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					                                   CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
   Element [Updated                                   Only Coding
                                  Element [Beta]                                      Updated Workbook (1.0)                                                             Beta
    Workbook (1.0)]                                    Changed
                             Domain 1 - Part B (The
Domain 1                     10 Essential Service                   [no additional change]
                             Domains)
Standard 1.2                 Standard 1.1 B               yes

                                                                    Participate or conduct a Tribal/local partnership for the
Measure 1.1.1 Tribal/local   New/not in beta                        development of a comprehensive community health assessment of New/not in beta
                                                                    the population served by the health department

                                                                    1. Participation of representatives of various sectors of the Tribal or
                                                                    local community
Required Documentation       New/not in beta                                                                                                New/not in beta
                                                                    2. Regular meetings
                                                                    3. Description of the process used to identify issues and assets

Measure 1.1.2 Tribal/Local   New/not in beta                        Complete a Tribal/local community health assessment                   New/not in beta


                                                                    1. A Tribal or local community health assessment dated within the
                                                                    last five years that includes:
                                                                    a. Documentation that data and information from various sources
                                                                    contributed to the community health assessment and how the data
                                                                    were obtained
                                                                    b. A description of the demographics of the population
Required Documentation       New/not in beta                        c. A general description of health issues and specific descriptions of New/not in beta
                                                                    population groups with particular health issues.
                                                                    d. A description of contributing causes of community health issues
                                                                    e. A description of contributing or Tribal assets or resources to
                                                                    address health issues
                                                                    2. Documentation that the Tribal or local community at large has
                                                                    had an opportunity to review and contribute to the assessment


                                                                    Ensure that the community health assessment is accessible to
Measure 1.1.3 All            New/not in beta                                                                                              New/not in beta
                                                                    agencies, organizations, and the general public
                                                                    1. Documentation that the community health assessment has been
                                                                    distributed to partner organizations
Required Documentation       New/not in beta                        2. Documentation that the community health assessment and/or its New/not in beta
                                                                    findings have been made available to the population of the
                                                                    jurisdiction served by the health department
                                                                    Maintain a surveillance system for receiving reports 24/7 in order to Demonstrate that a surveillance system is in place for receiving
Measure 1.2.1 All            Measure 1.1.1 B                        identify health problems, public threats, and environmental public reports 24/7 and for identifying health problems, threats, and
                                                                    health hazards                                                        hazards
                                                                                                                      Required Documentation
                                                   1. Processes and/or protocols to maintain the                      •Processes and protocols to maintain the comprehensive collection,
                                                   comprehensive collection, review, and                              review, and analysis of data from multiple sources,
                                                   analysis of data on multiple health                                •Processes and protocols to assure data are maintained in a secure
                                                   conditions from multiple sources2. Processes and/or protocols to   and confidential manner
Required Documentation   Documentation/Guidance    assure                                                             •Current 24/7contact information, in the form of a designated
                                                   data are maintained in a secure and                                telephone line or a designated contact person (which may be
                                                   confidential manner                                                provided in rural areas via regional or state agreements) •Reports of
                                                   3. Current 24/7contact information                                 testing 24/7 contact systems, such as, internet, fax, page phone line,
                                                   4. Reports of testing 24/7 contact systems                         etc.
                                                                                                                      See Domain 2 for investigation and response activities

Measure 1.2.2 All        Measure 1.1.2 B           Communicate with surveillance sites at least annually              Communicate with surveillance sites on at least an annual basis

                                                   1. Identification of providers and public health
                                                   system partners who are surveillance sites                         Required Documentation
                                                   reporting to the surveillance system                               •List of providers and public health system partners who are
                                                   2. Documentation of trainings/meetings held                        surveillance sites reporting to the surveillance system
                                                   with surveillance sites regarding reporting                        •Documentation of trainings/meetings held with surveillance sites
Required Documentation   Documentation/Guidance
                                                   requirements, reportable                                           regarding reporting requirements, reportable diseases/conditions,
                                                   diseases/conditions, and timeframes                                and timeframes •Reports of surveillance data by reporting site
                                                   3. Surveillance data concerning two different                      •Documentation of distribution of surveillance data (such as emails,
                                                   topics by reporting sites                                          phone calls, newsletters, etc.)
                                                   4. Documentation of distribution of surveillance data
                                                   Collect additional primary and secondary data                      Collect additional primary and secondary data on population health
Measure 1.2.3 All        Measure 1.1.3 B
                                                   on population health status                                        status and public health issues from multiple sources


                                                                                                                      Note: The scope of public health data assessment is broad and
                                                                                                                      includes collection of information by local and state agencies or
                                                                                                                      partners on communicable disease (food/water/air/waste/vector-
                                                                                                                      borne), injuries, chronic disease/disability and morbidity/mortality
                                                                                                                      for the purpose of analysis and use in health data profiles:
                                                                                                                      •Primary data includes communicable disease and public health
                                                   1. Documented aggregated primary and secondary data collected      environmental hazard reports (collected in 1.1.1 B), as well as
Documentation            Documentation/Guidance    and the sources of each                                            community surveys, registries and other methods for tracking
                                                   2. Documentation of standardized data collection instruments       chronic disease and injuries, census data, vital records
                                                                                                                      •Secondary data includes other state health agency data, hospital
                                                                                                                      discharge data and data collected by other agencies (e.g. EPA)
                                                                                                                      Required Documentation
                                                                                                                       •Two examples of aggregated primary and secondary data
                                                                                                                      collected and sources of each •Two examples of standardized data
                                                                                                                      collection instruments


                                                   Provide reports of primary and secondary
                         *Measure 1.1.4 L
Measure 1.2.4 Local                                data to the state health department and Tribal                     Provide reports of primary and secondary data to SHA
                         SEE COMMENT
                                                   health departments in the state
                                                                                                                      Examples of Documentation
                                                   1. Reports of data to the state health                             •Reports to SHA may include entries in registries, web-based
                                                   department and to a Tribal health                                  communicable disease reporting system, faxed paper reports, e-
Required Documentation   *Documentation/Guidance
                                                   department (if one or more is located in                           mail confirmation of receipt of reports
                                                   the state)                                                         See Domain 3 and 4 regarding provision of data/analysis to
                                                                                                                      stakeholders
                                                             Provide reports of primary and secondary data to the state health
Measure 1.2.4 Tribal         *Measure 1.1.4 L                                                                                       Provide reports of primary and secondary data to SHA
                                                             department and local health departments in the state
                                                                                                                               Examples of Documentation
                                                                                                                               •Reports to SHA may include entries in registries, web-based
                                                             1. Reports of data to the state health department and one example communicable disease reporting system, faxed paper reports, e-
Required Documentation       *Documentation/Guidance
                                                             of reports of data to a local health department                   mail confirmation of receipt of reports
                                                                                                                               See Domain 3 and 4 regarding provision of data/analysis to
                                                                                                                               stakeholders
Standard 1.3                 Standard 1.2 B            Yes
                                                                                                                                    1.2.1 B: Analyze and draw conclusions from data to identify trends
                                                                                                                                    over time, clusters, health problems, behavioral risk factors,
Measure 1.3.1 All            Measure 1.2.1 B                 Analyze and draw conclusions from public health data
                                                                                                                                    environmental health hazards, and social and economic conditions
                                                                                                                                    that affect the public’s health

                                                                                                                                    Required Documentation
                                                                                                                                    •Two examples of reports containing analysis of data collected and
                                                                                                                                    conclusions from review of the data (such as epidemiologic reports,
                                                             1. Reports containing analysis of data collected and conclusions
                                                                                                                                    cluster identification or investigation reports, outbreak
                                                             from review of the data with the following characteristics:
                                                                                                                                    investigations, environmental public health hazards, population
                                                             a. Reports are within defined timelines based on policy guidelines
                                                                                                                                    health status or key health indicator reports, community surveys,
                                                             and/or evidence-based practice
                                                                                                                                    outbreak after action reports, Community Health Status Indicators
Required Documentation       Documentation/Guidance          b. Reports compare data to other agencies and/or the state or
                                                                                                                                    [CHSI] reports, with the following characteristics:
                                                             nation, and/or other Tribes, and/or similar data over time to
                                                                                                                                    -Reports are within defined timelines based on policy guidelines
                                                             provide trend analysis
                                                                                                                                    and/or evidence-based practice
                                                             2. Documentation of meetings to review and discuss selected data
                                                                                                                                    -Reports compare data to other agencies and/or the state or nation
                                                             reports
                                                                                                                                    and/or provide trend data
                                                                                                                                    •Minutes or documentation of meetings (e.g., internal/external, or
                                                                                                                                    leadership/community) to review and discuss selected data reports

                                                             Provide public health data to the community in the form of reports
Measure 1.3.2 Local          New/not in beta                                                                                    New/not in beta
                                                             on a variety of public health issues, at least annually
                                                             1. Analytic reports designed to address community public health
Required Documentation       New/not in beta                                                                                        New/not in beta
                                                             issues, distributed to specific audiences with proof of distribution
                                                             Provide public health data to the Tribal community on a variety of
Measure 1.3.2 Tribal         New/not in beta                                                                                        New/not in beta
                                                             public health issues, at least annually
                                                             1. Analytic reports designed to address community public health
Required Documentation       New/not in beta                 issues, distributed to specific audiences with proof of                New/not in beta
                                                             distribution

Standard 1.4                 Standard 1.3 B            Yes

Measure 1.4.1 All            Measure 1.3.1 B           Yes

                                                                                                                                    Required Documentation
                                                             1. Data used to inform public health policy, processes, programs
Required Documentation       Documentation/Guidance                                                                                 •Two examples that demonstrate use of data to inform public
                                                             and/or interventions
                                                                                                                                    health policy, processes, programs and/or interventions
                                                             Develop and distribute Tribal/community health data profiles to
Measure 1.4.2 Tribal/Local   New/not in beta                 support public health improvement planning processes at the Tribal New/not in beta
                                                             or local level
                                           1. Completed health data profiles at least every five years
                                           2. Documented distribution of health profiles to public health
Required Documentation   New/not in beta   system partners, community groups and key stakeholders such as   New/not in beta
                                           governing entities or community advisory groups, via email and
                                           websites, etc.
                                    CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                    Only Coding
                                  Element [Beta]                                      Updated Workbook (1.0)                                                             Beta
   Workbook (1.0)]                                     Changed
Domain 2                     PART B - Domain 2                      [no additional change]
                                                                                                                                          Conduct timely investigations of health problems and
                                                                    Conduct timely investigations of health problems and
Standard 2.1                 Standard 2.1 B                                                                                               environmental public health hazards in coordination with other
                                                                    environmental public health hazards
                                                                                                                                          governmental agencies and key stakeholders


Measure 2.1.1 A              Standard 2.1.1 B             Yes


                                                                                                                                          Required Documentation
                                                                    1. Current written protocols that include:
                                                                                                                                          Current written protocols that include: - Assignment of
                                                                    a. Assignment of responsibilities for investigations of health
                                                                                                                                          responsibilities for investigations of health problems and
Required Documentation       Documentation/Guidance                 problems, environmental, and/or occupational public health hazards
                                                                                                                                          environmental public health hazards - Identifying information about
                                                                    b. Identifying information about the health problem or hazard, case
                                                                                                                                          the health problem or hazard, case investigation steps and timelines,
                                                                    investigation steps and timelines, and reporting requirements
                                                                                                                                          and reporting requirements
                                                                    Demonstrate capacity to conduct and/or support multiple
Measure 2.1.2 State          New/not in beta                        investigations of infectious or communicable diseases                New/not in beta
                                                                    simultaneously
                                                                    1. Procedures for the conduct of multiple, simultaneous
                                                                    investigations
Required Documentation       New/not in beta                        2. Audits, programmatic evaluations, case reviews, or peer reviews New/not in beta
                                                                    of investigation reports against protocols.
                                                                    3. Completed after action reports (AARs)
                                                                    Demonstrate capacity to conduct an investigation of an infectious or
Measure 2.1.2 Tribal/Local   Measure 2.1.2 L                        communicable disease                                                 Demonstrate expertise and capacity to conduct an investigation


