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The PHAB Accreditation Process Explained

Considering PHAB accreditation? Get a brief overview of the process to learn what’s in store for you with this on-going performance improvement effort.

Abby, Senior Account Executive at ClearPoint, introduces potential customers to ClearPoint's strategic planning software, helping them to improve the efficiency of performance management processes across their organization.

Most healthcare organizations pursue accreditation of one form or another. The types of accreditation vary by healthcare sector, but by and large, the process centers on an in-depth performance review. It’s not easy—and it’s not something a facility can do once and be done. Accreditation is a commitment to ongoing performance improvement, as well as measuring and reporting on that improvement to retain accreditation status.

In this article, we’re focusing on the public sector and the Public Health Accreditation Board (PHAB) accreditation process. This brief overview can help your organization learn more about what PHAB has in store for you.

Table of Contents

Chapter 1: What is public health accreditation?

PHAB accreditation involves the “measurement of health department performance against a set of nationally recognized, practice-focused, and evidenced-based standards.” More specifically, PHAB accreditation requires that applicants meet 32 total standards across 12 domains.

Initial PHAB accreditation assesses a health department’s ability to perform “10 Essential Public Health Services”; it also measures your capacity to manage and communicate effectively with a governing entity.

PHAB accreditation process

Accreditation must be achieved within a specific timeframe and maintained year after year. As we mentioned in the introduction, this isn’t a “one and done” process—it requires continual quality improvement and process development to remain accredited. Health departments can hold the PHAB accreditation for five years and then must reapply.

If your organization is public, it can apply. Local, state, territorial, and tribal health departments are all eligible for PHAB accreditation.

Chapter 2: Why pursue PHAB accreditation?

Even if you skimmed everything prior and just saw the image above, it’s still pretty clear that the PHAB accreditation process is a serious commitment. Why would any organization go to all this trouble? Because it works.

The PHAB accreditation process is a serious commitment. Why would any organization go to all this trouble? Because it works. Click To Tweet

PHAB’s mission of improving and protecting the public health by transforming healthcare quality and performance is synonymous with the mission of hospitals. In other words, the goals of all parties are aligned. The in-depth self-review that’s inherent in accreditation has proven to help healthcare departments improve processes, community engagement, quality of care, and patient outcomes.

The value of PHAB accreditation

Also, healthcare organizations that achieve accreditation can qualify for federal funding, and it increases their odds of receiving grants and donations. The additional financial support is a big contributor to providing the best care for patients.

Chapter 3: Seven steps of the PHAB accreditation process

1. Pre-Application

Hold your horses. Before you can even apply for PHAB accreditation, you have to prove you’re capable of undertaking the process. In this step, a healthcare organization must self-assess its readiness to apply via PHAB’s four Readiness Checklists, complete a four-part online orientation, and register with PHAB confirming intent to apply.

PHAB plans and processes checklist

The checklists alone require detailed preparation to complete. If your healthcare facility doesn’t already have strategic plans and data reporting in place, it could take months to implement processes that make you ready to apply to PHAB.

2. Application

After successfully passing the trial by fire of pre-application, your health department can formally submit its application and fee. At this point, you will have obtained approvals at the highest level (and well in advance) to pursue PHAB accreditation, demonstrating your rock-solid commitment to this ongoing process. The cost to apply also ensures this isn’t a casual pursuit—initial review fees range from $14,000 to $56,000, depending on population size. These fees are paid to PHAB and don’t include potential fees for third-party consultants.

Applicants must also complete a two-day, in-person training before moving to the next step.

3. Document Selection and Submission

This is where the rubber hits the road. Applicants provide documentation for each required PHAB measure and upload it to e-PHAB for review. This is one of the most important steps in the process. These documents and metrics prove the health department meets the PHAB accreditation standards; they are what the site team will review during their visit (wait for step four). Applicants have 12 months to submit documentation after completing step two.

It’s critical for healthcare facilities to use a performance management system like ClearPoint to track and report on required measures. Not only is this type of software a PHAB standard, but it fuels strategic planning and execution outside of the accreditation process. We've outlined how ClearPoint can simplify this step and make the submission less stressful here.

Find PHAB-required performance metrics in this healthcare KPI library.

4. Site Visit

After initial documentation is submitted, a small group of PHAB experts visit your facility in person. This trained team will verify documentation accuracy, ask follow-up questions about standards and measures, and generally discuss your application and documentation further.

The PHAB on-site team develops a report after the visit that summarizes whether or not each PHAB measure was tracked appropriately, as well as areas of excellence and areas of improvement in health department practices. That report is submitted to the PHAB Accreditation Committee.

5. Accreditation Decision

The Accreditation Committee reviews the site visit report and decides whether to award your healthcare organization accreditation status. If PHAB accreditation is won, you retain that designation for five years (as long as you submit annual reports...see next step).

If accreditation is denied, you have the opportunity to submit an Action Plan to address areas of non-compliance and achieve accreditation status.

6. Reports

After you earn accreditation, you can’t rest on your laurels. To maintain your recognition, health departments must submit annual reports that summarize how they’ve addressed areas of improvement since the prior report and verify continuing compliance with PHAB accreditation standards.

