical tools.
2 examples
5 years
5. Identification of
results and next
steps
5. The health department must document that performance results,
opportunities for improvement, and next steps for the identified goals and
corresponding objectives were documented and reported.
2 examples
5 years
Documentation could be, for example, from run charts, dashboards, histograms, data
reports, monitoring logs, or other statistical tracking forms demonstrating analysis or
progress in achieving measures; or meeting minutes from a quality team.
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6. A completed
performance
management selfassessment
209
6. The health department must provide a completed performance
management self-assessment that reflects the extent to which
performance management practices are being used.
5 years
The health department may develop its own performance management
assessment or use existing models, such as The Public Health Performance
Management Self-Assessment Tool (http://www.phf.org) or the Self-assessment
tools available through the Baldrige Performance Excellence Program
(http://www.nist.gov/baldrige/enter/self.cfm).
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Standard 9.1: Use a performance management system to monitor achievement of
organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.4 A
The purpose of this
measure is to assess
the health department’s
process for measuring
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.
Implemented systematic
process for assessing
customer satisfaction
with health department
services
REQUIRED
DOCUMENTATION
1. Collection, analysis,
and conclusions of
feedback from two
different customer
groups
2. Results and actions
taken based on
customer feedback
GUIDANCE
1. Using a broad, customer/stakeholder identification list developed as part
of a strategic planning or health improvement planning process, the health
department must document how customer/stakeholder feedback was
collected, analyzed, and conclusions drawn from two different types of
customers (e.g., vital statistics customers; food establishment operators;
individuals receiving population immunizations, population screenings, or
other services; partners and contractors; elected officials, etc.). Special
effort to address those who have a language barrier, are disabled, or are otherwise
disenfranchised must be included.
Examples of instruments to collect customer/stakeholder satisfaction include forms,
surveys, focus groups, or other methods.
Documentation could be a report, memo, or other written document that describes
the process and the results and conclusions of the analysis of the feedback.
2. The health department must document results and action taken based
on the collection, analysis, and conclusions drawn from feedback from
customer groups.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Customers
must be from
two different
programs
2 examples
5 years
Documentation must relate to the examples in Required Documentation above.
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organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.5 A
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.
Opportunities provided to
staff for involvement in the
department’s performance
management
REQUIRED
DOCUMENTATION
1. Staff development
in performance
management
GUIDANCE
1. The health department must document its staff professional development
in the area of performance management. At a minimum, targeted staff includes
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.
211
DATED
WITHIN
2 examples
5 years
Documentation could be, for example, training attendance rosters, training curricula
and objectives, presentations, participation in webinars, and other training materials,
or specific work with consultants or technical assistants in performance management.
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NUMBER OF
EXAMPLES
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organizational objectives.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.1.6 S
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.
Technical assistance and/
or training provided on
performance management
to Tribal and local health
departments
REQUIRED
DOCUMENTATION
1. Provision of
technical
assistance about
performance
management
systems
GUIDANCE
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.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Documentation could be, for example, attendance rosters, curricula, presentations,
exercises to apply tools and techniques, newsletters, briefing papers, e-newsletters,
email notification, or flyer or brochure distribution.
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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 quality improvements. An important component
of the performance management system is 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.
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Standard 9.2: Develop and implement quality improvement processes integrated
into organizational practice, programs, processes, and interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.2.1 A
The purpose of this measure is to
assess the health department’s efforts
to develop 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.
Established quality
improvement program
based on organizational
policies and direction
REQUIRED
DOCUMENTATION
GUIDANCE
1. A written quality
improvement plan
1. The health department must provide a quality improvement plan. The
plan must address:
NUMBER OF
EXAMPLES
DATED
WITHIN
1 plan
5 years
• 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 effort’s structure, for example:
-- Organization structure
-- Membership and rotation
-- Roles and responsibilities
-- Staffing and administrative support
-- Budget and resource allocation
• Types of quality improvement training available and conducted within the
organization for example:
-- New employee orientation presentation materials
-- Introductory online course for all staff
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-- Advanced training for lead QI staff
-- Continuing staff training on QI
-- Other training as needed – position-specific QI training (MCH, Epidemiology,
infection control, etc.)
• Project identification, alignment with strategic plan and initiation process:
-- Describe and demonstrate how improvement areas are identified and how
they are prioritized for project activity
-- Describe and demonstrate how the improvement projects align with the
health department’s strategic vision/mission
• Quality improvement 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.
• 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
215
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• 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.
216
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Standard 9.2: Develop and implement quality improvement processes integrated
into organizational practice, programs, processes, and interventions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 9.2.2 A
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.
Implemented quality
improvement activities
REQUIRED
DOCUMENTATION
1. Quality
improvement
activities based on
the QI plan
GUIDANCE
1. The health department must document implementation of quality
improvement activities and the health department’s application of its
process improvement model. Examples must demonstrate:
• how staff problem-solved and planned the improvement,
• how staff selected the problem/process to address and described the
improvement opportunity,
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
one example
must be from
a program
area and the
other from an
administrative
area.
5 years
• how they described the current process surrounding the identified improvement
opportunity,
• how they determined all possible causes of the problem and agreed on
contributing factors and root cause(s),
• how they developed a solution and action plan, including time-framed targets
for improvement,
• what the staff did to implement the solution or process change, and
• how staff reviewed and evaluated the result of the change, and how they
reflected and acted on what they learned.