                                                                                                                                         Note: This includes infectious health problems and environmental
                                                                                                                                         public health hazards investigations.
                                                                                                                                         Examples of Documentation
                                                                    1. Audits, programmatic evaluations, case reviews or peer reviews of •Documented statement of qualifications for staff conducting
Required Documentation       Documentation/Guidance                 investigation reports against protocols                              investigations
                                                                    2. Completed After Action Report (AAR)                               •Documentation of on-the-job training related to investigations.
                                                                                                                                         •Audits, programmatic evaluations, case reviews or peer reviews of
                                                                                                                                         investigation reports against protocols
                                                                                                                                         •Completed AARs (see 2.2.3 B)
                                                                    Demonstrate capacity to conduct investigations of non-infectious
                                                                                                                                          Demonstrate expertise and capacity to conduct investigations of non-
Measure 2.1.3 All            Measure 2.1.3 B                        health problems, environmental, and/or occupational public health
                                                                                                                                          infectious health problems and hazards
                                                                    hazards
                                                                                                                             Note: This includes morbidity and mortality associated with
                                                                                                                             emergent and non-emergent non-infectious health problems (e.g.
                                                                                                                             non-communicable health problems, drowning, injuries and
                                                                                                                             environmental public health hazards) including risk factors and root
                                                                                                                             causes
                                                                                                                             Required Documentation
                                                  1. Completed investigation of a non-infectious health problem or           •Documented statement of qualifications for staff conducting
Required Documentation   Documentation/Guidance
                                                  hazard                                                                     investigations, OR
                                                                                                                             •Documentation of on-the-job training related to investigations. OR
                                                                                                                             •An example of a partnership established through
                                                                                                                             contracts/MOAs/MOUs/ agreements with other governmental
                                                                                                                             agency or key stakeholders that plays a role in investigations
                                                                                                                             •An example of a completed investigation of a non-infectious health
                                                                                                                             problem or hazard


                                                  Work collaboratively through established governmental and                  Establish partnerships and work collaboratively with governmental
Measure 2.1.4 A          Measure 2.1.4 B          community partnerships on investigations of reportable/disease             and community partners on reportable/disease outbreak or
                                                  outbreaks and environmental public health issues                           environmental public health investigations


                                                                                                                             Required Documentation
                                                  1. Established partnerships with other governmental
                                                                                                                             •Two examples of partners/partnerships established through
                                                  agencies/departments and/or key community stakeholders that play
                                                                                                                             contracts/MOAs/MOUs/ agreements with other governmental
Required Documentation   Documentation/Guidance   a role in investigations or have direct jurisdiction over investigations
                                                                                                                             agencies and key stakeholders that play a role in investigation or
                                                  2. Evidence of working with partners to conduct investigations
                                                                                                                             have direct jurisdiction over investigation.
                                                  3. Provision for laboratory testing for notifiable/reportable diseases
                                                                                                                             •Two examples of working with partners to conduct investigations

                                                  Monitor timely reporting of notifiable/reportable diseases, lab test       Monitor timely reporting of notifiable diseases, lab test results, and
Measure 2.1.5 All        Measure 2.1.5 B
                                                  results, and investigation results                                         investigation results.
                                                                                                                             Required Documentation
                                                  1. Current tracking log or audit or reports of disease reporting,          •Current tracking log of reporting, lab tests and/or investigations
Required Documentation   Documentation/Guidance   laboratory tests reports, and/or investigations with actual timelines      with actual timelines noted, OR
                                                  noted.                                                                     •Current report or audit of reporting, lab tests and/or investigations
                                                  2. Copy of applicable laws                                                 •Copy of applicable laws
                                                  Provide consultation, technical assistance, and/or information to
Measure 2.1.6 State      New/not in beta          Tribal and local health departments in the state regarding disease         New/not in beta
                                                  outbreak and environmental public
                                                  1. Documentation of consultation, technical assistance, and/or
Required Documentation   New/not in beta                                                                                     New/not in beta
                                                  information provided
                                                                                                                             Contain/Mitigate Health problems and environmental public health
                                                  Contain/mitigate health problems and environmental public health
Standard 2.2             Standard 2.2B                                                                                       hazards in coordination with other governmental agencies and key
                                                  hazards
                                                                                                                             stakeholders
                                                                                                                              Maintain protocols for containment/mitigation, including disease-
                                                  Maintain protocols for containment/mitigation of public health
Measure 2.2.1 All        Measure 2.2.1 B                                                                                     specific procedures for outbreaks and conducting follow-up
                                                  problems and environmental public health hazards
                                                                                                                             documentation and reporting
                                                  1. Current written protocol that address containment/mitigation of         Required Documentation
                                                  public health                                                              •Current written protocols for mitigation, contact and clinical
Required Documentation   Documentation/Guidance
                                                  problems and environmental public health                                   management, providing prophylaxis, use of emergency biologics,
                                                  hazards                                                                    and the process for exercising legal authority for disease control
                                                                                                                             Demonstrate that protocols include decision criteria for determining
                                                  Demonstrate a process for determining when the All Hazards
Measure 2.2.2 All        Measure 2.2.2 B                                                                                     when a public health event triggers the All Hazards Plan or the public
                                                  Emergency Operations Plan (EOP) will be implemented
                                                                                                                             health emergency response plan
                                                  1. Infectious disease outbreak protocols
                                                  describing processes for the review of
                                                  specific situations and for determining the                            Note: This includes outbreaks, clusters and environmental public
                                                  activation of the All Hazards Emergency                                health hazards.
                                                  Operations Plan                                                        Required Documentation
                                                  2. Environmental public health protocols                               •Infectious disease outbreak protocols describing initiation triggers
                                                  describing processes for the review of                                 for All Hazards/ERP or the public health emergency response plan
Required Documentation   Documentation/Guidance
                                                  specific situations and for determining the                            •Environmental public health protocols describing initiation triggers
                                                  initiation of the All Hazards Emergency Operations Plan                for All Hazards/ERP or the public health emergency response plan
                                                  3. Cluster evaluation protocols describing                             •Cluster evaluation protocols describing initiation triggers for All
                                                  processes for the review of specific                                   Hazards/ERP or the public health emergency response plan
                                                  situations and for determining initiation of                           [See Standard 5.4 B]
                                                  the All Hazards Emergency Operations
                                                  Plan
                                                                                                                         Complete an After Action Report (AAR) following communicable
Measure 2.2.3 All        Measure 2.2.3 B          Complete and After Action Report (AAR) following events                disease outbreaks, environmental public health risks, natural
                                                                                                                         disasters, and other events that threaten the health of people

                                                                                                                         Note: While AARs have been used for drills and exercises as part of
                                                                                                                         All Hazards Plans (see 5.4.3 B), the intent is to apply the AAR
                                                                                                                         methodology to actual events that significantly threaten the health
                                                                                                                         of people.
                                                  1. Protocols describing the processes used to determine when
                                                                                                                         Required Documentation
                                                  events rise to significance for an AAR review
                                                                                                                         •Thresholds used to determine when events rise to significance and
                                                  2. List of significant events that occurred, including outbreaks and
                                                                                                                         AAR review
Required Documentation   Documentation/Guidance   environmental public health risks
                                                                                                                         •List of significant events that occurred, including outbreaks,
                                                  3. Completed AAR for two events that document successes, issues,
                                                                                                                         environmental public health risks, etc.
                                                  and recommended changes in investigation
                                                                                                                         •Completed After Action Reports for two events which document
                                                  and response procedures or other process improvements
                                                                                                                         what worked well, identify issues and recommend changes in
                                                                                                                         investigation/response procedures and other process improvements
                                                                                                                         See Domain 9 for use of AARs in program evaluation and quality
                                                                                                                         improvement


                                                  Ensure access to laboratory and epidemiological/environmental          Maintain access to laboratory and epidemiological/environmental
                                                  public health expertise and capacity to investigate and                public health expertise and capacity to investigate and
Standard 2.3             Standard 2.3 B
                                                  contain/mitigate public health problems and environmental public       contain/mitigate public health problems and environmental public
                                                  health hazards                                                         health hazards

                                                  Maintain provisions for 24/7 emergency
                                                  access to epidemiological and environmental                             Maintain 24/7 emergency access, including surge capacity, to
                                                  public health resources capable of providing                           epidemiological and environmental public health resources capable
Measure 2.3.1 All        2.3.1 B:                 rapid detection, investigation, and                                    of providing for rapid detection, investigation and
                                                  containment/mitigation of public health                                containment/mitigation of public health problems and
                                                  problems and environmental public                                      environmental public health hazards
                                                  health hazards
                                                                                                                         Examples of Documentation
                                                  1. Policies and procedures ensuring 24/7 coverage                      •All Hazards Plan/ERP
                                                  2. Call Down lists                                                     •Policies and Procedures ensuring 24/7 coverage
Required documentation   Documentation/Guidance
                                                  3. Contracts/MOAs/MOUs/mutual assistance agreements detailing          •Call Down lists
                                                  relevant staff                                                         •Contracts/MOAs/MOUs/Mutual assistance agreements detailing
                                                                                                                         relevant staff
                                                  Maintain 24/7 access to laboratory resources capable of providing       Maintain 24/7 access, including surge capacity, to laboratory
                                                  rapid detection, investigation and containment of health problems      resources capable of providing for rapid detection, investigation and
Measure 2.3.2 All        Measure 2.3.2 B
                                                  and environmental public health                                        containment of health problems and environmental public health
                                                  hazards                                                                hazards
                                                                                                                                  Examples of Documentation
                                                                                                                                  •Laboratory certification, maintains a CLIA certificate or waiver for
                                                        1. Laboratory certification
                                                                                                                                  laboratory testing done on site
                                                        2. Policies and procedures ensuring 24/7
                                                                                                                                  •All Hazards Plan/ERP
Required Documentation   Documentation/Guidance         coverage
                                                                                                                                  •Policies and Procedures ensuring 24/7 coverage
                                                        3. Protocols for handling and submitting
                                                                                                                                  •Contracts/MOAs/MOUs/Mutual assistance agreements with other
                                                        specimens
                                                                                                                                  public and private laboratories
                                                                                                                                  •Protocols for handling and submitting specimens
                                                        Maintain access to laboratory and other
                                                                                                                                   Maintain access to other support personnel and infrastructure
Measure 2.3.3 All        Measure 2.3.3 B                support personnel and infrastructure capable
                                                                                                                                  capable of providing additional surge capacity
                                                        of providing surge capacity
                                                                                                                                  Examples of Documentation
                                                                                                                                  •All Hazards Plan/ERP •Protocol that pre-identifies support
                                                        1. Protocol that pre-identifies support personnel to provide surge
                                                                                                                                  personnel to provide surge capacity •Call Down lists •Staffing list
                                                        capacity
                                                                                                                                  for surge capacity (e.g., nursing, health education, communications,
                                                        2. Staffing list for surge capacity and description of how staff
                                                                                                                                  IT, logistics, and administrative personnel) and description of how
                                                        accesses this information
Required Documentation   Documentation/Guidance                                                                                   staff accesses this information •Documented availability of
                                                        3. Documented availability of equipment
                                                                                                                                  equipment for transportation, field communications, PPE (e.g.,
                                                        4. Training/exercise schedule for surge personnel
                                                                                                                                  Equipment logs, Inventory of transportation vehicles) •On-going
                                                        5. Contracts/MOAs/MOUs/Mutual assistance agreements for
                                                                                                                                  training/exercise schedule (e.g., Basic ICS , PPE training)
                                                        additional staff capacity for surge situations
                                                                                                                                  •Contracts/MOAs/MOUs/Mutual assistance agreements for
                                                                                                                                  additional staff capacity for surge situations

