The collective impact model and its creative and adapted implementation in NCDOH's effort to become accredited is sustainable because it strengthened the relationship within the department. While the department was awarded accreditation status, annual reporting is still on-going and re-accreditation will be in its future. Therefore, the key lessons learned as described below, have led to a sustainable method going forward.
The first key lesson was related to time necessary to complete accreditation. Staffing dedicated to this project was limited. Therefore, the CHA, CHIP, SP and QI and Performance Management System components plus the collection and annotation of documents took several years to amass. The advantage to a long time-line was that it gave the staff time to consider and accept this process, and especially inculcate key concepts, such as quality improvement and branding. These efforts contributed strongly to investing in a common agenda and moving forward. The disadvantage was that continuity of the process was not necessarily maintained with the same intensity over several years and documentation at times did expire. Nevertheless, often over time, better examples of evidence were identified, and a better working knowledge and appreciation of division efforts was realized.
By far, the most successful method to data collection was an incremental approach whereby key staff became invested in the process and saw its rewards, personally. This resonates with importance of building strong relationships and sharing credit, important features to the collective impact approach. In addition, after the initial application, once timelines were set by PHAB, the Commissioner's efforts to direct staff to provide necessary documentation was more fruitful. Here, true leadership is clearly important. If the leader is unequivocally supporting the process, then the staff will more likely prioritize, engage or at least adhere to the direction appropriately. Leadership and committed staff should not disappear once accreditation is achieved, but should be perpetuated.
Documentation was evaluated by the ACs and deemed either sufficient or insufficient. The two ACs worked in concert and maintained control over what was eventually submitted. Even so, errors did occur, which were not recognized until post submission. The site visit provided an opportunity to make some small corrections.
Communication among staff was critical. Meetings of different combinations of staff and continuous updating of staff via emails and the e-PHAB dashboard were necessary to keep everyone current, and the data transparent. The language and complexity of the domains required thoughtful and repeated critical analysis. Ease with applications and e-PHAB was also required and improved coordination along the way. There existed variation among staff with these skills and tools and therefore additional training was needed, provided by the ACs. Again, training and communication tools that were learned during the process are still being used in other efforts.
Mutually reinforced activities, including the strategic plan subcommittee meetings, and leadership verification process proved successful. The strategic plan subcommittees provided internal goals and objectives that were inter-divisional. Membership was derived from many divisions and the goals were cross-cutting; Community Engagement and Workforce Development are good examples. Strategies to improve reaching the underserved population were explored, by understanding what was already in place and what approaches could be used. Training across the department in cultural competency was also promoted. These subcommittees continue to meet and seek improvements for the department to deliver public health to the community.
In preparation for the site visit, the ACs provided opportunities for department staff to practice the interviews. Mock interview conferences allowed staff to defend their documents and understand how the documents, together, met the measure—and were mutually reinforced. It also reminded staff of the documents submitted, since in some cases, significant time had passed. This type of preparation was invaluable and energized the staff in anticipation of the visit. Such opportunities for cross-collaboration across the areas of accreditation will continue, especially as relationships have expanded.
In addition to the internal work that the department conducted to achieve the accreditation, stakeholders also played a role. These relationships are long-standing and pre-dated the department's decision to seek accreditation.
The PHAB site visitors specifically commented that our community partnerships were, numerous, long-standing…across diverse sectors… [and that] these partners recognize the NCDOH as the hub or force that brings the community together around priority health issues…NCDOH team is to be commended for leveraging existing resources for the benefit of the community's health.” These relationships have been nurtured by the leadership team over time. They are built on mutual respect, attention to communication, and public health goals. In advance of the meeting where the community partners would be interviewed in a group setting, department staff reached out to these colleagues with accreditation material with which to familiarize themselves.
The NCDOH BOH was an important partner. It was necessary to maintain communication and educational efforts between the board and the department to update them on new processes, committees and trainings. These were often accomplished through monthly reporting as well as communication between the Commissioner and the board directly.
NYSDOH also provided support to the accreditation process. Since NYSDOH had already achieved accreditation itself, it provided trainings and tools that benefited the process at the county level. One example included trainings on quality improvement approaches.
In addition, partnerships with universities provided important collaboration, as an outside sector. Intern staff were essential during the entire process, including developing the CHA and CHIP. The ACs selected students based on their acumen and independence, as needed, during different phases. Their skills consisted of critical thinking, analysis, creativity, organization and writing. These volunteers assisted the backbone operations of the effort. Continued efforts to host interns remain on-going. The department actively seeks to establish these relationships with universities and unique, capable students.