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MEASURE 9.2.2 A, continued
Documentation must demonstrate ongoing use of an improvement model,
including showing the tools and techniques used during application of the
process improvement model. Documentation must 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.
Documentation could be, for example, quality improvement project work plans or
storyboards that identify achievement of objectives and include evidence of action
and follow-up.
2. Staff participation
in quality
improvement
activities based on
the QI plan
218
2. The health department must document how staff were involved in the
implementation of the plan, worked on improvement interventions or
projects, and/or served on a quality team that oversees the health
department’s improvement efforts.
5 years
Documentation could be, for example minutes, memos, reports, or committee or
project responsibilities listings.
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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:
219
Standard 10.1:
Identify and Use the Best Available Evidence for Making Informed Public Health Practice Decisions
Standard 10.2:
Promote Understanding and Use of the Current Body of Research Results, Evaluations, and
Evidence-based Practices with Appropriate Audiences
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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
MEASURE
PURPOSE
SIGNIFICANCE
Measure 10.1.1 A
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.
Applicable evidencebased and/or promising
practices identified and
used when implementing
new or revised processes,
programs, and/or
interventions
REQUIRED
DOCUMENTATION
1. The use of
evidence-based
or promising
practices,
including:
a. Documentation of
the source of the
evidence-based or
promising practice
221
public health practice decisions.
Health departments should be aware of practices that are evidence-based
and incorporate them into their processes, programs, and interventions,
as appropriate. 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.
GUIDANCE
1. The health department must document the incorporation of an evidencebased or promising practice in a public health process, program, or
intervention.
a. The health department must document 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) an Initiative listed in the
NACCHO Model Practices Database, (3) the result of an information search (web,
library, literary review), or (4) result of interaction with consultants, academic
faculty, researchers, other health departments, or other experts.
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NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
examples must
come from
two different
program areas,
one of which
is a chronic
disease
program or
program that
seeks to
prevent chronic
disease.
3 years
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MEASURE 10.1.1 A, continued
b. Documentation
of how the
evidence-based or
promising practice
was incorporated
into the design of
a new or revised
process, program,
or intervention
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. Incorporation of the evidencebased or promising practice must be appropriate to the particular group or
community or it must be modified to be appropriate.
Documentation could be, for example, 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
MEASURE
PURPOSE
SIGNIFICANCE
Measure 10.1.2
T/S
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, multi- sectorial 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.
Fostered innovation in
practice and research
REQUIRED
DOCUMENTATION
223
public health practice decisions.
GUIDANCE
1. Relationships
with academic
institutions,
research centers/
institutes
1. The Tribal or state health department must document that it has a working
relationship with academic institutions, research centers/institutes, and/or
Tribal organizations and Tribal Epidemiology Centers.
2. Participation
in research
agenda-setting,
practicebased 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. The Tribal or state health department must
demonstrate involvement of the community in the development of the research agenda.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
2 examples
5 years
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, documentation can be, for example, meeting minutes, emails,
or a meeting agenda that demonstrates 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.
Documentation could be, for example, membership in a practice-based research
network, either with other states, institutions, or within the state. Community Based
Participatory Research is a model that could be used.
For Tribal health departments, this may include the incorporation of practice-based
evidence grounded in cultural values, beliefs, and traditional practices.
Documentation could be, for example, a membership list or meeting attendance roster.
Documentation could also be 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
PURPOSE
SIGNIFICANCE
Measure 10.2.1 A
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.
Protection of human
subjects when the health
department is involved
in or supports research
activities
REQUIRED
DOCUMENTATION
1. An adopted human
subjects research
protection policy
GUIDANCE
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 must have a copy of
the IRB approval from the institution where the IRB review was done. If the health
department does not currently engage in research that involves human subjects, a
statement to that effect could be accepted as documentation.
225
NUMBER OF
EXAMPLES
DATED
WITHIN
1 policy
5 years
Documentation for a Tribal health department could be a Tribal policy or protocol that
describes the process for research review and approval by the Tribal Council, Health
Oversight Committee, or other body or authority.
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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
PURPOSE
SIGNIFICANCE
Measure 10.2.2 A
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.
Access to expertise to
analyze current research
and its public health
implications
REQUIRED
DOCUMENTATION
1. The availability of
expertise (internal
or external)
for analysis of
research
GUIDANCE
1. The health department must document that it has expert staff or access
to outside experts who can analyze research and its public health
implications.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
or one list
5 years
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.
Documentation could be, for example, a list of experts and a description of their
training or expertise. The expertise may be within the department or may reside
outside the health department, for example, 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.
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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
PURPOSE
SIGNIFICANCE
Measure 10.2.3 A
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.
Communicated research
findings, including public
health implications
REQUIRED
DOCUMENTATION
1. The communication
of research findings
and their public
health implications
to stakeholders,
public health
system partners,
and/or the public
GUIDANCE
1. The health department must document the provision 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.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
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. Community Based Participatory Research is
an example of an approach that could be used.
Research referred to is research conducted and published by others, outside of the
health department. The research must have been evaluated by experts to provide
valid implications, for example, peer-review for publication in journals.
The state health department distribution list of research findings must include the
Tribal and local health departments in the state.
The local health department distribution list of research findings must include the
state health department and Tribal health department(s) in the state with which the
local health department coordinates.