                                                        Demonstrate that Tribal, state, and local health departments work
                                                                                                                                   Demonstrate that SHAs and LHDs work together to build capacity
                                                        together to build capacity and share resources to address Tribal,
                                                                                                                                  and share resources to address state and local efforts to provide for
Measure 2.3.4 All        Measure 2.3.4 B                state, and local efforts to provide for rapid detection, investigation,
                                                                                                                                  rapid detection, investigation, and containment/mitigation of public
                                                        and containment/mitigation of public health problems and
                                                                                                                                  health problems and environmental public health hazards
                                                        environmental public health hazards
                                                        1. Documentation demonstrating shared                                     Examples of Documentation
                                                        resources and/or additional capacity                                      •Reports or other documentation (e.g., meeting minutes,
                                                        2. Joint exercises for rapid detection,                                   memoranda of understanding, emails) demonstrating shared
Required documentation   Documentation/Guidance
                                                        investigation, and containment/mitigation of                              resources and/or additional capacity
                                                        public health problems and environmental                                  •All Hazards Plan/ERP
                                                        public health hazards                                                     •Joint exercises
Standard 2.4             Standard 2.4 B           Yes
Measure 2.4.1 All        Measure 2.4.1 B          Yes

                                                                                                                           Required Documentation (at least two examples updated
                                                                                                                           semiannually from the following)
                                                                                                                           •Protocols that include lists of partners, addresses, telephone lists,
                                                                                                                           email/website addresses for media, health providers, and other
                                                        1. Protocols, updated at least annually, for communication with
                                                                                                                           frequent contacts and provide for redundant communication
                                                        response partners
                                                                                                                           mechanisms, if needed
                                                        2. Documentation of information available to partners (and/or the
                                                                                                                           •Examples of information to the public on how to contact the LHD to
                                                        public) on how to contact the health department to report a public
Required Documentation   Documentation/Guidance                                                                            report a public health emergency or environmental public health risk
                                                        health emergency or environmental/ occupational public health risk
                                                                                                                           24/7 which may include calling 911, or 211, or 311
                                                        24/7
                                                                                                                           •Phone numbers for weekday/weekend and after-hours emergency
                                                        3. Method for partners and the public to contact the health
                                                                                                                           contacts are available to law enforcement and appropriate local
                                                        department 24/7
                                                                                                                           agencies and organizations, such as tribal governments, schools and
                                                                                                                           hospitals •Emails, faxes, websites with contact informati •Call-
                                                                                                                           Down list, telephone tree •After-hours phone answering messages,
                                                                                                                           24/7 pager phone access


                                                                                                                                  Implement a system to receive and provide health alerts and
                                                        Implement a system to receive and provide health alerts and to
Measure 2.4.2 All        Measure 2.4.2 B                                                                                          appropriate public health response for health care providers,
                                                        coordinate an appropriate public health response
                                                                                                                                  emergency responders, and communities on a 24/7 basis
                                                        1. Tracking system such as Health Alert Network (HAN) system        Examples of Documentation
Required documentation   Documentation/Guidance
                                                        2. Reports of testing 24/7 contact and phone line(s)                •Tracking system such as HAN system or other
                                                                                                                            •Reports of testing 24/7 contact and phone line(s)
DELETED FROM                                                                                                                Provide timely communication to local media during public health
                         Measure 2.4.3 B                DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                         emergencies
                                                                                                                            Examples of Documentation
                                                                                                                            •Press conference materials and packages or press releases with
DELETED FROM
                         Documentation/Guidance         DELETED FROM WORKBOOK/NOT IN 1.0                                    dates noted to validate timeliness
WORKBOOK/NOT IN 1.0
                                                                                                                            •Factsheets
                                                                                                                            •Media Contact Sheet
Measure 2.4.3            Measure 2.4.4 B          Yes
                                                        1. Communications to the public that provided accurate, accessible,
                                                                                                                            Examples of Documentation
                                                        and actionable information.
Required documentation   Documentation/Guidance                                                                             •Materials such as media contact sheet, website screen prints,
                                                        2. Use of the media to communicate information during a public
                                                                                                                            flyers, factsheets, with dates noted to validate timeliness
                                                        health emergency
                               CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
   Element [Updated                               Only Coding
                              Element [Beta]                                      Updated Workbook (1.0)                                                            Beta
    Workbook (1.0)]                                Changed
Domain 3                 PART B - Domain 3                      [no additional change]
Standard 3.1             Standard 3.1 B               Yes

                                                                                                                                    Provide information to the public on health risks, health behaviors,
Measure 3.1.1 All        Measure 3.1.1 B
                                                                                                                                    health needs, prevention, and/or wellness approaches

                                                                1. Documentation of the provision of information on health risks,
                                                                health behaviors, prevention, or wellness
                                                                2. Documentation that indicates how information was gathered from   Required Documentation:
                                                                the target group during the development of the                      •Two examples of providing information on health risks, health
Required Documentation   Documentation/Guidance
                                                                educational material/message                                        behaviors, health needs, prevention, and/or wellness including
                                                                3. Documentation of steps taken with Tribal, state, and/or local    information provided, to whom, date, and for what purpose
                                                                health departments; and/or community partners to promote
                                                                coordinated health education messages
                                                                Implement health promotion strategies to protect the population      Implement health promotion strategies to protect the population
Measure 3.1.2 All        Measure 3.1.2 B
                                                                from preventable health conditions                                  from preventable conditions

                                                                                                                                    Note: As in 1.1.3 B, the scope of preventable conditions is very broad.
                                                                                                                                    Required Documentation
                                                                1. Documentation of implemented health promotion strategies         •Two examples of health education and promotion strategies that:
                                                                2. Documentation that indicates how input and/or feedback was       -Correspond to community needs identified through community
                                                                gathered from the target audience during the development of the     health assessment data
Required Documentation   Documentation/Guidance
                                                                health promotion strategy                                           -Are based on sound theory, evidence of effectiveness and/or
                                                                3. Documentation that strategies have been implemented in           promising practices
                                                                collaboration with stakeholders and/or partners                     -Reflect social marketing methods
                                                                                                                                    •Documentation that strategies have been implemented in
                                                                                                                                    collaboration with community partners


                                                                Provide Information on Public Health Issues and Public Health       Provide information on public health issues and functions through
Standard 3.2             Standard 3.2 B
                                                                Functions Through Multiple Methods to a Variety of Audiences        multiple methods to a variety of audiences
                                                                Provide information on public health mission,
                                                                                                                                    Provide information on public health mission, roles, processes,
Measure 3.2.1 All        Measure 3.2.1 B                        roles, processes, programs and interventions to
                                                                                                                                    programs and interventions to improve the community’s health
                                                                improve the public’s health

                                                                                                                                      Required Documentation
                                                                                                                                      •Two examples of providing information on public health mission,
                                                                1. Documentation of providing information to the public about what roles, processes, programs, and/or interventions, including
                                                                public health is, its value, and/or on the health department’s roles, information provided, to whom, date, and for what purpose
                                                                processes, programs, and                                              •At least one example of two of the following items:
Required Documentation   Documentation/Guidance
                                                                interventions                                                         -Educational materials with logo(s)
                                                                2. Documentation of branding or communication of presence of the -Reports or materials distributed to media (such as advertisements,
                                                                health department                                                     press releases etc)
                                                                                                                                      -Agency uniform/department apparel
                                                                                                                                      -Appropriate Signage inside and outside the facility
                                                        Establish and maintain communication procedures to provide               Establish and maintain communication procedures to provide
Measure 3.2.2 All        Measure 3.2.2 B
                                                        information outside the health department                               information outside the agency



                                                        1. Written procedures for communications, updated biennially, that      Required Documentation
                                                        include:                                                                •Written communications procedures with date created and updated
                                                        a. Disseminating accurate, timely, and appropriate information for      biennially, that include:
                                                        different audiences                                                     -Disseminating accurate, timely and appropriate information for
                                                        b. Informing and/or coordinating with community partners for the        different audiences
                                                        communication of targeted and unified public health messages            -Coordinating with community partners for the dissemination of
                                                        c. Maintaining a current contact list of media and key stakeholders     public health messages
Required Documentation   Documentation/Guidance
                                                        d. Designating a staff position as the public information officer       -Maintaining a current contact list of media and key stakeholders
                                                        e. Describing responsibilities and expectations for positions           -Designating a position or person as the public information officer.
                                                        interacting with the news media and the public, including, as           Responsibilities include managing media relationships, creating public
                                                        appropriate, any governing entity members and any department staff      health messages, and other communications activities
                                                        member                                                                  -Describing responsibilities for positions interacting with the news
                                                        2. Dissemination of public health messages outside the health           media and the public, including, as appropriate, any governing entity
                                                        department                                                              members and any public health staff member


Measure 3.2.3 All        Measure 3.2.3 B          Yes
                                                                                                                                Make information available through a variety of methods, including a
Measure 3.2.4 All        Measure 3.2.4 B                Make information available through a variety of methods
                                                                                                                                website

                                                                                                                                 Note: The LHD may have own web site or be part of another entity’s
                                                                                                                                 internet domain
                                                                                                                                 Required Documentation
                                                                                                                                 •Website or web page that contains current information on, at a
                                                        1. Website or web page that contains current information on the
                                                                                                                                 minimum, the following issues:
                                                        following issues:
                                                                                                                                 -24 hr. contact number for reporting health emergencies
                                                        a. 24/7 contact number for reporting health emergencies
                                                                                                                                 -Notifiable conditions line or contact number
                                                        b. Notifiable/reportable conditions line or contact number
                                                                                                                                 -Health data, such as morbidity and mortality data
                                                        c. Health data
                                                                                                                                 -Links to laws
Required Documentation   Documentation/Guidance         d. Links to public health related laws
                                                                                                                                 -Information and materials from program activities such as
                                                        e. Information and materials from program activities
                                                                                                                                 communicable disease, environmental public health and prevention
                                                        f. Links to CDC and other public health related federal, state, or local
                                                                                                                                 -Hyperlink to SHA, CDC and other agencies, as appropriate
                                                        agencies, as appropriate
                                                                                                                                 Other Examples of Documentation
                                                        2. Two examples of other communication strategies for informing the
                                                                                                                                 •Description of communication strategies, including:
                                                        public about public health issues or functions
                                                                                                                                 -Methods (e.g., radio, telephone brochures, flyers, newsletters, press
                                                                                                                                 releases, and other mechanisms)
                                                                                                                                 -Targeted audiences (e.g., the public, governing entity and elected
                                                                                                                                 officials, health care providers)

                                                        Provide accessible, accurate, actionable, and
                                                        current information in culturally sensitive and                         Demonstrate that accurate and current information is available in
Measure 3.2.5 All        Measure 3.2.5 B
                                                        linguistically appropriate formats for                                  formats that are accessible to everyone in the community
                                                        populations served by the health department
                                                  1. Demographic data regarding ethnicity and languages spoken in the         Required Documentation
                                                  community                                                                   •Demographic data regarding ethnicity and languages spoken in the
                                                  2. List of staff or contractors providing interpretation, translation, or   community
                                                  other specific communication services                                       •List of culturally competent staff or contractors providing
                                                  3. Availability of assistive staff or technology devices to meet ADA        interpretation or translation services, as needed based on
Required Documentation   Documentation/Guidance
                                                  requirements                                                                demographic data
                                                  4. Materials that are culturally appropriate, in other languages, at low    •Availability of TTY and other assistive staff or technology devices to
                                                  reading level, and/or address a specific population that                    meet ADA requirements
                                                  may have difficulty with the receipt or understanding of public health      •Two examples of current materials that are culturally appropriate, in
                                                  communications                                                              other languages, and/or at low reading level
                                    CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                    Only Coding
                                  Element [Beta]                                       Updated Workbook (1.0)                                                               Beta
   Workbook (1.0)]                                     Changed
Domain 4                     PART B - Domain 4                      [no additional change]
                                                                    Engage with the Public Health System and the Community in              Engage the public health system and the community in identifying
Standard 4.1                 Standard 4.1.B                         Identifying and Addressing Health Problems                             and addressing health problems through an ongoing, collaborative
                                                                    Through Collaborative Processes                                        process.
                                                                    Establish and/or actively participate in partnerships and/or coalitions Establish and actively participate in collaborative partnerships and
Measure 4.1.1 All            Measure 4.1.1 B
                                                                    to address specific public health issues or populations                 coalitions to address public health issues

                                                                                                                                           Required Documentation
                                                                    1. Documentation of current collaborations that address specific       •Two examples of ongoing collaborations that address public health
                                                                    public health issues or populations                                    issues (e.g. tobacco coalition, maternal child health coalitions,
                                                                    2. List of partner organizations or representation in each             HIV/AIDS coalition, or a planning process such as CHIP)
Required Documentation       Documentation/Guidance
                                                                    collaboration                                                          •List of partners in each collaboration
                                                                    3. Description of process used to mobilize the Tribal/state/local      •Description of process and templates used for collecting feedback
                                                                    community                                                              and evaluating at least one partnership.
                                                                                                                                           •Documentation of use of evaluation findings.

