PU550 Unit 9 Accreditation Readiness Review Example

Which Documents Does the Agency Actually Have: A Unit 9 Accreditation Readiness Review Crosswalking a Composite District Health Department's Dated Files Against the Standards, With Three Measures It Would Fail Today

[Student Name]

Purdue University Global

PU550: Public Health Leadership and Administration

Unit 9 Accreditation Readiness Review

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[Date]

The Aldermere Valley district, its file dates and its findings are composite; the accreditation structure and the research cited are real.

What the Board Asked and What This Answers

The board's motion asked for an inventory, not a recommendation to apply. This review therefore reports what exists, what exists but is out of date, and what does not exist, with a file date for every entry. It makes one recommendation at the end, about sequence rather than about applying.

Domain by Domain, With Dates

1. Assessment. Community health assessment on file, dated four years and two months ago, past the three-year currency expectation. Primary data collection complete; the report was never adopted by the board. Status: exists, stale, unadopted.

2. Investigation. Communicable disease protocols current, last reviewed eight months ago. Epidemiologic capacity documented through a position that has been vacant seven months. Status: documents yes, capacity no.

3. Inform and educate. Communications plan dated six years ago, naming two staff who have left and a social platform the district no longer uses. Status: exists, obsolete.

4. Community engagement. Partnership list current; no written agreements for four of the eleven partnerships named. Status: partial.

5. Policies and plans. Community health improvement plan dated four years ago, aligned to the stale assessment; strategic plan expired last year. Status: both out of date, and dependent on the assessment above.

6. Public health laws. Legal authorities compendium complete and reviewed 14 months ago by the district's retained counsel. Status: strongest domain in the inventory.

7. Access to care. Documented referral arrangements with two federally qualified health centers, both current. Status: adequate.

8. Workforce. Workforce development plan adopted this year; training records complete for 71 percent of staff; no supervisory training delivered in three years. Status: plan yes, records incomplete.

9. Quality improvement. Quality improvement plan dated three years ago listing four projects, none completed, committee minutes showing two meetings in two years. Status: exists in name only.

10. Capacity and resources. Audited financial statements current; no documented information systems plan. Status: partial.

11. Governance. Board bylaws current; board orientation materials not updated since two members joined. Status: minor gaps.

12. Administration and management. Policies current; performance management system consists of the 64-indicator dashboard with no thresholds. Status: exists, not functioning as a system.

The Three Measures the District Would Fail Today

1. A current community health assessment. The file is four years old and was never adopted, which makes the gap a governance gap rather than a research gap.

2. A functioning quality improvement process. Four listed projects and no completions is the clearest fail in the inventory, and it cannot be fixed by writing another plan.

3. A performance management system in use. A dashboard with no thresholds, no owners and no documented decisions does not evidence a system, and the review found no minutes in which a dashboard figure prompted an action.

Two of the three failing measures are not missing documents. They are documents the agency wrote and then did not use, which is the harder thing to fix.

What the Inventory Says About Sequence

The dependencies run one way, and they decide the order of work. The improvement plan cannot be rewritten before the assessment is redone and adopted, since the plan's priorities come from it. The strategic plan should follow both, because its priorities should not contradict them. The quality improvement process has to begin running now rather than after the documents are written, because evidence of a functioning process requires completed cycles with dates, and those take months to accumulate. The performance management fix is already proposed in the district's nine-measure dashboard memo and should be adopted as part of this work rather than as a separate effort.

Recommendation on Sequence, Not on Applying

The review recommends that the district spend the next twelve months on four things: redo and adopt the assessment, complete two quality improvement cycles start to finish, adopt the nine-measure dashboard with thresholds, and update the communications plan, which is cheap and currently embarrassing. It recommends that the board revisit the application question after that, with the inventory re-run. Departments that got something lasting out of accreditation were the ones whose preparation altered the daily work; where it was treated as a filing exercise, the fee was most of what they remembered (Siegfried et al., 2018).

Cost of Readiness

Staff time is the main cost: an estimated 740 hours across twelve months, concentrated in the assessment and the two improvement cycles, of which roughly 200 hours can come from the dashboard reduction already proposed. Direct costs are 26,000 dollars for survey work in the assessment and 9,000 dollars for facilitation. Almost all of this work falls in the capabilities that no categorical grant pays for, assessment, policy development and the agency's own quality management, which is why it has been deferred for four years and why the foundational services framework treats it as spending that has to be named rather than assumed (Resnick et al., 2017). Application fees are excluded from this estimate because the review is not recommending application yet. National evaluation of accredited departments found reported gains in quality improvement and in identifying strengths and weaknesses, which is the return this district should expect from the preparation itself even if it never applies (Kronstadt et al., 2016).

What This Review Could Not Determine

Three things. Whether the four partnerships without written agreements would produce documentation if asked, since the review did not contact the partners. Whether the 29 percent of staff with incomplete training records attended training that was never recorded, which is likely and is a records problem rather than a training problem. And whether the board would adopt a reworked assessment, since the last one reached it during the budget cycle and was never brought back.

References

Kronstadt, J., Meit, M., Siegfried, A., Nicolaus, T., Bender, K., & Corso, L. (2016). Evaluating the impact of national public health department accreditation: United States, 2016. Morbidity and Mortality Weekly Report, 65(31), 803-806. https://doi.org/10.15585/mmwr.mm6531a3

Resnick, B. A., Fisher, J. S., Colrick, I. P., & Leider, J. P. (2017). The foundational public health services as a framework for estimating spending. American Journal of Preventive Medicine, 53(5), 646-651. https://doi.org/10.1016/j.amepre.2017.04.015

Siegfried, A., Heffernan, M., Kennedy, M., & Meit, M. (2018). Quality improvement and performance management benefits of public health accreditation: National evaluation findings. Journal of Public Health Management and Practice, 24, S3-S9. https://doi.org/10.1097/PHH.0000000000000692