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MEASURE 10.2.3 A, continued
The Tribal health department distribution list of research findings must include
the state and local health department(s) in the state with which the Tribal health
departments coordinates.
Documentation could be, for example, a presentation, prepared report, discussion at
a meeting recorded in the minutes, web posting, email list-serve, newspaper article,
webinar, or press release.
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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
PURPOSE
SIGNIFICANCE
Measure 10.2.4 S
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.
Consultation or technical
assistance provided to Tribal
and local health departments
and other public health
system partners in applying
relevant research results,
evidence-based and/or
promising practices
REQUIRED
DOCUMENTATION
1. Provision of
consultation or
technical assistance
to Tribal and/or local
health departments,
and/or other public
health system
organizations in
applying relevant
research, evidencebased, and/or
promising practices
229
GUIDANCE
1. The state health department must document 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, 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.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
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
PURPOSE
SIGNIFICANCE
Measure 10.2.4 T
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.
Technical assistance
provided to the state health
department, local health
departments, and other
public health system partners
in applying relevant research
results, evidence-based and/
or promising practices
REQUIRED
DOCUMENTATION
1. Provision of
consultation or
technical assistance
to state and/or local
health departments,
other Tribal health
departments, and/or
Tribal organizations
in applying relevant
research, evidencebased, promising
practices, and/
or practice-based
evidence
230
GUIDANCE
1. The Tribal health department must document the provision of
consultation, technical assistance, advice, direction, or guidance
to others in the application of relevant research or evidencebased, promising practices, and/or practice-based evidence. 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 the state health department, local health departments, other
Tribal health departments or Tribal organizations in the state, or other partners
or stakeholders.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
Examples of technical assistance provided by the Tribe may be done together
with a federal partner, such as IHS, 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.
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Domain 11: Maintain Administrative and Management Capacity
Domain 11 focuses on health department management and administration capacity. Organizational administration and management
is the process of organizing, leading, and controlling the efforts of organizational human and other resources to make decisions and
achieve organizational goals. Health departments must have a well-managed human resources system, be competent in general financial
management, have data management capacity and capability, and be knowledgeable about public health authorities and mandates. And,
because of the nature of public health – the focus on the collective good, the employment of government action, and the objective of
population-based outcomes – public health leaders need an infrastructure to ensure that decisions, policies, plans, and programs are ethical
and address health equity. 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.
DOMAIN 11 INCLUDES TWO STANDARDS:
231
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
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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
PURPOSE
SIGNIFICANCE
Measure 11.1.1 A
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 needs
to have ready access to policies and procedures to be
informed of organizational and operations expectations.
Policies and procedures
regarding health
department operations,
reviewed regularly, and
accessible to staff
REQUIRED
DOCUMENTATION
1. Policy and
procedure manual
or individual
policies
GUIDANCE
1. The health department must provide written operations policies/
procedures. This could be one manual or a group of policies.
These are operations policies, not human resource policies, which are addressed
in Measure 11.1.5. Policies could address these topics, for example, records
retention and back-up procedures, reimbursement, invoicing, emergency/
evacuation, events planning, procurement of office supplies, facilities operations,
use of department equipment (including phones and internet), use of department
vehicles, tobacco use, recycling, scheduling the use of meeting rooms, the
development of policies that includes who needs to sign what types of policies and
how often they are reviewed, and any policies and procedures that concern the
operations of the department.
The policies can be provided to staff in paper form, on a central computer file, or
a link to an electronic format. If electronic, the policies can be files on a server or
postings on the web. If the policies are voluminous, the health department may
provide a Table of Contents or list of policies.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 Manual
or, if a Table
of Contents
or list is
provided,
2 example
policies
are also
required.
5 years
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MEASURE 11.1.1 A, continued
2. Health department
organizational
chart
3. Review of policies
and procedures
2. The health department must provide its 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. Position titles or program names are required; individuals’
names are not required.
If changes are made to the organizational chart between the submission of
documentation to PHAB and the site visit, the health department must submit a
copy of the revised chart to the site visit team. NOTE: This and the budget are
the only two 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.
3. The health department must document the review of policies and
procedures. 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.
4. Methods for staff
access to policies
234
Only the most recent version of policies must be provided. 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.
1 organizational chart
2 years
2 examples
5 years
1 example
5 years
Documentation could be policies that were adopted longer than 5 years ago but
that have been reviewed, revised, and signed off on by the health department
within the last five years.
4. The health department must document how staff access policies.
Access methods can include for example, the website; health department
intranet; server access; or paper copy distributed to staff, available from
supervisors, or located in central locations.
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.2 A
The purpose of this measure is to assess
the health department’s policies and process
for the identification and resolution of ethical
issues that arise from the department’s
program, policies, interventions, or employee/
employer relations.
Efforts to achieve the goal of protecting and promoting the public’s
health have inherent ethical challenges. Employer/employees
relations may also raise ethical issues. Understanding the ethical
dimensions of policies and decisions is important for the provision
of effective public health and public health management. Defining
and addressing ethical issues should be handled through an explicit,
rigorous, and standard manner that uses critical reasoning.