                                                                                                                                           4.1.2 B: Recruit and engage governing entity members, stakeholders,
DELETED FROM
                             Measure 4.1.2 B                        DELETED FROM WORKBOOK/NOT IN 1.0                                       community partners and the public to participate in collaborative
WORKBOOK/NOT IN 1.0
                                                                                                                                           partnerships and coalitions to address important public health issues

                                                                                                                                           NOTE: The following is a list of groups, sectors, and types of
                                                                                                                                           organizations that should be considered for participation in
                                                                                                                                           collaborative partnerships and coalitions; community
                                                                                                                                           representatives, governmental agencies, medical care providers,
                                                                                                                                           education, criminal justice, environmental organizations, regulated
                                                                                                                                           entities, faith-based and business organizations, philanthropy and
                                                                                                                                           others, that reflects diversity and includes representatives of at-risk
DELETED FROM
                             Documentation/Guidance                 DELETED FROM WORKBOOK/NOT IN 1.0                                       and vulnerable populations.
WORKBOOK/NOT IN 1.0
                                                                                                                                           Examples of Documentation
                                                                                                                                           •Documentation of partners who participated in the planning
                                                                                                                                           process
                                                                                                                                           •Documentation of use of an established national or state model to
                                                                                                                                           engage a wide range of diverse stakeholders (e.g. MAPP or use of
                                                                                                                                           the NPHPSP state/local public health system performance
                                                                                                                                           assessment, APEX-PH)
                                                                    Link stakeholders and partners to technical
                                                                                                                                            Link stakeholders to technical assistance regarding models of
Measure 4.1.2 Tribal/local   Measure 4.1.3 B                        assistance regarding models of engaging with
                                                                                                                                           recruiting and engaging with the community, as requested
                                                                    the community
                                                                                                                                           Examples of Documentation
                                                                                                                                           •Documentation of requests and what was provided
                                                                    1. Documentation of consultation, technical assistance, or             •Documentation of technical assistance (e.g. documentation of on-
Required Documentation       Documentation/Guidance
                                                                    information provided on models of community engagement                 site, telephone, web-based assistance or trainings) provided on
                                                                                                                                           using an established model of community planning (e.g., MAPP,
                                                                                                                                           PACE-EH, and others).
                                                                    Promote the community’s understanding of and support                   Promote understanding of and support for policies and strategies
Standard 4. 2                Standard 4.2 B
                                                                    for policies and strategies that will improve the public’s health.     that will improve the public’s health.
DELETED FROM                                                                                                                               Disseminate the results of community health assessments to the
                             Measure 4.2.1 B                        DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                                        community
                                                                                                                       Required Documentation
                                                                                                                       •Two examples of assessment reports on priority community health
DELETED FROM                                                                                                           issues within the last 24 months
                         Documentation/Guidance   DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                    •Documentation of distribution (e.g., e-mails, distribution list)
                                                                                                                       and/or review of reports in Advisory or Coalition minutes within the
                                                                                                                       last 24 months
                                                  Engage with the community about policies and/or strategies that will Engage the community about policies and strategies that will
Measure 4.2.1 All        Measure 4.2.2 B
                                                  promote the public’s health                                          promote the public’s health
                                                                                                                       Required Documentation
                                                  1. Engagement with members of the community that will be affected •Two examples of agency efforts to educate the community,
Required Documentation   Documentation/Guidance   by a policy and/or strategy to promote the public’s                  governing entity and/or elected officials (e.g., presentations,
                                                  health                                                               meeting packets, press stories, event summaries or other
                                                                                                                       documentation)
                                                  Engage with governing entities, advisory boards, and elected officials
Measure 4.2.2 All        New/not in beta                                                                                 New/not in beta
                                                  about policies and/or strategies that will promote the public’s health

                                                  1. Engagement of the governing entity, advisory boards, and/or
Required Documentation   New/not in beta          elected officials about policies and/or strategies that will promote   New/not in beta
                                                  the public’s health
                                CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                Only Coding
                              Element [Beta]                                       Updated Workbook (1.0)                                                                Beta
   Workbook (1.0)]                                 Changed
Domain 5                 PART B - Domain 5                      [no additional change]
                                                                                                                                         Serve as a primary resource to governing entities and elected
                                                                Serve as a primary and expert resource for establishing
Standard 5:1             Standard 5.1 B                                                                                                  officials to establish and maintain public health policies, practices,
                                                                and maintaining public health policies, practices, and capacity
                                                                                                                                         and capacity based on current science and/or promising practice.

                                                                Monitor and track public health issues that are being discussed by       Monitor public health issues under discussion by governing entities
Measure 5.1.1 All        Measure 5.1.1 B
                                                                individuals and entities that set public health policies and practices   and elected officials

                                                                                                                                         Required Documentation
                                                                                                                                         •Two examples of monitoring/tracking public health issues under
                                                                1. Documentation of monitoring/tracking public health policies
                                                                                                                                         discussion by various governing entities (e.g., a tracking system or
Required Documentation   Documentation/Guidance                 under consideration by the governing entity, individuals, and/or
                                                                                                                                         other documentation such as meeting minutes, membership on list-
                                                                other entities that set public health policies and practices
                                                                                                                                         serv, newsletters that show the agency periodically reviews policy
                                                                                                                                         development activity)

                                                                                                                                         Contribute to the development and/or modification of public health
                                                                Engage in activities that contribute to the development and/or
Measure 5.1.2 All        Measure 5.1.2 L                                                                                                 policy by facilitating community involvement and engaging in
                                                                modification of public health policy
                                                                                                                                         activities that inform the policy development process
                                                                                                                                    Required Documentation
                                                                                                                                    •Two current examples of any of the following:
                                                                                                                                    -Informational materials (e.g., issue briefs, media statements, talking
                                                                1. Documentation of the health department’s contributions to
Required Documentation   Documentation/Guidance                                                                                     points, fact sheets)
                                                                deliberations concerning public health policy
                                                                                                                                    -Records of public testimony by agency staff
                                                                                                                                    -Documented participation in advisory groups responsible for
                                                                                                                                    advising on health policy
                                                                Inform governing entities, elected officials, and/or the public of   Inform governing entities, elected officials and the public of
Measure 5.1.3 All        Measure 5.1.3 B                        potential public health impacts, both intended and unintended, from potential public health impacts (both intended and unintended)
                                                                current and/or proposed policies                                    from current and/or proposed policies
                                                                                                                                    Note: Policies include those from other sectors that impact public
                                                                                                                                    health such as land use, housing, transportation, etc.
                                                                                                                                    Required Documentation
                                                                                                                                    •Two current examples of any of the following:
                                                                1. Documentation of the health department informing policy makers -Impact statements or fact sheets about the impact of current or
                                                                and/or the public about potential public health impacts of policies proposed policies
Required Documentation   Documentation/Guidance
                                                                that are being considered or are                                    -Documented distribution of memorandum, emails, briefing
                                                                in place                                                            statements, or discussion of policy issues (e.g., agency staff
                                                                                                                                    involved,governing entity/elected official contacted, topic discussed,
                                                                                                                                    response and follow up)
                                                                                                                                    -Documented presentation of evaluations and/or assessments of
                                                                                                                                    current and/or proposed policies
                                                                Conduct a comprehensive planning process resulting in a             Conduct a comprehensive planning process resulting in a
Stamdard 5.2             Standard 5.3L
                                                                Tribal/state/community health improvement plan                      community health improvement plan [CHIP].
                                                                                                                                    Conduct a community health improvement process that includes
Measure 5.2.1 Local      Measure 5.3.1                          Conduct a process to develop community health improvement plan
                                                                                                                                    broad participation from the community
                                                                                                                   Note: The Community Health Improvement Plan (CHIP) has a larger
                                                                                                                   focus than the organization, and will involve partners in the
                                                                                                                   assessment, planning, and strategy development process, as well as
                                                                                                                   in implementation of strategies. A CHIP and a Strategic Plan can and
                                                                                                                   should cross-reference one another, so a strategic initiative that is in
                                                                                                                   a CHIP may also be in the Strategic Plan. [See Glossary for definitions
                                                  1. Completed community health improvement planning process that and relationships of Strategic Plans, CHIPs/SHIPs and QI plans.] This
                                                  included:                                                        may be a single plan or a series of plans that focus on populations or
                                                  a. Broad participation of community partners                     geographic areas.
Required Documentation   Documentation/Guidance   b. Information from community health assessments                 Required Documentation
                                                  c. Issues and themes identified by stakeholders in the community -Broad participation of community partners
                                                  d. Identification of community assets and resources              -Information from community health assessments
                                                  e. A process to set community health priorities                  -Issues and themes identified by the stakeholders and the
                                                                                                                   community
                                                                                                                   -Identification of community assets and resources
                                                                                                                   -Established set of priority community health issues
                                                                                                                   -Development of measurable health objectives
                                                                                                                   •Completed health improvement process framework such as MAPP
                                                                                                                   or other tools

                                                  Conduct a process to develop a Tribal community health
Measure 5.2.1 Tribal     New/not in beta                                                                                 New/not in beta
                                                  improvement plan
                                                  1. Completed community health improvement
                                                  planning process that included:
                                                  a. Broad participation of public health system partners
Required Documentation   New/not in beta          b. Information from Tribal or community health assessments             New/not in beta
                                                  c. Issues and themes identified by the stakeholders
                                                  d. Identification of Tribal assets and resources
                                                  e. A process to set Tribal health priorities
                                                  Produce a community health improvement plan as a result of the         Produce a community health improvement plan as a result of the
Meausre 5.2.2 Local      Measure 5.3.2 L
                                                  community health improvement process                                   community health improvement process


                                                                                                                         Required Documentation
                                                                                                                         •Documentation that the process included:
                                                                                                                         •Community health improvement plan (CHIP) dated within the last
                                                                                                                         five years that includes:
                                                  1. Community health improvement plan dated within the last five
                                                                                                                         -Assessment data about the prevailing health of the population
                                                  years that includes:
                                                                                                                         -Community health priorities, objectives, improvement strategies
                                                  a. Community health priorities, measurable objectives,
                                                                                                                         and performance measures with measureable and time-framed
                                                  improvement strategies and performance measures with
                                                                                                                         targets. Measurable and time-framed targets may be contained in
                                                  measurable and time-framed targets
                                                                                                                         another document such as an annual workplan.
Required Documentation   Documentation/Guidance   b. Policy changes needed to accomplish health objectives
                                                                                                                         -Policy changes needed to accomplish health objectives
                                                  c. Individuals and organizations that have accepted responsibility for
                                                                                                                         -Individuals and organizations that have accepted responsibility for
                                                  implementing strategies
                                                                                                                         implementing strategies (does not need to be a formal agreement
                                                  d. Measurable health outcomes or indicators to monitor progress
                                                                                                                         such as an MOU)
                                                  e. Alignment between the community health improvement plan and
                                                                                                                         -Measureable health outcomes or indicators to monitor progress
                                                  the state and national priorities
                                                                                                                         Other Examples of Documentation
                                                                                                                         •If available, documentation of alignment between the health
                                                                                                                         improvement plan and community/state/national priorities (i.e.,
                                                                                                                         CHIP takes state and national priorities into consideration)