7. Reaccreditation

PHAB accreditation expires after five years. Unfortunately, there’s no shortcut for reaccreditation—the process begins at step two with the application. We’ve provided more details about reaccreditation in chapter 5.

Chapter 4: PHAB Annual Reports

Each year, all accredited health departments must submit their complete Annual Report to PHAB. This is not required during the year that the health department is applying for reaccreditation.

An Annual Report is an opportunity for health departments to show how they continue to advance the quality and performance of tribal, state, local, and territorial public health departments. Beyond PHAB’s need to ensure that health departments remain in conformity with the requirements under which it was reviewed for accreditation or reaccreditation, the organization also supports health departments’ efforts to improve their quality of service.

There are three sections required in the Annual Report. Section I addresses the health department’s continued accreditation status; Section II addresses the health department’s ongoing quality improvement work and preparations for future reaccreditation; finally, Section III provides for Population Health Outcomes Reporting. PHAB provides PHAB-prescribed forms for all three sections of the Annual Report, which is then submitted via e-PHAB.

Chapter 5: Comparison of accreditation and reaccreditation

As previously discussed, health departments must seek reaccreditation every five years. Though accreditation and reaccreditation are very similar, there are slight differentiations between the two processes.

PHAB accreditation and reaccreditation similarities

  • Reaccreditation continues to address the ten Essential Public Health Services through the arrangement of the Standards and Measures into Domains. The Standards in each Domain for reaccreditation are the same as the Standards set forth in the PHAB Standards and Measures, Version 1.5, for initial accreditation
  • The reaccreditation Measures are designed to confirm health departments’ continued conformity with the PHAB Standards and Measures from the initial accreditation

PHAB accreditation and reaccreditation differences

  • The required Measures, Requirements, and Guidance are different for reaccreditation
  • Conformity with any new requirements adopted since the health department’s time of initial accreditation must be proved. Reaccreditation Measures combine the requirements in Version 1.5 of the Standards and Measures for initial accreditation with the new requirements for reaccreditation
  • While the first accreditation confirms that the health department has the capacities required to provide the ten Essential Public Health Services, reaccreditation focuses more closely on capabilities and performance, as well as on continuous quality improvement.
    • In other words, the reaccreditation process is tailored to assess health departments’ improvements and advancements in the five years since their accreditation (or last reaccreditation). These requirements for reaccreditation are designed to encourage accredited health departments to continue to evolve, improve, and advance, thus becoming increasingly effective at improving the health of the populations they serve.
  • Reaccreditation also requires the new reporting of a selection of Population Health Outcomes. The purpose of reporting Population Health Outcomes is for the PHAB organization to establish and maintain a national database of selected health outcomes and their associated objectives that accredited health departments monitor.
    • Population Health Outcomes Reporting must be completed at the time the health department submits its documents for reaccreditation. The health department must select between five and ten Population Health Outcome Objectives they are tracking to report to PHAB with its reaccreditation material and with its Annual Reports, even after reaccreditation is achieved.

Each Reaccreditation Standards and Measures Requirement will require one of four types of document uploads: (1) a descriptive narrative (using the PHAB Reaccreditation Documentation Form), (2) a descriptive narrative of examples (using a PHAB Reaccreditation Documentation Form), (3) specific examples, or (4) a complete department-adopted item (plan, protocol, template, etc.).

PHAB makes a package of Reaccreditation Documentation Forms, with a form that is specific to each requirement, available to any department seeking reaccreditation. These forms are mandatory and cannot be substituted.

Chapter 6: Recommendations for pursuing PHAB accreditation

A big part of earning accreditation is being able to offer proof that you are continually improving processes and the overall quality of healthcare services. Manual processes and Excel formulas aren’t going to cut it and PHAB makes that clear in standard 9.1: “Use a performance management system to monitor achievement of organizational objectives.”

This seems more than reasonable when you consider PHAB requires you meet 32 standards across 12 domains. Even if you’re trying to meet the public health accreditation standards of other organizations, they are likely just as rigorous, and you’re going to need the help of technology.

ClearPoint’s performance management software can:

  • Keep teams organized as they work together to meet PHAB’s accreditation standards with project management tools, including Gantt charts. You can see a timeline of when each step is due, assign task ownership, and use automation tools to make sure people are aware of due dates and end dates.
  • Automate tracking of measures and metrics like KPIs to populate the initial PHAB documentation, as well as the annual reports. You can see status indicators of progress and view dashboard summaries.

ClearPoint's PHAB accreditation dashboard

  • Set up templates to streamline the process of creating the reports you need for PHAB’s standards and measures. Simply build them once, compile them into a briefing book, and then update annually with a few clicks. You don’t have to start from scratch for every annual report or when reapplying for accreditation.
  • Track all reaccreditation measures in ClearPoint, creating dashboards and reports so you always know whether you're on track.
  • Document your organization's progress so that you can prove continuous improvement when applying for reaccreditation. With all of your information in ClearPoint, it's easy to compile the reports that you need.
  • Report on Population Health Outcomes. Easily track and report on the five to ten Population Health Outcome Objectives you are required to report on for reaccreditation.

Contact us to learn more about how ClearPoint can help you meet public health accreditation standards.

The PHAB Accreditation Process Explained