Ethical issues identified
and ethical decisions
made
REQUIRED
DOCUMENTATION
1. Strategies for
decision making
relative to ethical
issues
GUIDANCE
1. The health department must document the identification of issues
with ethical considerations and a strategic deliberative process for
consideration and resolution of ethical issues. The policies and procedures
must set forth a transparent process that provides an opportunity for input from
affected stakeholders and considers their interests. The policies and procedures
must provide for the consideration of the best evidence available. There must be
opportunities to evaluate decisions as new information becomes available and
there must be a provision for accountability of the decision makers.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 process
or set of
policies and
procedures
5 years
1 example
5 years
Examples of a process include the adoption of the Public Health Code of Ethics,
the establishment of an ethics board, the designation of a committee or process of
the governing entity, or other process.
2. Ethical issues
reviewed and
resolved
235
2. The health department must document the consideration, deliberation,
and resolution of ethical issues.
Examples of ethical issues include, for example, privately constructed sewers,
distribution of vaccine in a shortage situation, staff mandatory immunizations, an
employee’s use of social media, an employee’s acceptance of gifts.
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.3 A
The purpose of this measure
is to assess how the health
department protects customer
confidentiality.
It is critical that health departments and the individuals who work in them maintain
customer confidentiality and protect client 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.
Policies regarding
confidentiality, including
applicable HIPAA
requirements
REQUIRED
DOCUMENTATION
1. Confidentiality
policies
GUIDANCE
1. The health department must provide written confidentiality policies
and procedures. Policies must define the health department’s processes for
protecting customer 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.
2. Training staff on
the implementation
of confidentiality
policies
DATED
WITHIN
1 policy
or a set of
policies
5 years
2 examples
of training
5 years
Policies may be maintained as either a paper copy or in an electronic format. If
electronic, the policies can be files on a server or posted on the web. 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.
2. The health department must document that staff has been trained on
confidentiality policies, including training content and names of those
who received the training.
Documentation could be, for example, a copy of training materials and an agenda
for the training session – whether group or individual.
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NUMBER OF
EXAMPLES
The health department must have a record of who attended the training.
Documentation could also be a log, a sign-in sheet or a record/statement from
web-based training.
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MEASURE 11.1.3 A, continued
3. Signed employee
confidentiality
form, as required
by policies
237
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. Do not submit copies of every
employee-signed form; a log or other tracking mechanism showing that
employees have signed the form is sufficient.
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and 1
example of
a tracking
form or log
5 years
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.4 A
The purpose of
this measure is to
assess the health
department’s
social, cultural,
and linguistic
competence in
providing public
health programs to
specific populations
with higher health
risks and poorer
health outcomes.
Public health departments are responsible for all residents in the health department’s
jurisdiction, and that usually includes people of various backgrounds, languages, 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, how open they are to health information and
health education, and how they can change health behaviors.
Policies, processes,
programs, and
interventions provided
that are socially,
culturally, and
linguistically appropriate
to specific populations
with higher health
risks and poorer health
outcomes.
REQUIRED
DOCUMENTATION
1. Policy or procedure
for the development
of interventions
and materials that
address areas of
health inequity
among the specific
populations and
are culturally
and linguistically
appropriate for
the population the
health department
serves in its
jurisdiction
238
Ensuring that the health department’s policies, programs, 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 programs and services to meet the needs of the population.
Ensuring that the health department’s policies, programs, services, materials, and processes
intentionally address health disparities and health inequities will enhance the health
department’s ability to impact the health of the population.
GUIDANCE
1. The health department must provide a policy or procedure that
demonstrates how health equity is incorporated as a goal into the
development of policies, processes, and programs. A policy or procedure
must ensure that social, cultural, and linguistic characteristics of the various
populations groups of the population it serves are incorporated into processes,
programs, and interventions. Characteristics of populations addressed in the
policy or procedure may include social, racial, ethnic, cultural, sexual orientation
and gender identity, linguistic characteristics, including non-English speaking
populations, and the disabled.
PUBLIC HEALTH ACCREDITATION BOARD
Standards & Measures
NUMBER OF
EXAMPLES
DATED
WITHIN
1 policy or
procedure
5 years
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MEASURE 11.1.4 A, continued
239
2 examples;
The two
examples
must come
from two
different
program
areas of
the health
department
5 years
3. The health department must provide an assessment of cultural and
linguistic competence. This could be, for example, the Cultural and Linguistic
Competency Policy (CLCPA) self-assessment from the National Center for Cultural
Competence, assessment against Culturally and Linguistically Appropriate
Services (CLAS) standards, Health Equity at Work: Skills Assessment of Public
Health, or another assessment tool.
1 example
5 years
4. The health department must document staff training on health equity
and cultural competence, including social, cultural, and/or linguistic
aspects of policies, processes and programs. Training may include:
examining biases and prejudices; developing cross-cultural 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.
1 example
5 years
2. Processes,
programs, or
interventions
provided in a
culturally or
linguistically
competent manner
2. The health department must document the provisions of processes,
programs, or interventions that are culturally or linguistically
appropriate, as defined above.
3. Assessment of the
health department’s
cultural
competence and
knowledge of
health equity
4. Health equity
and cultural
competency
training provided
to health
department staff
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, for
example, 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.
The health department must provide a record of who attended the training. This
may be a log, a sign-in sheet, or a record/statement from web-based training. An
example of training includes the Prevention Institute’s Health Equity Training Series.
Documentation could be, for example, a copy of the training materials or an
agenda for the training session as well as a sign-in sheet or attendance list.