                                                  Produce a Tribal community health improvement plan as a result of
Measure 5.2.2 Tribal     New/not in beta                                                                                 New/not in beta
                                                  the health improvement process
                                                        1. Tribal health community improvement plan dated within the last
                                                        five years that includes:
                                                        a. Tribal health priorities, measurable objectives, improvement
                                                        strategies and performance measures with
                                                        measurable and time-framed targets
Required Documentation   New/not in beta                b. Policy changes needed to accomplish health objectives               New/not in beta
                                                        c. Individuals and organizations that have accepted responsibility for
                                                        implementing strategies
                                                        d. Measurable health outcomes or indicators to monitor progress
                                                        e. Documentation of alignment between the health improvement
                                                        plan and state and national priorities
                                                        Implement elements and strategies of the health improvement plan, Implement elements and strategies of the community health
Measure 5.2.3 All        Measure 5.3.3 L
                                                        in partnership with others                                        improvement plan, in partnership with others

                                                                                                                               Examples of Documentation
                                                        1. Reports of actions taken related to implementing strategies to
                                                                                                                               •Reports of actions taken related to strategies to improve health
Required Documentation   Documentation/Guidance         improve health
                                                                                                                               •CHIP Workplan with documentation of progress
                                                        2. Examples of how the plan was implemented
                                                                                                                               Note: This measure is Not Applicable if measure 5.3.1 L is not met

                                                        Monitor progress on implementation of strategies in the community
                                                                                                                          Monitor progress on strategies and health improvement in order to
Measure 5.2.4 All        Measure 5.3.4 L                health improvement plan in collaboration with broad participation
                                                                                                                          revise the CHIP, as needed
                                                        from stakeholders and partners

                                                                                                                               Required Documentation
                                                        1. Evaluation reports on progress made in implementing strategies in   •Evaluation reports on progress related to strategies in a CHIP
                                                        the community health improvement plan including:                       including:
                                                        a. Monitoring of performance measures                                  -Monitoring of performance measures
Required Documentation   Documentation/Guidance
                                                        b. Progress related to health improvement indicators                   -Progress related to health improvement indicators (for future
                                                        2. Revised health improvement plan based on evaluation results         iterations of accreditation cycles as these changes may take a while)
                                                                                                                               •Revised CHIP based on evaluation results
                                                                                                                               Note: This measure is Not Applicable if measure 5.3.1 L is not met.

Standard 5.3             Standard 5. 2 B          Yes
Measure 5.3.1 All        Measure 5.2.1 B          Yes


                                                                                                                               Note: The intent of these measures is to develop and implement a
                                                                                                                               strategic plan to strengthen the organization internally. The Strategic
                                                                                                                               Plan focuses on a range of agency level organizational goals,
                                                                                                                               strategies and objectives including new initiatives. [See Glossary for
                                                                                                                               definitions and relationships of Strategic Plans, SHIPs and QI plans.]
                                                        1. Description of elements of the planning process used to develop
                                                                                                                               Required Documentation
                                                        the organization’s strategic plan:
Required Documentation   Documentation/Guidance                                                                                •Documentation of the planning process used to develop the
                                                        a. Membership of the strategic planning group
                                                                                                                               organization’s strategic plan. This could include such topics as:
                                                        b. Strategic planning process steps
                                                                                                                               -Membership of the planning group including agency staff and
                                                                                                                               governing entity members
                                                                                                                               -Identification of external trends, events, or factors that may impact
                                                                                                                               community health or the agency -Assessment of agency strengths
                                                                                                                               and weaknesses -Link to SHIP or QI plan, as appropriate


Meausre 5.3.2 All        Measure 5.2.2 B                Adopt a department strategic plan                                      Develop a strategic plan
                                                  1. Health department strategic plan dated within the last five years
                                                  that includes:
                                                  a. Mission, vision, guiding principles/values                          Required Documentation
                                                  b. Strategic priorities                                                •Agency strategic plan dated within the last five years (may not be
                                                  c. Goals and objectives with measurable and time-framed                titled this, but should contain the following) including:
Required Documentation   Documentation/Guidance   targets                                                                -Mission, vision, guiding principles/values -Strategic priorities -Goals
                                                  d. Identification of external trends, events, or factors that may      and objectives with measureable and time-framed targets.
                                                  impact community health or the health department                       Measurable and time-framed targets may be contained in another
                                                  e. Assessment of health department strengths and weaknesses            document such as an annual work plan, etc
                                                  f. Link to the health improvement plan and quality improvement
                                                  plan
                                                  Produce a community health improvement
Measure 5.3.3 All        Measure 5.2.3 B          plan as a result of the community health                               Develop a strategic plan
                                                  improvement process
                                                                                                                         Required Documentation
                                                  1. Annual reports of progress towards goals and objectives             •Annual reports of progress towards goals and objectives including
Required Documentation   Documentation/Guidance   contained in the plan, including monitoring and conclusions on         monitoring of performance measures and conclusions on progress
                                                  progress toward meeting targets                                        toward targets
                                                                                                                         Note: This measure is Not Applicable if measure 5.2.2 B is not met.
Measure 5.3.3 All        Measure 5.2.4 B          Measure 5.3.3 All (Above)                                              Review and revise the strategic plan

                                                                                                                         Required Documentation
Required Documentation   Documentation/Guidance   Measure 5.3.3 All (Above)                                              •Documentation of revised strategic plan at least every five years
                                                                                                                         Note: This measure is Not Applicable if measure 5.2.2 B is not met.
                               CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                Only Coding
                              Element [Beta]                                       Updated Workbook (1.0)                                                             Beta
   Workbook (1.0)]                                 Changed
Domain 6                 PART B - Domain 6                      Enforce public health laws                                             Enforce public health laws and regulations
                                                                Review existing laws and work with governing entities and             Review existing laws and work with governing entities and elected
Standard 6.1             Standard 6.1 B
                                                                elected/appointed officials to update as needed                       officials to update as needed
                                                                                                                                      Maintain access to legal and program expertise to assist in the review
Measure 6.1.1 All        Measure 6.1.1 B                        Review laws to determine the need for revisions
                                                                                                                                      of laws

                                                                1. Reviews of public health laws or laws with public health          Required Documentation
                                                                implications within last three years that include the following:     •Documentation that legal counsel is available to the LHD, such as a
                                                                                                                                     contract or MOU or MOA for services with legal counsel or
                                                                a. Evaluations of laws for consistency with public health evidence-  documentation of legal assistance (e.g., legal opinions on file, review
Required Documentatino   Documentation/Guidance                 based and/or promising practices                                     and feedback)
                                                                b. Documented use of model public health laws, checklists, templates •Documentation of using program experts to review proposed laws
                                                                and/or exercises in reviewing laws                                   for conformance with programmatic requirements
                                                                c. Documentation of input solicited from key stakeholders on         Other Examples of Documentation
                                                                proposed and/or reviewed laws                                        •Documentation of attendance at seminars or training regarding laws

DELETED FROM
                         Measure 6.1.2 B                        DELETED FROM WORKBOOK/NOT IN 1.0                                      6.1.2 B: Evaluate the need for changes in laws
WORKBOOK/NOT IN 1.0

                                                                                                                                      Required Documentation
                                                                                                                                      •Two examples of review of laws (e.g., minutes or presentations)
                                                                                                                                      within last three years
                                                                                                                                      •At least one example of a regulation/ordinance or enforcement
                                                                                                                                      activity that changed as a result of review within last three years
                                                                                                                                      Other Examples of Documentation
DELETED FROM
                         Documentation/Guidance                 DELETED FROM WORKBOOK/NOT IN 1.0                                      •Evaluations of laws, and enforcement activities for consistency with
WORKBOOK/NOT IN 1.0
                                                                                                                                      evidence-based and/or promising practices for achieving compliance
                                                                                                                                      •Documented use of model public health laws, checklists, templates
                                                                                                                                      and/or exercises in reviewing laws
                                                                                                                                      •Documentation of input solicited from key stakeholders on
                                                                                                                                      proposed and/or reviewed laws (e.g., Issue forums; town meetings,
                                                                                                                                      hearings)

                                                                Inform governing entity and/or
                                                                elected/appointed officials of needed                                 Inform governing entity and elected officials of needed updates of
Measure 6.1.2 All        Measure 6.1.3 B
                                                                updates/amendments to current laws and/or                             laws and make recommendations for action
                                                                proposed new laws
                                                                                                                                      Examples of Documentation
                                                                1. Documentation of distribution of two written
                                                                                                                                      •Policy agendas, position papers, white papers, legislative briefs
                                                                recommendations to governing entity and/or elected/appointed
Required Documentatino   Documentation/Guidance                                                                                       including recommendations for action
                                                                officials concerning amendments or updates to current laws and/or
                                                                                                                                      •Documentation of distribution to governing entity and/or elected
                                                                proposed new laws
                                                                                                                                      officials
Standard 6.2             Standard 6.2                 Yes
                                                                Maintain agency knowledge and apply public health laws in a           Maintain agency knowledge and consistent application of public
Measure 6.2.1 All        Measure 6.2.1 B
                                                                consistent manner                                                     health laws
                                                                                                                               Required Documentation
                                                                                                                               •List of positions with regulatory and enforcement responsibilities
                                                        1. Documentation of staff training in laws to support public health
                                                                                                                               and their job descriptions
                                                        interventions and practice within the last two years
Required Documentatino   Documentation/Guidance                                                                                •Documentation of staff training in uses of laws to support public
                                                        2. Documentation of efforts to ensure consistent
                                                                                                                               health interventions and practice, within the last two years
                                                        application of public health laws
                                                                                                                               •Documentation of consistent application of public health laws, e.g.
                                                                                                                               audits of case files

                                                        Ensure that laws and permit/license application requirements are        Make laws, and permit/license application requirements accessible
Measure 6.2.2 All        Measure 6.2.2 B
                                                        accessible to the public                                               to the public
                                                                                                                               Examples of Documentation
                                                                                                                               •Website access (or alternative physical location within the agency)
                                                        1. Public access to information about laws and permit/license          to laws and permit/license application processes
Required Documentatino   Documentation/Guidance
                                                        application processes                                                  •Newsletters or direct mailings, with distribution list
                                                                                                                               •Other documentation of distribution, e.g. responses to requests,
                                                                                                                               logs of violations, and/or complaints
                                                         Provide information or education to regulated entities regarding      Provide education to regulated entities regarding their
Measure 6.2.3 All        Meaasure 6.2.3 B               their responsibilities and methods to achieve full compliance with     responsibilities and methods to achieve full compliance with
                                                        public health related laws                                             applicable laws

                                                                                                                               Examples of Documentation
                                                                                                                               •Website FAQ site and other educational materials
                                                        1. Written record of the provision of information or education to      •Newsletters, with distribution list                      •Training
Required Documentatino   Documentation/Guidance         regulated entities concerning their responsibilities for               sessions, with attendance list and materials
                                                        compliance with public health laws                                     •Public meetings with minutes, agendas, and attendance list
                                                                                                                               •Documentation of TA provided through email, phone logs, etc.
                                                                                                                               •Press releases


                                                                                                                               Conduct and monitor enforcement activities for which the agency
                                                        Conduct and monitor public health enforcement activities and
Standard 6.3             Standard 6.3 B                                                                                        has the authority and coordinate notification of violations among
                                                        coordinate notification of violations among appropriate agencies
                                                                                                                               appropriate agencies
Measure 6.3.1 All        Measure 6.3.1 B          Yes
                                                                                                                               Required Documentation
                                                        1. Documentation of authority to conduct enforcement activities
                                                                                                                               •Documentation of authority to conduct enforcement activities
Required Documentatino   Documentation/Guidance         2. Procedures and protocols for laws or enforcement actions for
                                                                                                                               •Procedures and protocols/decision trees for laws or enforcement
                                                        achieving compliance
                                                                                                                               actions for achieving compliance


                                                        Conduct and monitor inspection activities of
                                                                                                                               Conduct inspection activities of regulated entities according to
                                                        regulated entities according to mandated
Measure 6.3.2 All        Measure 6.3.2 B                                                                                       mandated frequency and/or a risk analysis method that guides the
                                                        frequency and/or a risk analysis method that
                                                                                                                               frequency and scheduling of inspections of regulated entities
                                                        guides the frequency and scheduling of
                                                        inspections of regulated entities
                                                                                                                               Examples of Documentation
                                                                                                                               •Protocol/algorithm for scheduling inspections (e.g., identify
                                                        1. Protocol/algorithm for scheduling inspections of regulated entities restaurants with frequent violations) or documentation of
Required Documentatino   Documentation/Guidance         2. Database or log of inspection reports with actions, status, follow- compliance with mandated frequencies
                                                        up, re-inspections, and final disposition                              •Inspection work plan or schedule with appropriate frequencies
                                                                                                                               •Database or log of inspection reports with actions, status, follow-up,
                                                                                                                               reinspections and final disposition
                                                                                                                           Conduct enforcement activities and follow up on complaints
Measure 6.3.3 All        Measure 6.3.3 B          Follow procedures and protocols for both routine and emergency           according to procedures and protocols for both routine and
                                                  situations requiring enforcement activities and complaint follow-up      emergency situations

                                                                                                                           Required Documentation
                                                  1. Data base or log of actions with analysis and standards for follow-
                                                                                                                           •Data base or log of actions with analysis and standards for follow-up
                                                  up at each level
Required Documentatino   Documentation/Guidance                                                                            at each level
                                                  2. Communications with regulated entities regarding a complaint or
                                                                                                                           •Documentation of hearings, meetings with regulated entities,
                                                  compliance plan
                                                                                                                           compliance plans
                                                                                                                           Conduct analysis of complaints, violations and enforcement activities
Measure 6.3.4 All        Measure 6.3.4 B          Determine patterns or trends in compliance from enforcement
                                                                                                                           to determine patterns, trends, compliance and effectiveness
                                                  activities, and complaints

                                                                                                                       Examples of Documentation
                                                                                                                       •Annual report summarizing complaints, violations, enforcement
                                                                                                                       activities
                                                  1. Annual report summarizing complaints, enforcement activities, and •Documentation of an evaluation of a random number of
                                                  compliance                                                           enforcement actions each year to determine compliance with
Required Documentatino   Documentation/Guidance
                                                  2. Debriefings or other evaluations of specific                      timeliness and effectiveness of enforcement procedures
                                                  enforcement for process improvements                                 •Debriefings or other evaluations of specific enforcement actions
                                                                                                                       with documentation of what worked well, issues and recommended
                                                                                                                       changes in investigation/response procedures and other process
                                                                                                                       improvements

                                                  Coordinate notification of violations to the public, when required,      Coordinate notification of violations to the public, when required,
                                                  and coordinate the sharing of information among appropriate              and coordinate the sharing of information about enforcement
Standard 6.3.5 All       Standard 6.3.5 B
                                                  agencies about enforcement activities, followup                          activities, analysis, results and follow-up activities among appropriate
                                                  activities, and trends or patterns                                       agencies


                                                                                                                       Required Documentation
                                                                                                                       •Communication protocol for interagency notification cooperation
                                                  1. Communication protocol for interagency notifications
                                                                                                                       •If notification of the public is required, documentation of the
                                                  2. Protocol for notification of the public when required
Required Documentatino   Documentation/Guidance                                                                        protocol for notification
                                                  3. Documentation of notification of enforcement actions, and sharing
                                                                                                                       •Two examples of notification of enforcement actions, e.g. websites,
                                                  information concerning enforcement activities
                                                                                                                       minutes, conference calls, emails, correspondence, MOUs and MOAs
                                                                                                                       that demonstrate sharing of information in enforcement activities
                                CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                 Only Coding
                              Element [Beta]                                        Updated Workbook (1.0)                                                               Beta
   Workbook (1.0)]                                  Changed
Domain 7                 PART B - Domain 7                       [no additional change]
                                                                 Assess health care service capacity and access to health care
Standard 7.1             Standard 7.1 B                                                                                                  Assess healthcare capacity and access to healthcare services
                                                                 services.
Measure 7.1.1 All        Measure 7.1.1 B                Yes

                                                                                                                                         Note: The intent of these measures is for LHDs to participate in
                                                                                                                                         community activities to assess and improve individuals’ access to
                                                                                                                                         general healthcare services. The LHD is NOT expected to directly
                                                                                                                                         provide any general healthcare services in order to improve access.
                                                                                                                                         Healthcare services include, but are not limited to, clinical preventive
                                                                                                                                         services, EMS, emergency departments, urgent care, ambulatory
                                                                                                                                         care (primary and specialty), inpatient care, dental, and behavioral
                                                                 1. A collaborative process to assess availability of health care        health. [See Glossary for definition of Healthcare Services]
                                                                 services                                                                Examples of Documentation
Required Documentation   Documentation/Guidance                  2. Description of partnerships across Tribal, state, and local health   •Charters, meeting agendas with minutes or rosters of
                                                                 departments and the health care system to make comprehensive            coalitions/networks/councils and their members (e.g., healthcare
                                                                 data available for the purposes of health care access planning          providers, social services organizations, and other stakeholders)
                                                                                                                                         working on collaborative processes to assess availability of
                                                                                                                                         healthcare services
                                                                                                                                         •Description of partnerships across the SHA, LHDs, and the
                                                                                                                                         healthcare system to make comprehensive data available for the
                                                                                                                                         purposes of healthcare planning (e.g., regional health information
                                                                                                                                         organizations (RHIOs) and health information exchanges (HIEs), less
                                                                                                                                         formal local planning efforts)

                                                                 Identify populations who experience barriers                            Identify underserved and at-risk populations and those who may
Measure 7.1.2 All        Measure 7.1.2 B
                                                                 to health care services                                                 experience barriers to healthcare services
                                                                                                                                         Examples of Documentation
                                                                                                                                         •Specific reports of needs of the population as indicated in other
                                                                                                                                         consumer satisfaction surveys, and surveys of special population
                                                                 1. Reports of health care needs of the population
                                                                                                                                         groups [See Standard 1.3 and Standard 5.3]
                                                                 2. Description of the process(s), used for the identification of
                                                                                                                                         •Description of process, e.g. sector maps or other tools, for including
                                                                 program gaps and barriers to accessing health care services
                                                                                                                                         diverse sets of community partners, including communities of color,
                                                                                                                                         tribal representatives, and specific populations to assist in
                                                                                                                                         identification of programs gaps and barriers to accessing care
Measure 7.1.3 All        Measure 7.1.3 B          yes

                                                                                                                                        Required Documentation
                                                                                                                                        •Data from across the partnership (see 7.1.1) that includes any of
                                                                 1. Reports of analysis of data from across the partnership (see 7.1.1)
                                                                                                                                        the following:
                                                                 that identify the gaps in access to health care services and the
                                                                                                                                        oAssessment of capacity and distribution of healthcare workforce
                                                                 causes of gaps in access. Reports must include:
                                                                                                                                        oAvailability of healthcare services such as clinical preventive
                                                                 a. Assessment of capacity and
Required Documentation   Documentation/Guidance                                                                                         services, EMS, emergency departments, urgent care, ambulatory
                                                                 distribution of health care providers
                                                                                                                                        care (primary and specialty), inpatient care, dental, behavioral
                                                                 b. Availability of health care services
                                                                                                                                        health, and other services
                                                                 c. Identification of causes of gaps in services
                                                                                                                                        oResults of periodic surveys of access, such as focus groups, studies
                                                                 d. Results of periodic surveys of access
                                                                                                                                        of eligibles receiving services and other assessment information•
                                                                                                                                        Analysis of data identifying gaps in access
                                                                                                                              Required Documentation
                                                                                                                              •One example of coalitions/networks/councils (e.g. charters or
                                                                                                                              rosters) working on collaborative processes to reduce barriers to
Standard 7.2             Standard 7.2 B           Yes                                                                         accessing healthcare services that are linked to gaps in access [See
                                                                                                                              7.1.3 above]
                                                                                                                              •Reports or meeting minutes of coalitions/networks with identified
                                                                                                                              strategies to improve access to healthcare services
Measure 7.2.1 All        Measure 7.2.1 B          Yes

                                                                                                                              Required Documentation
                                                        1. Documentation that a coalition/network/council is working on       •One example of coalitions/networks/councils (e.g. charters or
                                                        collaborative processes to reduce barriers to health care access or   rosters) working on collaborative processes to reduce barriers to
Required Documentation   Documentation/Guidance         gaps in access                                                        accessing healthcare services that are linked to gaps in access [See
                                                        2. Development of strategies through the collaborative process to     7.1.3 above]
                                                        improve access to health care services                                •Reports or meeting minutes of coalitions/networks with identified
                                                                                                                              strategies to improve access to healthcare services
                                                                                                                              Implement and/or collaborate to implement strategies to increase
                                                                                                                              access to healthcare services, including linking individuals with
Measure 7.2.2 All        Measure 7.2.2 B                Collaborate to implement strategies to increase access to health
                                                                                                                              needed services and/or establish systems of care in partnership with
                                                        care services
                                                                                                                              the community

                                                                                                                              Required Documentation
                                                                                                                              •Two examples of active relationships with community providers
                                                                                                                              such as schools, health care providers, tribal programs and social
                                                                                                                              services agencies, which include mechanisms to share information,
                                                                                                                              assist people in obtaining the services they need and optimize
                                                                                                                              access. Some examples include:
                                                                                                                              -Memoranda of Understanding
                                                                                                                              -Cooperative system of referral used by agency and community
                                                                                                                              partners to assist people who experience barriers to obtaining
                                                        1. Documentation of collaborative                                     needed health services
                                                        implementation of mechanisms or                                       -Documentation of outreach activities, case finding, case
                                                        strategies to assist the public in obtaining                          management, and activities to ensure that people can obtain the
                                                        access to health care services                                        services they need
                                                                                                                              -Assistance to eligible beneficiaries with application and enrollment
                                                                                                                              in Medicaid, or other medical assistance programs
                                                                                                                              -Service program coordination (e.g., common intake form) and/or co-
                                                                                                                              location (e.g., WIC, Immunizations and lead testing) to optimize
                                                                                                                              access
                                                                                                                              -Grant applications submitted by community partnerships
                                                                                                                              -Subcontracts in the community to deliver healthcare services
                                                                                                                              -Program/work plans that document strategies have been
                                                                                                                              implemented


                                                        Lead or collaborate in culturally competent initiatives to increase
                                                                                                                             Lead or collaborate in culturally competent initiatives to increase
Measure 7.2.3 All        Measure 7.2.3 B                access to health care services for those who may experience barriers
                                                                                                                             healthcare access for underserved and at-risk populations
                                                        due to cultural, language, or literacy differences
                                                                                                                   Note: Methods for including diverse sets of community partners,
                                                                                                                   including communities of color, tribal representatives, and specific
                                                                                                                   populations to assist in planning and implementing programs
                                                                                                                   intended to reach targeted population groups
                                                                                                                   Examples of Documentation
                                                  1. Interventions delivered in a culturally competent manner to   •Examples of interventions delivered in a culturally competent
Required Documentation   Documentation/Guidance
                                                  populations within the jurisdiction of the health department     manner, such as use of lay health advocates indigenous to targeted
                                                                                                                   population groups
                                                                                                                   •Documentation (such as staff resumes or attendance at training
                                                                                                                   session for cultural competency) that agency staff with appropriate
                                                                                                                   language and cultural competency skills work to gain trust and
                                                                                                                   develop rapport with targeted population groups
                                   CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                    Only Coding
                                  Element [Beta]                                      Updated Workbook (1.0)                                                           Beta
   Workbook (1.0)]                                     Changed
Domain 8                     PART B - Domain 8                      [no additional change]
                                                                    Encourage the development of a sufficient number of qualified      Recruit, hire and retain a qualified and diverse public health
Standard 8.1                 Standard 8.1 B
                                                                    public health workers.                                             workforce.
                                                                                                                                       Establish relationships and/or collaborate with schools of public
                                                                    Establish relationships and/or collaborations that promote the
Measure 8.1.1 Tribal/Local   Measure 8.1.4 B                                                                                           health and/or other related academic programs to promote the
                                                                    development of future public health workers
                                                                                                                                       development of qualified workers for public health