The cost of accreditation was $47,700 for five years of accreditation status. All staff effort was in-kind. The benefits of accreditation are short and long-term. Over the course of the accreditation process, specific standards were highlighted and required development and revision. Simple modifications, such as documentation of meetings by minutes with sign-in sheet and dates became more routine. Meaningful changes, such as the development of a branding strategy, its use and importance were created. NCDOH emphasized the process of collaboration, not just the outcomes of collaboration. The county provided necessary building ground improvements to align with necessary regulations and labeling needs of the department. Finally, the effort to apply for accreditation provided a sense of departmental pride and community.
The department has already seen some long-term benefits from accreditation. It became clear that the principle of standardization is important for documentation, protocols and policies. Maintaining and revising rules and procedures benefit the department's function; revisions provide an opportunity to convene and discuss them on an on-going basis. The culture of QI was seeded and centralized in the department, as consistent with the SP, and continues to be integrated within divisions and across them. With proper leadership support, more successful projects will be generated. Workforce Development increased its capacity to provide trainings, orientations and services to the department staff. Cultural competency will continue to be reinforced throughout the department, as will attention to disabilities and special needs.
Such benefits that lead to improved process will translate to better serving the community. These are difficult to quantify in terms of dollars, but rather are priceless if they lead efficiency, strength in staff and a healthier community. According to PHAB, improved competitiveness for funding is a benefit of accreditation. Such a direct dollar benefit remains to be seen. NCDOH looks forward to that outcome. Decisions for re-accreditation and the cost that it incurs for the future would need to be based on the intangible benefits of accreditation, as well as, grant funding that results.
Stakeholder commitment to sustain the practice may be assessed from two perspectives. The stake that the staff and division hold will only continue to ripple through the department. New quality improvement efforts continue to energize others. Strategic planning in which many staff participate also see goals realized. Truly more and more staff continue to appreciate the value of accreditation; the Commissioner continues to support this effort as well. Outside partners and the community also see the importance of accreditation. NYSDOH and BOH consider this achievement invaluable and understands that it effectuates better processes which will in turn serve the population. Accreditation demonstrates that NCDOH achieves, maintains, and commits to the highest standard of providing governmental public health services.
Plans to sustain this intradepartmental collaboration were realized and continue along a strong trajectory. The first annual report reflected additional quality improvement projects, efforts towards developing enhanced departmental culture of QI, performance management monitoring, tracking and modifications for the community health assessment and improvement plans. Engagement of staff in new and long-standing subcommittees continues. The department organizational structure was modified, creating a new bureau charged with continued accreditation activities and support for strategic planning. In addition, staff was hired to support this new bureau.
NCDOH worked on eight QI projects, five of which were administrative, which impact all staff, 212 employees. Of the four QI projects which were fully implemented, nearly 145/212 staff participated. The three programmatic projects affect three of the five divisions of the health department related to disease prevention and health promotion. The QI projects were initially generated from 5 different members of the QI subcommittee but were supported by three strategic plan subcommittees which included approximately 25 individuals. Each QI project had a Project Owner. The number of QI projects did expand in general from prior to QI plan's initial date of approval and PHAB site visit and now equal eight. Four of the eight have been implemented this year; two of the four projects have been conducted long enough for analysis of feedback. The QI projects were : 1) Give a Superstar-administrative, derived from the QI and HR programs, implemented throughout the department, peer-to-peer recognition program to build morale, pilot program that has continued to expand in terms of participation; 2) Information and Referral Improved Scheduling-administrative, derived from clerical staff and HR, pending implementation, program to improve coverage issue related to phone calls from the public; 3) Improving Access to Care- programmatic, derived and implemented by Division of Maternal and Child Health, program designed to increase specific population's access to healthcare services, program has continued to expand in terms of the public participation over time; 4) Speakers' Bureau-administrative, derived from the Strategic Plan Community Engagement subcommittee, implemented throughout the department, program designed to streamline public requests for expert speakers from the health department; 5) Community Courtyard-administrative, derived from QI and HR programs, to be implemented throughout the department, program to create an outdoor space for employees to network and recharge during breaks, pending implementation; 6) Health Department Call-A-Colleague-administrative, derived from QI and Workforce Development subcommittees, to be implemented throughout the department but in early phase of development, program to identify key staff with technical skills (such as knowledge of Outlook or Excel) who can offer assistance to others who request it; 7) Standardized Surveillance Case Progress Notes-programmatic, derived from QI, implemented in TB Control, Immunization Program, Perinatal Hepatitis B Program and Communicable Disease Control, project to establish template on which to write progress notes with accompanying training for progress note procedures, currently program implemented in 4/5 disease control bureaus, may expand to STD/HIV if resources permit; and, 8) ResRem Online Database-programmatic, derived from Environmental Heath, will be implemented in the Office of Toxic and Hazardous Materials Storage once database design is complete, project will allow contractors and the public to schedule or confirm oil tank abandonment or removal online without having to call, fax or email NCDOH.
The commitment to accreditation beyond the award is evident by all staff's perceptions, efforts and continued support from administration.