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.5 A
The purpose of this measure is to assess the health department’s
management of its human resources. A comprehensive human resource
function 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 in a combination of ways. If the larger human resources system
is outside of the health department, the health department still must perform
human resources management functions, for example, ensuring that human
resource policies are available to staff, keeping time sheets, managing leave,
and conducting employees’ performance evaluations. A health department
may also contract for certain human resource actions to an outside
organization that specializes in human resource management functions.
A well-defined and structured human
resources function is important for any
organization. It provides the health
department with the management
processes to hire, manage, evaluate
personnel, and improve personnel
performance. A human resource
function supports the health
department, individual staff members,
staff development, and the overall
workplace environment.
A human resources
function
REQUIRED
DOCUMENTATION
1. Human resource
(HR) policies and
procedures
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. The health department must provide a human resource manual or set of
policies and procedures. The policies and procedures must address all of the
following:
1 set of HR
policies and
procedures
5 years
• Employment and human resources legal requirements that pertain to the
jurisdiction served by the health department (Tribal, state, and/or local);
• Personnel recruitment, selection, and appointment;
• Employee confidentiality;
• Equal opportunity employment;
• Salary structure;
• Hours of work;
• Benefits package;
• Performance evaluation process based on job/position descriptions 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., Tribe, state, city, or county).
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MEASURE 11.1.5 A, continued
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)].
241
2. Staff access to
human resource
policies and
procedures
2. The health department must document how department staff access
human resource policies and procedures.
3. Employment
working
relationship
agreements
3. The health department must provide documents in use to establish
working relationships.
4. A human
resource function
that supports
management,
the workforce,
and workforce
development by
being a responsive
partner to
programs
4. The health department must document that the human resource
function demonstrates a responsive partnership with management,
programs, services, and staff to enable staff that provide public health
programs, services, and products.
1 example
5 years
1 example
5 years
2 examples
5 years
Methods may include, for example, web-based, health department intranet, server
access, or distribution of a hard copy that is available from supervisors or located in
central locations.
Examples of documents used to establish working relationships include, for
example, employment agreements, contract template, letter of employment
template, contracts, or labor agreements (if appropriate).This does not include
contracts for service.
Documentation could be, for example, the human resource function and a program
collaboratively resolving a human resource issue, human resource staff that are
educated/experienced in public health (for the purpose of assessing workforce
needs, enabling workforce development, and recruiting candidates for public
health positions), human resource policies that support the public health program
functions, and programs and the human resource function working together to
develop policies and provide training and development.
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.6 A
The purpose of this measure is to
assess the health department’s capacity
and capability to store, manage, protect,
and utilize electronic information
and data in order to provide relevant
information for operational efficiency
and informed decision making.
Effective public health decisions require accurate information and data.
Health departments have access to a wealth of data, either created by
the department or collected by others. To use data effectively, the health
department must organize and process data in a manner to appropriately
protect data and also make it available for decision making. The health
department must maintain an information management system that
provides the ability to store, protect, process, manage, analyze, utilize, and
communicate information and data available from multiple sources.
Information management
function that supports
the health department’s
mission and workforce by
providing infrastructure
for data storage,
protection, and
management; and data
analysis and reporting
REQUIRED
DOCUMENTATION
1. Information
technology
infrastructure that
supports public
health functions
242
GUIDANCE
1. The health department must document that information technology
supports public health and administrative functions of the department.
Documentation could be, for example, a scanning system to preserve records,
a grant management system, vital records systems, program (such as WIC or
immunization) information systems, licensing information systems, inspections and
violations records, and on-line data services.
PUBLIC HEALTH ACCREDITATION BOARD
Standards & Measures
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
The two
examples
must be
from different
areas. The
health
department
may select
the areas.
They may
be program
and/or
administrative
areas.
5 years
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MEASURE 11.1.6 A, continued
243
2. Secure information
systems
2. The health department must document information vulnerability audits,
security policies, and/or internal controls to ensure the privacy and
security of information.
1 example
3 years
3. Maintenance of
confidentiality of
data
3. The health department must provide a policy that the department
adheres to federal, state, and local privacy protection regulations for
handling data.
1 policy
5 years
4. Maintenance
of information
management
system
4. The health department must provide a written process for reviewing and
developing information management business system requirements to
guide systems changes and development.
1 example
5 years
5. Management of
information assets
5. The health department must provide an inventory of data or data
systems (either collected by the health department or by others)
available to the health departments.
1 example
3 years
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Standard 11.1: Develop and maintain an operational infrastructure to support
the performance of public health functions.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.1.7 A
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 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.
Facilities that are clean,
safe, accessible, and
secure
REQUIRED
DOCUMENTATION
244
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. Licenses for
laboratory
1. The health department must provide copies of licenses to meet national
or state requirements appropriate for the laboratory services provided.
Access to a laboratory that has Select Agent certification is required.
As needed
5 years
2. Inspection reports
2. The health department must provide examples of inspection reports,
for example, OSHA, internal (department conducted), or external (an
independent organization) inspection reports, cleaning and maintenance
policies, logs, records, certificate of occupancy, contracts or orders.
Other examples of documentation include environmental public health and safety
committee meeting minutes and federal or Tribal environmental audits.
2 examples
5 years
3. Assurance of
accessibility
to the health
department’s
facilities
3. The health department must provide documentation that it is in
compliance with Federal/state/local laws concerning accessibility.
