The Action Plan is a common step on the road to accreditation. Using quality improvement (QI) principles and tools, PHF can provide many types of support to help health departments needing Action Plans to achieve accreditation. This is just one of the ways that PHF supports accreditation preparation.

 

What is an Action Plan?
Following submission of documentation and a site visit, the Public Health Accreditation Board (PHAB) asks one in three health department applicants to develop and submit an Action Plan within 90 days. The Action Plan articulates what the health department will improve upon in order to become accredited. If the Action Plan is approved by the Accreditation Committee, and is effectively implemented and documented, then accreditation can be granted.

 

Embracing the Action Plan Challenge
A health department asked to create an Action Plan is at a crossroads in the evolution of its culture of quality. After many months of careful preparation and teamwork, not immediately being accredited is a huge disappointment. Naturally, people are discouraged. But once this initial reaction passes, choosing to energetically embrace this challenge is a test of the organization’s commitment to continuous improvement. Having chosen to create an Action Plan, a health department must effectively address the shortcomings identified by PHAB site visitors in order for the Accreditation Committee to approve the Action Plan.

 

Some health departments have found an Action Plan to be an unexpected blessing for their organizations. Nonetheless, this challenge often contains a paradox: Domain 9 – the area of accreditation devoted to QI and performance management – is the area site visitors most commonly identify as needing improvement. So how can a health department that is working to overcome gaps in QI create and implement a successful improvement plan? By getting assistance from improvement experts; PHF has worked with 25% of accredited HDs and specializes in technical assistance and training related to Domains 8 and 9.

 

Why PHF?
PHAB Action Plan support is well-aligned with PHF’s focus areas: QI, performance management, and workforce development. Accredited health departments that have worked with PHF have been identified as having particular strength in Domain 9. For example, Ty Kane, former Accreditation Coordinator at the Sedgwick County (Kansas) Health Department, noted that, "The PHAB Site Visit Team cited ‘Evidence of QI Culture’ as a strength, noting the commitment of newer and older employees to QI, employee empowerment to lead QI initiatives, and the focus on customer service, and teamwork." From the Frederick County (Maryland) Health Department, Monica Grant reported a similar result: "PHAB cited our use of data informed decision-making and the intentional use of the QI tools as evidence of our strong commitment to quality improvement." Having received PHF performance improvement services, these health departments have a solid foundation in QI that enables them to tackle any problem with skill and confidence. Successful Action Plans go well beyond Domain 9; every improvement goal is an opportunity to practice QI and performance management. All Action Plans will benefit from systematic application of the Plan-Do-Check-Act framework, regardless of which PHAB Domains are the focus.

 

How Can PHF Help?
All Action Plans require use of QI principles to identify the root cause of a problem, make adjustments to improve outcomes, and monitor progress. In our Action Plan Technical Assistance, our experts will: