Michigan Local Public Health Accreditation Commission MeetingMinutes – Pending Approval

January 9, 2014

Capitol View Building

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Introduction/Teleconference Roll Call

COMMISSION: Renee Canady (dialed in), Marcus Cheatham, Jack Enderle, Kathy Forzley, Dan Hale (dialed in), Corinne Miller, and Liane J. Shekter-Smith.

GUESTS: Jessie Jones, Rachel Melody, Mark Miller, Dilhara Muthukuda, Denise Reinhart, and Debra Tews.

Meeting convened at 9:34a.m.

General Announcements – All members

Miller welcomed the new commission members. Forzleyis the Health Officer of the Oakland County Health Department. Canady was the Health Officer of Ingham County and the soon-to-be director of the Michigan Public Health Institute (MPHI).

Agenda Approval – All Members

The agenda was reviewed and accepted. Cheatham initiated the vote, Shekter-Smith moved to support, and the motion carried unanimously.

Organizational Items – All Members

Jones asked if anyone is willing to serve as the next Vice Chair. Shekter-Smith asked if Cheathamis willing to continue to serve in the position. Cheatham expressed interest in continuing in the position. Shekter nominated Cheatham as Vice Chair. Enderle seconded. Cheatham was voted in unanimously as the Vice Chair.

Local Public Health Department Accreditation Cycle 5 Schedule and CPA Status Updates – Jessie Jones

Jones discussed the Cycle 5 Spreadsheet. The local health departments (LHD) that are highlighted in grey are LHDs that have already been accredited duringCycle 5. These LHDs are Kalamazoo, Branch-Hillsdale-St. Joseph, Marquette, Delta-Menominee, Chippewa, Ottawa, Muskegon, Tuscola, Grand Traverse, Huron, Van Buren/Cass, Bay, Mid-Michigan, DHD #2, and Shiawassee.

LHDs that are in green are currently working through their Corrective Plan(s) of Action (CPA). These LHDs are Barry-Eaton, LMAS, Western UP, Benzie-Leelanau, Dickinson-Iron, and Berrien. The LHD in red is in critical status; they have less than 90 days to fully implement their CPAs. The LHD in critical status is City of Detroit. City of Detroit has a return visit set up in mid-February and should be able to clear their CPA before their deadline of March 1, 2014.

The nine LHDs in blue are ready to be recommended for accreditation by the commission. The LHDs in blue are Sanilac, DHD #4, St. Clair, Northwest, Washtenaw, DHD #10, Kent, Allegan, and Jackson.

Miller provided an update on Detroit. In fiscal year 2013, the Michigan Local Public Health Accreditation Program (MLPHAP) contracted directly with the Institute for Population Health (IPH) to provide public health services since there was not a governmental entity available. But in 2014, since the City now has governmental authority, the contract will be made directly with the City of Detroit instead. Then the City will subcontract with IPH.We are working closely with them to ensure that the services continue and make sure the CPAs will be completed in time.

Miller said that if the CPAs are not completed in time, then an extension will be requested and the permission will need to come from the mayor, Mike Duggan.

Accreditation status recommendation –Jessie Jones

Jones presented a summary of the LHDs that are eligible for accreditation. Sanilac County Health Department’s On-Site Review occurred the week of October 22, 2012. Sanilac had eight missed indicators: two in Food Service, three in On-Site Wastewater Treatment Management, and three in Children’s Special Health Care Services (CSHCS). Sanilac has fully implemented their CPAs and are eligible for Accreditation. Sanilac participated in the Quality Improvement Supplement (QIS) and met nine out of the ten indicators. They have one commonly missed indicator between Cycle 4 and Cycle 5, MPR 20 in Food Service. Since Sanilac missed more than two indicators in On-Site Wastewater, they are not eligible for Accreditation with Commendation. C. Miller motioned to approve, Shekter-Smith supported, and the motion carried unanimously. Sanilac County Health Department was recommended for Accreditation.

District Health Department #4 was reviewed the week of November 5, 2012. DHD #4 had seven missed indicators: three in Food Service, two in Family Planning, and two in CSHCS. All CPAs have been fully implemented. There were three commonly missed indicators between Cycle 4 and Cycle 5: MPR 8 and MPR 20 in Food Service and Indicator 1.1 in Family Planning. They did not participate in the QIS, so they are not eligible for Accreditation with Commendation. Hale motioned to approve, C. Miller supported, and the motion carried unanimously. District Health Department #4 was recommended for Accreditation.

St. Clair County Health Department had their review the week of November 26, 2012. St. Clair had two Food Service indicators that were not met. The CPAs for these indicators have been fully implemented. They had one commonly missed indicator, MPR 8, between Cycle 4 and Cycle 5. They did not participate in the QIS. Shekter-Smith motioned to approve, Enderle supported, and the motion carried unanimously. St. Clair County Health Department was recommended for Accreditation.

The Health Department of Northwest Michigan had their Accreditation On-Site Review during the week of April 15th, 2013. They missed two indicators: one in Food Service and one in CSHCS. Their CPAs have been fully implemented. They participated in the QIS and met ten out of ten indicators. They do not have any repeat missed indicators between Cycles 3, 4, and 5 and is eligible for Accreditation with Commendation.C. Miller motioned to approve, Shekter-Smith supported, and the motion carried unanimously. Health Department of Northwest Michigan was recommended for Accreditation with Commendation.

Washtenaw County Public Health Department had their Accreditation On-Site Review during the week of June 3rd, 2013. Washtenaw missed one indicator in CSHCS. The CPA has been fully implemented and accepted by the reviewers. Chippewa participated in the QIS and met ten out of ten indicators. They do not have any repeat missed indicators between Cycles 3, 4, and 5 and is eligible for Accreditation with Commendation. Enderle moved to approve, C. Miller supported, and the motion carried unanimously. Washtenaw County Public Health Department was recommended for Accreditationwith Commendation.

District Health Department #10 had their Accreditation On-Site Review during the week of June 17th, 2013. DHD #10 missed six indicators: two in Food Service and four in CSHCS. The CPA has been fully implemented. Chippewa participated in the QIS and met ten out of ten indicators. They do not have any repeat missed indicators between Cycles 3, 4, and 5 and is eligible for Accreditation with Commendation. Enderle moved to approve, Hale supported, and the motion carried unanimously. District Health Department #10 was recommended for Accreditationwith Commendation.

Kent County Health Department had their Accreditation On-Site Review during the week of August 19th, 2013. Kent did not miss any indicators and do not have any repeat missed indicators between Cycles 3, 4, and 5. Kent participated in the QIS and met ten out of ten indicatorsand is eligible for Accreditation with Commendation. C. Miller moved to approve, Enderle supported, and the motion carried unanimously. Kent County Health Department was recommended for Accreditationwith Commendation.

Both Cheatham and Shekter-Smith noted that they are impressed by Kent’s performance. Tews suggested that sometimes it can be easier to not to miss any indicators if a department does not have a Family Planning program.

Allegan County Health Department had their Accreditation On-Site Review during the week of September 9th, 2013. Allegan did not miss any indicators and do not have any repeat missed indicators between Cycles 3, 4, and 5. Allegan participated in the QIS and met ten out of ten indicatorsand is eligible for Accreditation with Commendation. C. Miller moved to approve, Canady supported, and the motion carried unanimously. Allegan County Health Department was recommended for Accreditationwith Commendation.

Jackson County Health Department had their Accreditation On-Site Review during the week of October 21st, 2013. Jackson did not miss any indicators and do not have any repeat missed indicators between Cycles 3, 4, and 5. Jackson did not participated in the QIS and is eligible for Accreditation. C. Miller moved to approve, Enderle supported, and the motion carried unanimously. Jackson County Health Department was recommended for Accreditation.

Three health departments had their on-site reviews since September. Benzie-Leelanau District Health Department’s Accreditation On-Site Review occurred the week of September 30th, 2013. Benzie-Leelanau met 142 indicators out of a total of 167. Benzie-Leelanau missed eight indicators this Cycle: one in Powers and Duties, four in Food Service, two in On-Site Wastewater Treatment Management, and one in Vision. Their CPA in Powers and Duties has been fully implemented. The remaining seven CPAs have been accepted with further action required. They had one repeat missed indicator between Cycles 3, 4, and 5, MPR 8 in Food Service and two repeat missed indicators between Cycles 3and 5, Indicators 2.1 and 2.2 in On-Site Wastewater Treatment Management.

C. Miller noted that Wastewater Indicators 2.1 and 2.2 were missed in both Cycle 3 and Cycle 5. Cheatham asked if Benzie-Leelanau still in the process of going through implementing their CPAs. Jones replied that they are still working on them. Enderle asked when their deadline for completion is and Jones replied that they have 1 year after their review so it would be in September 2014.

Dickinson-Iron District Health Department’s Accreditation On-Site Review occurred the week of October 7th, 2013. Dickinson-Iron missed six indicators this Cycle: two in Food Service, one in Immunization, one in Family Planning, and two in CSHCS. Dickinson-Iron participated in the QIS and passed nine out of ten indicators. Their Food Service CPAs have been accepted with further action required.The remaining CPAs have been fully implemented. They did not have any repeat missed indicators between Cycle 3, Cycle 4, and Cycle 5.

Berrien County Health Department’s Accreditation On-Site Review occurred the week of November 4th, 2013. Berrien missed four indicators this Cycle: two in Food Service and two in Family Planning. Berrien participated in the QIS and passed ten out of ten indicators. Their CPAs are due on January 7th, 2014. They did have any commonly missed indicators between Cycles 4 and 5.

Cheatham mentioned that it seems as if everything is running smoothly.Enderle asked if there was a change in the Food Service program. It seems to be a downfall for several LHDs. M. Miller will follow up with Sandra Walker and asked about the number of missed indicators across LHDs.

Cheatham asked if LHDs are participating in the 2 different reviews. One is the “full court press” and the other is the quality assurance version. Is there a difference in how many indicators are missed depending on which path LHDs pursue? Jones replied that MPHI does not receive any information regarding which version an LHD pursues. M. Miller said he would ask Walker about that.

Forzley asked about the most commonly missed indicators in CSHCS and if anyone has any idea on what might be troubling LHDs on those indicators. Jones referenced the most frequently missed indicators chart and noted CSHCS Indicators 3.2 and 3.3 have been missed by more than 5 LHDs. M. Miller noted that CSHCS became a part of MLPHAP in Cycle 5 and had to work through some issues of interpret some of the indicators. M. Miller added that many of these issues have been resolved now and CSHCS is working with MPHI to update their data collection and reporting. Hopefully this will cascade through to the MPRs.

Tews commented that, currently, there are 8 LHDs who have received the distinction of Accreditation with Commendation and asked Jones to go through the requirements to achieve this status. Jones explained that the health department must:

  • Meet 95%,cumulatively, of the essential indicators for the seven mandated services and Powers and Dutiessections
  • Not miss more than two indicators within each program
  • Have zero repeat missed indicators between cycles
  • Meet80% of the QIS indicators

Accreditation Data Reports – Jessie Jones

The Cycle 5 Missed Indicator by Frequency report provides a list of the indicators that have been most commonly missed by LHDs. Thirty-two Accreditation On-Site Reviews have been completed at this point and thirty-two were reflected in the report.

Jones indicated that there have not been many changes since the last Accreditation Commission meeting. Food Service MPR 8 is the most frequently missed indicator with thirty-four percent (11 LHDs) missing it. Twenty-five percent (eight LHDs) missed Food Service MPR 20.Twenty-one percent (7 LHDs) missedFood Service MPR 7 and CSHCS Indicator 3.2.

The Cumulative Quality Improvement Supplement Missed Indicators Report provides the list of indicators that have been most commonly missed by LHDs who chose to participate in the QIS. The most frequently missed indicator is QI Indicator 3.3, which two LHDs missed. Indicator 3.3 is about assuring QI training and technical assistance are available to staff. Each LHD that has participated in the QIS has met at least nine of the ten indicators and twenty-one out of thirty-two LHDs have participated in the QIS.

Cheatham commented that it was great to see that all who participate in QIS are meeting most, if not all, of the indicators.

Jones presented the review evaluation data and explained that the review evaluations are an opportunity for the different sections undergoing the accreditation process to respond to the reviewers about how they feel the review was conducted. Generally all responses fall between the Agree and Strongly Agree range. BCCCP has the highest satisfaction rating among all LHDs. Family Planning, Vision, and Hearing are also doing well. CSHCS is rated the lowest but it has gone up since the beginning of Cycle 5 as reviewers have gotten more experience.

Jones noted that in the future, the question regarding the exit interview being scheduled (question #10) will be removed from future evaluations. It tends to be scored lower than the rest. But it is a moot point because the exit interview is always scheduled in advance.

Tews asked if there is a change in the response rate of the reviewer evaluations. Jones replied that is has decreased and CD, BCCCP, On-Site Sewage, etc. only have 9 responses, compared to CSHCS which has 18 responses. Tews commented that it might indicate that the LHDs might be satisfied with the Accreditation program. Shekter-Smith agreed that people tend to fill out surveys less when they are satisfied. Jones suggested that having to mail in a paper survey might lead to the lower response rates.

M. Miller commented that CSHCS used to have lower ratings because went through a period of time where they were trying to figure out their review method. Cheatham commented that CSHCS was trying to figure out their own process because they had never done it before. C. Miller commented that CSHCS is moving to a managed care model so are the indicators independent of the changes within CSHCS itself? Wonders if the indicators can stand alone and measure what is happening at the local level and not be skewed by what is happening at the state program or the larger healthcare level. Cheatham said that at Mid-MI they were concerned about transitioning to managed care system would not work and that they would lose track of families. But it has worked out well and the CSHCS staff feel positive about the changes. The numbers have not dwindled and communication has stayed the same. The indicators about engaging with families remained. Canady added that there is a distinction between a community plan of care and clinical plan of care. Forzley agreed that it has provided the plans with the opportunity to understand what the families are going through. M. Miller said he would pass on the comments to the CSHCS program and report back to the Commission in March.

Full Accreditation Notification Letters – Jessie Jones

The LHDs that have received their Cycle 5 Accreditation letters since the last voting in September 2013, areGrand Traverse County Health Department, Van Buren-Cass District Health Department, Mid-Michigan District Health Department, and Shiawassee County Health Department.

Cheatham recalled that at his health department, they were looking into MDCH coming in to present to the Board of Health. However, his accreditation team suggested that the presentation should be for the staff at the health department. They thought the Board of Health sees plaques often and wanted the staff to see it. M. Miller presented twice, once to the Environmental Health staff and then to the personal health services staff. The staff has always been told by the administrators that their LHD was special but the presentation created a lot of buy in and emphasized the importance of accreditation. Staff approached Cheatham after the presentation and expressed their satisfaction.