1 example
5 years
PHAB will accept a copy of the ADA compliance report or the health department’s
self-evaluation, as described by federal regulations. PHAB will accept
documentation of compliance with ADA related Tribal, state, and/or local laws and
regulations that pertain to the jurisdiction which the health department is authorized
to serve. For health departments that may operate in buildings that are either
exempt from the federal regulations or have waivers (such as buildings on the
national register of historic buildings), PHAB requires documentation of the health
department’s procedures to serve members of the public and health department
staff who have physical disabilities, are sight impaired, or are hearing impaired.
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STANDARD 11.2: Establish effective financial management system.
Sound financial practices are basic to any organization. They are required to manage resources
wisely, to analyze present and future needs, to sustain operations, and demonstrate accountability.
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 system.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.2.1 A
The purpose of this measure is to
assess the health department’s ability
to manage grants and contracts and
comply with external governmental
funding requirements.
Health departments receive funding from a variety of 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 and that the health department has systems for accountability.
Financial and
programmatic oversight
of grants and contracts
REQUIRED
DOCUMENTATION
1. Audited financial
statements
GUIDANCE
1. The health department must provide regular (as defined by the health
department) department-wide financial audit reports. Audits are formal
examinations of the health department’s financial accounts. Audits are performed by
external auditors.
2. Program reports
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
Previous
two fiscal
years
2 examples
5 years
The health department’s audit may be part of a large audit of the governmental
unit (for example, umbrella agency, super agency, county government, or state
government) of which the health department is a part.
2. The health department must provide program reports that it has
submitted to funding organizations.
Documentation could be, for example, compliance reports to federal funders,
reports to legislatures or local city/county/Tribal councils, and reports to foundations.
Monitoring reports or corrective action plans that show compliance with funding
requirements are also acceptable. Contracts or agreements between state, local,
and/or Tribal health departments to provide services may show the expectations
for funding but might not show the compliance with funding agency requirements. If
such contracts are used, they must be combined with follow-up reports that validate
compliance.
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MEASURE 11.2.1 A, continued
3. Communications
from federal or
state funding
agencies or
organizations
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All, as
appropriate
3. The health department must provide any formal communications from
state or federal funders that indicate the health department is a “highrisk grantee.”
5 years
Disclosure and documentation must be provided in the following types of instances:
the department being put on manual draw-down; the department being put on a
corrective action plan; placement on a ‘do not fund’ list; receivership status; and
instances of malfeasance or misappropriations of funds.
Documentation could be letters or emails that officially and formally describe
concerns from funding agencies (e.g., federal agencies, state health department
funding to local health departments).
Documentation must also include a description of follow-up actions and internal
controls that have occurred to remedy the situation.
If there have been no communications regarding “high-risk grantee” status, the
health department director must provide a signed statement attesting to that fact.
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Standard 11.2: Establish effective financial management system.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.2.2 A
The purpose of this measure is to assess
the health department’s management of
agreements with other organizations to
provide services, processes, programs,
or interventions on behalf of the health
department.
The health department may not directly deliver or provide all services and
administrative activities. They may depend on other entities to act on its
behalf. These services could be related to organizational, management,
and administrative functions, or to program services or interventions
delivered to the public.
Written agreements
with entities from which
the health department
purchases, or to which
the health department
delegates, services,
processes, programs,
and/or interventions
REQUIRED
DOCUMENTATION
1. Contracts/MOUs/
MOAs or other
written agreements
for the provision
of services,
processes,
programs, and/or
interventions
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GUIDANCE
1. The health department must provide contracts or MOU/MOAs or other
written agreements that have been executed with other organizations or
departments.
State health department documentation could be, for example, a written agreement
with a local or district health department for one of the examples. The other example
must be with another agency or organization.
Local health department documentation could be 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 department documentation could be 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
Epidemiologic Centers funded by IHS.
PUBLIC HEALTH ACCREDITATION BOARD
Standards & Measures
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples;
the examples
must be from
two different
program/
administrative
areas
featuring
written
agreements
with different
entities
2 years
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Standard 11.2: Establish effective financial management system.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.2.3 A
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 use and oversight
of public funds.
Financial management
systems
REQUIRED
DOCUMENTATION
1. Approved health
department budget
GUIDANCE
1. The health department must provide the approved budget that is in
effect when the documentation for accreditation is submitted to PHAB.
The budget may be approved by the governing entity or other body with approval
authority, such as a governor’s budget office.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 budget
2 years
2 examples
5 years
If a new budget is approved between the submission of documentation to PHAB
and the site visit, the health department must provide a copy of the new budget to
the Site Visit Team. NOTE: The budget and the organizational chart are the only two
instances 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.
2. Financial reports
2. The health department must provide quarterly financial reports. The
examples provided may demonstrate two different types of reporting or may be two
successive reports of the same type.
249
Documentation could be, for example, expense reports, reimbursement reports,
reports to governing entities, and/or monthly budget reports – summarized or
itemized.
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Standard 11.2: Establish effective financial management system.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 11.2.4 A
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.
Additional funding to support public health processes, programs, and
interventions should be sought through a variety of means, including
budget increase requests, budget revision requests, and grants.
Financial resources should be maximized by leveraging current funds to
increase resources available for public health.