                                                                                                                                       Required Documentation
                                                                                                                                       •One example of partnership or collaboration with educational
                                                                                                                                       organization with evidence of strategies for promoting public health
                                                                    1. Documentation of relationships or collaborations that promote   as a career or of training in public health fields, such as:
Required Documentation       Documentation/Guidance
                                                                    public health as a career                                          -Practicum, student placements/academic service learning, and/or
                                                                                                                                       internship opportunities -Involvement in joint programs - Faculty
                                                                                                                                       positions or guest lectures
                                                                                                                                       - Participation in high school, college and/or job/career fairs
DELETED FROM                                                                                                                           Apply recruitment and retention policies and make them available to
                             Measure 8.1.1 B                        DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                                    staff

                                                                                                                                       Required Documentation
                                                                                                                                       •Two examples of recruitment of qualified and diverse staff that
                                                                                                                                       reflects the population being served (e.g. job postings and position
                                                                                                                                       descriptions specify needed competencies, educational and
                                                                                                                                       experience requirements)
                                                                                                                                       •Two examples of conducting retention activities of qualified and
                                                                                                                                       diverse staff (e.g. employee satisfaction survey results, needs
                                                                                                                                       assessments of work environment, reward and recognition programs,
                                                                                                                                       career ladders, promotion opportunities, supervisor mentoring
DELETED FROM                                                                                                                           programs)
                             Documentation/Guidance                 DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                                    •Two examples of how policies are made available to staff such as
                                                                                                                                       intranet, policy manual, or review of policies as part of orientation
                                                                                                                                       •One example of how recruitment efforts are designed to promote
                                                                                                                                       diversity
                                                                                                                                       •One example of succession planning for critical positions
                                                                                                                                       Examples of Documentation
                                                                                                                                       •Data and analysis of recruitment actions (e.g. percent of minority
                                                                                                                                       staff, percent of vacancies filled in timely manner)
                                                                                                                                       •Data and analysis of retention actions (e.g. turnover rate for last
                                                                                                                                       three years)

DELETED FROM
                             Measure 8.1.2 B                        DELETED FROM WORKBOOK/NOT IN 1.0                                   Make job standards and position descriptions available to staff
WORKBOOK/NOT IN 1.0

                                                                                                                                       Required Documentation
DELETED FROM                                                                                                                           •Demonstrate that job and position descriptions are available to staff
                             Documentation/Guidance                 DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                                    •Documentation of review of job duties and responsibilities with new
                                                                                                                                       staff (within last two years)
DELETED FROM                                                                                                                     8.1.3 B: Confirm that staff meet qualifications for their positions, job
                             Measure 8.1.3 B                DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                              classifications and licensure

                                                                                                                                 Note: The intent of this measure is that LHDs have stated the
                                                                                                                                 qualifications, including core competencies, necessary for each
                                                                                                                                 position and verify staff compliance with these qualifications.
                                                                                                                                 Required Documentation
DELETED FROM
                             Documentation/Guidance         DELETED FROM WORKBOOK/NOT IN 1.0                                     •Description of process to verify staff qualifications
WORKBOOK/NOT IN 1.0
                                                                                                                                 •Evidence that qualifications have been checked for all staff hired in
                                                                                                                                 last two years (e.g. logs or spreadsheets or other evidence showing
                                                                                                                                 verification of licensure or certification; education and/or degrees,
                                                                                                                                 required core competencies, prior public health experience)

Standard 8.2                 Standard 8.2 B           Yes

                                                            Maintain, implement and assess the health department workforce        Implement an agency workforce development plan that addresses
Measure 8.2.1 Tribal/Local   Measure 8.2.2 B                development plan that ddresses the training needs of the staff and   the training needs of the staff and development of core
                                                            the development of core competencies                                 competencies

                                                                                                                                 Examples of Documentation
                                                                                                                                 •Agency workforce development plan that includes:
                                                                                                                                 -Nationally adopted core competencies, such as Core Competencies
                                                                                                                                 for Public Health Professionals from Council on Linkages or other set
                                                            1. Health department workforce de velopment plan that includes:      of competencies
                                                            a. Nationally adopted core competencies                              -Use of results from agency customer satisfaction studies (See
Required Documentation       Documentation/Guidance         b. Curricula and training schedules                                  Standard 9.1)
                                                            2. Documentation of implementation of the health department          -Description of the overall work of the agency and how various
                                                            workforce development plan                                           functions contribute to that work
                                                                                                                                 -Curricula and training schedules
                                                                                                                                 •Two examples of implementing the agency workforce development
                                                                                                                                 plan (e.g. training curricula to address gap, staff attendance at state
                                                                                                                                 or national conferences)
DELETED FROM
                             Measure 8.2.1 B                DELETED FROM WORKBOOK/NOT IN 1.0                                     Complete performance evaluations and improvement/training plans
WORKBOOK/NOT IN 1.0

                                                                                                                                 Required Documentation
                                                                                                                                 •Policy for conducting employee evaluations
                                                                                                                                 •Template/form for performance evaluations with
DELETED FROM
                             Documentation/Guidance         DELETED FROM WORKBOOK/NOT IN 1.0                                     improvement/training objectives
WORKBOOK/NOT IN 1.0
                                                                                                                                 •Report on percent of eligible employees (employed longer than 12
                                                                                                                                 months) with performance evaluations and improvement/training
                                                                                                                                 objectives updated annually or as required by agency policy

                                                            Provide leadership and management                                   Make provisions for staff leadership and management development
Measure 8.2.2 All            Measure 8.2.3 B
                                                            development activities                                              activities
                                                                                                                                Examples of Documentation
                                                                                                                                •Documented training activities in the past two years, with content
                                                                                                                                and attendance list
                                                                                                                                •Documented participation in courses such as :
                                                            1. Documented training/development activities in the past two years -National Public Health Leadership Institute
Required Documentation       Documentation/Guidance
                                                            2. Documented participation in courses                              -Environmental Public Health Leadership Institute
                                                                                                                                -Regional, state or local public health leadership institutes
                                                                                                                                -Executive management seminars or programs
                                                                                                                                -Graduate programs in leadership/management
                                                                                                                                •An example of succession planning for critical positions
                               CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
   Element [Updated                               Only Coding
                              Element [Beta]                                        Updated Workbook (1.0)                                                                Beta
    Workbook (1.0)]                                Changed

                                                                Evaluate and continuously improve health          Evaluate and continuously improve processes,
Domain 9                 PART B - Domain 9
                                                                department processes, programs, and interventions programs, and interventions
                                                                Use a performance management system to                                    Evaluate public health processes, programs, and interventions
Standard 9.1             Standard 9.1 B
                                                                monitor achievement of organizational objectives.                         provided by the agency and its contractors.
                                                                Engage staff at all organizational levels in establishing or updating a
                                                                                                                                           Engage governing entity in establishing agency policy direction
Measure 9.1.1 All        Measure 9.1.1 B                        performance
                                                                                                                                          regarding a performance management system
                                                                management system
                                                                1. Documentation of engaging the health department leadership and
                                                                management in establishing or updating a performance management           Note: this measure is focused on governing entity activities.
                                                                system                                                                    Examples of Documentation
Required Documentation   Documentation/Guidance
                                                                2. Documentation of engaging the health department staff at all           •Documentation of governing entity policy direction (e.g., meeting
                                                                other levels in establishing or updating a performance                    packets and minutes)
                                                                management system
                                                                                                                                          Establish agency policy and capacity to implement a performance
Measure 9.1.2 All        Measure 9.1.2 B
                                                                Implement a performance management system                                 management system
                                                                                                                                          Note: this measure is focused on administrative capacity to support
                                                                                                                                          performance management
                                                                                                                                          Examples of Documentation
                                                                1. A completed performance management self-assessment                     •Relevant agency policies and proof of updates •Documented staff
Required Documentation   Documentation/Guidance                 2. A current, functioning performance management committee or             availability and/or involvement to support evaluation of agency
                                                                team                                                                      performance and quality improvement (e.g., access to or assignment
                                                                                                                                          of staff with knowledge and skill in evaluation methodologies and
                                                                                                                                          tools and in quality improvement methodologies and tools)
                                                                                                                                          •QI Committee charter, minutes


Measure 9.1.3 All                                               Use a process to determine and report on achievement of goals,            Establish goals, objectives and performance measures for processes,
                         Measure 9.1.3 B
SEE COMMENT                                                     objectives, and measures set by the performance                           programs and interventions
                                                                management system
                                                                                                                                          Note: The intent of this measure is that key processes and all
                                                                1. Written goals and objectives which include time frames for
                                                                                                                                          programs and interventions of the agency (whether delivered
                                                                measurement
                                                                                                                                          directly, delegated or contracted) have goals, objectives, and
                                                                2. Demonstration of a process for monitoring of performance of goals
                                                                                                                                          quantifiable performance measures, including process and/or health
                                                                and objectives
Required Documentation   Documentation/Guidance                                                                                           outcomes
                                                                3. Demonstration of analysis of progress toward achieving goals and
                                                                                                                                          Required Documentation
                                                                objectives, and identify areas in need of focused
                                                                                                                                          •Two examples of goals, objectives and related quantifiable
                                                                improvement processes
                                                                                                                                          performance measures with time-framed targets for a process,
                                                                4. Documentation of results and next steps
                                                                                                                                          program, or intervention
                                                                                                                                          Monitor performance measures for processes, programs and
                         Measure 9.1.4 B                        9.1.3 ALL (ABOVE)
Measure 9.1.3 All                                                                                                                         interventions
                                                                                                                             Note: The intent of this measure is that key processes and all
                                                                                                                             programs and interventions of the agency have quantifiable
                                                                                                                             performance measures that are monitored
                                                                                                                             Required Documentation
Required Documentation   Documentation/Guidance         9.1.3 ALL (ABOVE)
                                                                                                                             •For the two examples in 9.1.3 B, documentation of monitoring
                                                                                                                             actual performance (e.g., data reports, statistical summaries,
                                                                                                                             graphical presentations of performance on the measures)
                                                                                                                             Note: this measure is Not Applicable if 9.1.3 B is not met
                                                                                                                             Evaluate the effectiveness of processes, programs, and interventions
Measure 9.1.3 All        Meausure 9.1.5 B               9.1.3 ALL (ABOVE)
                                                                                                                             and identify needs for improvement
                                                                                                                             Note: The intent of this measure is that key processes and all
                                                                                                                             programs and interventions of the agency are evaluated and
                                                                                                                             monitoring data is used to identify areas and methods for
                                                                                                                             improvement
                                                                                                                             Required Documentation
Required Documentation   Documentation/Guidance         9.1.3 ALL (ABOVE)
                                                                                                                             •For the two examples in 9.1.3 B, documentation of analysis of goals,
                                                                                                                             objectives, actual performance on measures compared to time-
                                                                                                                             framed targets, and use of QI tools (e.g., root cause analysis) to
                                                                                                                             identify areas for improvement
                                                                                                                             Note: this measure is Not Applicable if 9.1.3 B is not met
                                                        Implement a systematic process for assessing customer satisfaction   Implement a systematic process for assessing and improving
Measure 9.1.4 All        Measure 9.1.6 B
                                                        with health department services                                      customers’ satisfaction with agency services

                                                                                                                             Required Documentation
                                                                                                                             •Description of types of customers (e.g., vital statistics customers,
                                                                                                                             restaurant operators, individuals receiving immunizations or other
                                                        1. Description of the process used to collect and analyze feedback   services) and specific processes and templates used for collecting
Required Documentation   Documentation/Guidance
                                                        from two different customer groups                                   feedback and evaluating results
                                                                                                                             •Two examples of results of collecting and analyzing customer
                                                                                                                             satisfaction data
                                                                                                                             •Documentation of how these examples were used for improvement