Resources sought
to support agency
infrastructure and
processes, programs,
and interventions
250
REQUIRED
DOCUMENTATION
GUIDANCE
NUMBER OF
EXAMPLES
DATED
WITHIN
1. Formal efforts to
seek additional
financial resources
1. The health department must provide grant applications (funded or
unfunded) or must document the leveraging funds to obtain additional
resources (for example, providing matching funds).
2 examples
5 years
2. Communications
concerning the
need for financial
support to maintain
and improve
public health
infrastructure and
services
2. The health department must document its communication concerning
the need for additional investment in public health. Communication could
address a specific issue or address public health in general.
2 examples
5 years
Documentation could be, for example, articles or letters to the editor of a newspaper,
presentations to the community, or testimony to elected officials.
Tribal health department documentation could be, for example, 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 support and engagement of its governing entity in maintaining and strengthening the public health
infrastructure for the jurisdiction served. 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, 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
applying for accreditation, has the primary responsibility for supporting the applicant health department in achieving accreditation.
DOMAIN 12 INCLUDES THREE STANDARDS:
251
Standard 12.1:
Maintain Current Operational Definitions and Statements of the Public Health Roles,
Responsibilities, and Authorities
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
Standard 12.3:
Encourage the Governing Entity’s Engagement In the Public Health Department’s Overall
Obligations and Responsibilities
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STANDARD 12.1: Maintain current operational definitions and statements
of public health roles, responsibilities, and authorities
A 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 and/or
programmatic. This standard assures that the health department understands its authority, roles, and
responsibilities and that of its governing entity, that such authority is put into practice, and that the
governing entity is informed and engaged.
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Standard 12.1: Maintain current operational definitions and statements of public
health roles, responsibilities, and authorities.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 12.1.1 A
The purpose of this measure is to
assess the health department’s
knowledge of and provision of the
operations, programs, and services
that it is mandated to provide.
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 it serves. It is important that the
health department is knowledgeable of these mandates and performs
them as required.
Mandated public health
operations, programs, and
services provided
REQUIRED
DOCUMENTATION
1. Authority to conduct
public health
activities
2. Operations that
reflect authorities
GUIDANCE
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 make copies or access to the laws and regulations
available to the Site Visit Team.
For example, the health department could provide the disease reporting rules or
regulations reflected by the Council of State and Territorial Epidemiologist’s list of
Nationally Notifiable Conditions; mandates for vaccinations; mandated oversight
of environmental public health conditions, for example, solid waste, small public
water systems, underground storage tanks, and hazardous materials; and various
inspection programs, such as restaurant inspections.
Tribal health departments could provide a Tribal resolution, ordinance, or
executive order.
2. The health department must document how it implements its mandated
processes, programs, or interventions.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 example
5 years
1 example
5 years
Documentation could be, for example, service descriptions, annual reports,
reports to the governing entity, meeting minutes, reports to governance, functional
descriptions, organizational descriptions, or other written material.
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Standard 12.1: Maintain current operational definitions and statements of public
health roles, responsibilities, and authorities.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 12.1.2 A
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 governing entity is the point of accountability for the
health department. The health department should have
a clear understanding of the governing entity’s structure,
responsibilities, and expectations.
Operational definitions and/
or statements of the public
health governing entity’s
roles and responsibilities
REQUIRED
DOCUMENTATION
GUIDANCE
1. The governing
entity’s authority
1. The health department must provide a description of the governing
entity and formal written statement of the governing entity’s authority.
The governing entity could be, for example, a board of health, a governor’s office,
county commissioners, or other point of accountability.
NUMBER OF
EXAMPLES
DATED
WITHIN
1 or more
documents,
as required
No date
restriction
1 example
No time
restriction
Documentation could be a copy of the body of law (for example, statutes, rules,
regulations, ordinances, charter) that sets forth the mandated authority or a
description of the authority and the reference to the legal citation.
Tribal health department documentation could be aTribal resolution, ordinance,
or executive order.
2. The governing
entity’s structure
and composition
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, for example, a statute, rules, regulations, a charter, an
official charge statement, or other formal written document.
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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 knowledgeable of 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
PURPOSE
SIGNIFICANCE
Measure 12.2.1 A
The purpose of this measure is to
assess the health department’s
education of and communications
with its governing entity regarding
the health department’s
responsibilities and the roles and
responsibilities of the governing
entity.
Governing entities significantly influence the direction of health
departments through policy making and other similar activities. Many
governing entities have key roles in resource allocation, policy making,
legal authority, collaboration, and/or quality improvement activities. As a
result, they may heavily influence whether health departments are fulfilling
their responsibilities. The governing entity, to be an effective advocate for
public health and for the agency, must be aware of its responsibilities and
duties and of the health department’s roles and responsibilities.
Communication with the
governing entity regarding
the responsibilities of the
public health department
and of the responsibilities
of the governing entity
REQUIRED
DOCUMENTATION
1. Communication
with the governing
entity regarding the
responsibilities of
the public health
department
GUIDANCE
1. The health department must document communications provided to the
governing entity concerning the health department’s responsibilities,
as set forth in the health department’s authorizing document(s).
Documentation must demonstrate the process of informing the governing entity
about the responsibilities of the health department.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
for a; 1
process
for b
5 years
The health department will select its documentation for this measure based on
the model of governance in place for the health department.
Documentation could be, for example, reports, testimonies, speeches,
presentations, or emails.
a. Communication with
the governing entity
about its operational
definitions and/
or statements
of the public
health governing
entity’s roles and
responsibilities
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a. The health department must document its sharing with the governing entity
operational definitions and/or statements of the public health governing entity’s
public health related roles and responsibilities. The health department will
select its documentation based on and appropriate to the health department’s
model of governance.
Documentation could be, for example, meeting minutes, memos, emails,
briefing papers, or other correspondence.
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MEASURE 12.2.1 A, continued
b. The orientation
process for new
members of the
governing entity
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b. The health department must document its process for orientation of new
members of the governing entity. New member orientation must include both
the responsibilities of the health department and of the governing entity.
Documentation could be, for example, orientation agenda, meeting minutes,
orientation materials.
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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 entities exercise a wide range of responsibilities, including policy development,
resource stewardship, legal authority, partner engagement, continuous improvement, and oversight.
Specific areas of responsibilities may include, strategic planning, adopting and ensuring enforcement of
public health regulations, ensuring that the governing body and health department act ethically, serving
as a strong link between the health department and the community and other community organizations,
supporting a culture of quality improvement, hiring and evaluating the health department director, taxing
authority, and budget adoption. These responsibilities demand that the governing entity is well-versed
in public health and in the work of the health department and the health challenges of the community.
The governing entity and the health department should communicate regularly on the health of the
community, strategic plan implementation, program activities, health department policy issues, public
health ethical issues, and quality 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
PURPOSE
SIGNIFICANCE
Measure 12.3.1 A
The purpose of this measure is to
assess health department efforts
to keep the governing entity
informed of public health issues
and health department activities.
The health department has a responsibility 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.
Information provided to
the governing entity about
important public health issues
facing the community, the
health department, and/or the
recent actions of the health
department
REQUIRED
DOCUMENTATION
1. Communication with
the governing entity
regarding important
public health issues
and/or recent
actions of the health
department
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GUIDANCE
1. The health department must document communications with the
governing entity regarding important public health issues and/or
recent actions of the health department. Important public health issues
include a population’s health status, health indicators, health equity and
disparities, disease outbreaks, environmental health hazards, etc.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
2 years
Documentation could be 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).
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Standard 12.3: Encourage the governing entity’s engagement in the public health
department’s overall obligations and responsibilities.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 12.3.2 A
The purpose of this measure is to assess the
health department’s familiarity and awareness
of the governing entity’s actions in order for the
health department to identify patterns of issues
discussed and topics or areas that call for
increased communication and information.
It is important that the health department understand
the priorities, policy positions, opinions, and actions
of the governing entity in order to continually improve
communication and effectiveness, leading to a quality
governing entity-health department relationship.
Actions taken by the
governing entity tracked and
reviewed
REQUIRED
DOCUMENTATION
GUIDANCE
1. Consistently review
issues discussed,
actions taken, and
policies set by the
governing entity
1. The health department must document that it has consistently
reviewed the governing entity’s1) patterns of issues discussed; 2)
opinions of the governing entity members; and/or 3) positions taken.
This will highlight topics or issue areas where increased communication is
desirable. Review must be done at least annually.
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Documentation could be, for example, health department meeting minutes,
reports, dashboards, presentations, memos, or other record of health
department leadership’s discussion of governing entity actions.
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Standards & Measures
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
14
months
Examples
do not
need to
be from
different
years.
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Standard 12.3: Encourage the governing entity’s engagement in the public health
department’s overall obligations and responsibilities.
MEASURE
PURPOSE
SIGNIFICANCE
Measure 12.3.3 A
The purpose of this measure is to assess the
health department’s communication with the
governing entity on the overall assessment and
improvement of the 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 it is aware of improvements being undertaken.
Communication with the
governing entity about health
department performance
assessment and improvement
REQUIRED
DOCUMENTATION
1. Communication
with the governing
entity concerning
assessment of the
health department’s
performance
GUIDANCE
1. The health department must document communications with the
governing entity on plans and processes for improving health
department performance.
NUMBER OF
EXAMPLES
DATED
WITHIN
2 examples
5 years
2 examples
5 years
The health department will select its documentation for this measure based on
the model of governance in place for the health department.
Communication efforts could include, for example, program reviews,
accreditation efforts, quality improvement projects, and other performance
improvement activities.
Documentation could be, for example, meeting minutes, reports, presentations,
memos, or other discussion records.
2. Communication
with the governing
entity concerning the
improvement of the
health department’s
performance
2. The health department must document communication with the
governing entity on its performance improvement efforts as a result of
performance improvement processes and/or activities.
The health department will select its documentation for this measure based on
the model of governance in place for the health department.
Documentation could be, for example, annual reports, department dashboards,
program reviews, meeting minutes, reports, presentations, memos, or other
record of discussion.
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Standards & Measures
VERSION 1.5 APPROVED DECEMBER 2013
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PUBLIC HEALTH ACCREDITATION BOARD
1600 Duke Street, Suite 200
Alexandria, VA 22314
T: 703.778.4549
F: 703.778.4556
www.phaboard.org
This publication was supported through grant funding from the Robert Wood Johnson Foundation (RWJF) and
Cooperative Agreement #1U900T000228-01 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 © 2014 Public Health Accreditation Board. All rights reserved.
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