                                                        Provide staff development opportunities regarding performance
Measure 9.1.5 All        Measure 9.1.7 L                                                                                     Require staff participation in evaluation methods and tools training
                                                        management
                                                                                                                             Examples of Documentation
Required Documentation   Documentation/Guidance         1. Documentation of staff development in performance management
                                                                                                                             •Documentation of evaluation training, attendance rosters
                                                        Develop and implement quality improvement processes integrated
                                                                                                                       Implement quality improvement of public health processes,
Standard 9.2             Standard 9.2 B                 into organizational practice, programs, processes, and
                                                                                                                       programs, and interventions
                                                        interventions.
Measure 9.2.1 All        Measure 9.2.1 B          Yes
                                                                                                                         Note: See Glossary for definitions of and relationships among
                                                                                                                         Strategic Plans, Health Improvement Plans and Quality Improvement
                                                                                                                         Plans.
                                                                                                                         Opportunities for evaluation and improvement can be identified
                                                                                                                         through:
                                                                                                                         •Analysis of health data/health indicators
                                                                                                                         •Program evaluations including surveillance functions
                                                                                                                         •AARs
                                                                                                                         •Planning processes, See Standard 5.2, Standard 5.3 and Standard
                                                                                                                         5.4
                                                                                                                         Required Documentation
                                                                                                                         •Quality Improvement (QI) Plan that includes the following
                                                                                                                         components:
                                                                                                                         oPurpose and scope of QI activities
                                                                                                                         oGoals and objectives with quantifiable and time-framed measures
                                                                                                                         oResponsible person(s) for each objective
                                                                                                                         oDescription of QI projects
                                                                                                                         oDescription of process to evaluate the effectiveness of QI activities
                                                                                                                         Other Examples of Documentation
                                                                                                                         •Documentation of implementation of the QI Plan such as QI project
                                                                                                                         reports or reports of progress
                                                                                                                         •Annual evaluation and revision of the QI Plan

Measure 9.2.2 All        Measure 9.2.2 B          Implement quality improvement activities                               Implement quality improvement efforts
                                                  1. Documentation of quality improvement activities based on the QI
                                                  plan                                                                   Examples of Documentation
Required Documentation   Documentation/Guidance   2. Demonstrate staff participation in quality improvement activities   •Two examples of implementing QI (e.g., QI project work plan,
                                                  based on the                                                           evidence of improvement actions and follow up monitoring)
                                                  QI plan
                                                                                                                         Examples of Documentation
DELETED FROM                                                                                                             •Documentation of QI training, attendance rosters
                         Measure 9.2.3 L          DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                      •Documentation of the availability of quality improvement expertise
                                                                                                                         for technical assistance
                                    CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
   Element [Updated                                    Only Coding
                                   Element [Beta]                                      Updated Workbook (1.0)                                                               Beta
    Workbook (1.0)]                                     Changed
Domain 10                     PART B - Domain 10                     [No additional change]
                                                                     Identify and use the best available evidence for making informed
Standard 10.1                 Standard 10. 1 B                                                                                              Identify and use evidence-based and promising practices
                                                                     public health practice decisions

                                                                                                                                            Review and use applicable evidence-based and/or promising
                                                                     Identify and use applicable evidence-based and/or promising
Measure 10.1.1 All            Measure 10.1.1 B                                                                                              practices when implementing new or improved processes, programs
                                                                     practices when implementing new or revised processes,
                                                                                                                                            or interventions
                                                                     programs and/or interventions


                                                                                                                                            Required Documentation
                                                                     1. Two examples from within the past three years of evidence-based
                                                                                                                                            •Two examples from within the past three years of review and use of
                                                                     or promising practices, including:
                                                                                                                                            evidence-based or promising practices, including:
Required Documentation        Documentation/Guidance                 a. Source of evidence-based or promising practice
                                                                                                                                            - Source of EBP or promising practice
                                                                     b. Description of how evidencebased or promising practice was
                                                                                                                                            - Description of how EBP or promising practice was implemented in
                                                                     implemented in agency processes, programs, and/or interventions
                                                                                                                                            agency processes, programs and interventions

Measure 10.1.2 Tribal/State   New/not in beta                        Foster innovation in practice and research                             New/not in beta
                                                                     1. Relationships with academic institutions, research
                                                                     centers/institutes
Required Documentation        Documentation/Guidance                                                                                        New/not in beta
                                                                     2. Participation in research agenda-setting, practice-based research
                                                                     networks, or other research efforts
Standard 10.2                 Standard 10.2 B              Yes

Measure 10.2.3 All            Measure 10.2.1 B                                                                                              Communicate research findings, including public health implications
                                                                     Communicate research findings, including public health implications

                                                                                                                                            Required Documentation
                                                                     1. Documentation of communication of research findings and their
                                                                                                                                            •Two examples of communication of research findings (evaluated
Required Documentation        Documentation/Guidance                 public health implications to stakeholders, public health
                                                                                                                                            pursuant to 10.2.3 S) and their implications to stakeholders, public
                                                                     system partners, and/or the public
                                                                                                                                            health system partners, and/or the public

                                                                                                                                       Develop and implement policies that ensure human subjects are
Measure 10.2.1 All            Measure 10.2.2 B                       Ensure human subjects are protected when the health department is
                                                                                                                                       protected when the agency is involved in research activities
                                                                     involved in or supports research activities
                                                                                                                                       Required Documentation
                                                                                                                                       •Policies regarding research, such as Institutional Review Board (IRB)
Required Documentation        Documentation/Guidance                 1. Human subjects research protection policy                      policy
                                                                                                                                       •One example within the last three years, where applicable, of use of
                                                                                                                                       policies
Standard 10.2.3 All:          New/not in beta                        Communicate research findings, including public health implications    New/not in beta


                                                                     Provide technical assistance to the state health department, local
Measure 10.2.4 Tribal         New/not in beta                        health departments, and other public health system partners in         New/not in beta
                                                                     applying relevant research results, evidencebased
                                                                     and/or promising practices
                                           Required Documentation
                                           1. Consultation or technical assistance to state and/or local health
Required Documentation   New/not in beta   departments, other Tribal health departments, and/or Tribal          New/not in beta
                                           organizations in applying relevant research,
                                           evidence-based, promising practices, and/or practice-based evidence
                                CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
  Element [Updated                                 Only Coding
                              Element [Beta]                                        Updated Workbook (1.0)                                                               Beta
   Workbook (1.0)]                                  Changed

Domain 11                PART A                                  Maintain Administrative and Management Capacity                        Administrative Capacity and Governance
Standard 11.1            Standard A1B                   Yes
                                                                 Maintain policies and procedures regarding health department
                                                                                                                                        Maintain policies and procedures regarding agency operations,
Measure 11.1.1 All       Measure A1.1 B                          operations, review policies and procedures regularly, and make
                                                                                                                                        review policies regularly and assure these are accessible to staff
                                                                 them accessible to staff
                                                                 1. Policy and Procedure Manual or individual policies
                                                                                                                                        Required Documentation: • Policy and Procedure Manual or
                                                                 2. Health department organizational chart
                                                                                                                                        individual policies (may be electronic) • Agency organizational chart
Required Documentation   Documentation/Guidance                  3. Reports of review at least every five years or proof of regular
                                                                                                                                        ▪Reports of review at least every five years or proof of ongoing
                                                                 updating process
                                                                                                                                        updating process • Description of methods for staff acces to policies
                                                                 4. Description of methods for staff access to policies
                                                                 11.1.2 All: Maintain written policies regarding confidentiality,       Demonstrate written policies regarding confidentiality, including
Measure 11.1.2 All       Measure A1.2 B
                                                                 including applicable HIPAA requirements                                applicable HIPAA requirements
                                                                                                                                        Required Documentation: • Confidentiality Policies, including
                                                                 1. Confidentiality Policies
                                                                                                                                        business associate agreements and electronic transfer of data
Required Documentation   Documentation/Guidance                  2. Training content and staff participants
                                                                                                                                        policies •Documentation of training content and staff participants
                                                                 3. Signed employee confidentiality forms, as required by policies
                                                                                                                                        •Signed employee confidentiality forms, as required by policies


                                                                 Maintain socially, culturally, and linguistically
                                                                 appropriate approaches in health department                            Maintain socially, culturally, and linguistically relevant approaches in
Measure 11.1.3 All       Measure A1.3 B
                                                                 processes, programs, and interventions,                                agency processes, programs and intereventions
                                                                 relevant to the population served in its
                                                                 jurisdiction

                                                                                                                                         Required Documentation
                                                                                                                                         •Policy or procedure for development of culturally and linguistically
                                                                 1. Policy or procedure for development of culturally and linguistically
                                                                                                                                         appropriate interventions and materials
                                                                 interventions and materials appropriate to the population it serves
                                                                                                                                         •Two examples (policies or materials) that demonstrates provision
                                                                 in its jurisdiction
                                                                                                                                         of processes, programs or interventions in a cultural or linguistic
                                                                 2. Demonstration of providing two different processes, programs or
                                                                                                                                         competent manner, including application of social marketing
                                                                 interventions in culturally or linguistically competent
Required Documentation   Documentation/Guidance                                                                                          activities •One example of documentation of training content and
                                                                 manner, including application of social marketing activities
                                                                                                                                         staff participants
                                                                 3. Documentation of one training session content and staff
                                                                                                                                         Other Examples of Documentation
                                                                 participants
                                                                                                                                         •Report of a cultural and linguistic competence assessment of the
                                                                 4. Report of a cultural and linguistic competence assessment of the
                                                                                                                                         agency (this could be the CLCPA
                                                                 health department
                                                                                                                                         self-assessment from the National Center for Cultural Competence,
                                                                                                                                         assessment against CLAS standards or another tool)
Measure 11.1.4 All       Measure A1.4 B:          Yes
                                                                                                                                Required Documentation
                                                                                                                                •Human Resource Policy and Procedure Manual or individual
                                                                                                                                policies(may be electronic) that address at least eight of these
                                                                                                                                topics:
                                                        1. Human resource policy and procedure manual or individual             -Personnel recruitment -Personnel selection and appointment -
                                                        policies                                                                Salary structure -Equal opportunity employment -Hours of work -
                                                        2. Labor agreements, employment agreements, or contracts,               Time reporting -Overtime -Benefit package - Training and
Required Documentation   Documentation/Guidance         including descriptions of mechanisms for working                        continuing education -Performance evaluation and individualized
                                                        relationships                                                           training plan -Sexual and other harassment -Problem solving and
                                                        3. Description of methods for staff access to human resources           complaint handling -Computer use
                                                        policies and procedures                                                 Other Examples of Documentation
                                                                                                                                •Labor agreements, including description of mechanisms for
                                                                                                                                working relationships
                                                                                                                                See also Domain 8 for implementation of Human Resource policies
                                                                                                                                and procedures
                                                        Implement and adhere to the health department’s human resources
Measure 11.1.5 All       New/not in beta                                                                                        New/not in beta
                                                        policies and procedures
                                                        1. Documentation of the recruitment of qualified individuals that
                                                        reflect the population served
                                                        2. Documentation of retention activities conducted
Required Documentation   New/not in beta                3. Position descriptions, available to staff                            New/not in beta
                                                        4. Description of process to verify staff qualifications
                                                        5. Evidence that qualifications have been checked for all staff hired
                                                        in the last two years
                                                        Use information systems that support the
                                                        health department mission and workforce by                              Maintain information systems that support the agency’s mission and
Measure 11.1.6 All       Measure A1.5 B                 providing infrastructure for data                                       workforce by providing infrastructure for data collection/analysis,
                                                        collection/analysis, program management,                                program management, and communication
                                                        and communication
                                                        1. Demonstration of the use of technology to support public health      Examples of Documentation
                                                        functions                                                               •Two examples that demonstrate use of technology to support
Required Documentation   Documentation/Guidance         2. Inventory of hardware                                                public health functions •Inventory list of hardware •List of
                                                        3. Inventory of software, including capacity for data analysis, word    software, including capacity for data analysis, word processing,
                                                        processing, internet/website                                            internet/website
Measure 11.1.7 All       Measure A1.6 B           Yes
                                                                                                                                Examples of Documentation
                                                        1. Licenses for clinics and laboratory
                                                                                                                                •Licenses for clinical areas •Inspection reports
Required Documentation   Documentation/Guidance         2. Inspection reports and/or certificate of occupancy
                                                                                                                                •Certificate of occupancy •Log of facility work orders or facility
                                                        3. ADA compliance audit
                                                                                                                                related issues ▪ADA compliance audit
Standard 11.2            Standard A2B             Yes
                                                        Comply with external requirements for the receipt of program
Measure 11.2.1 All       Measure A2.1 B                                                                                         Comply with requirements for externally funded programs
                                                        funding
                                                        1. Audited financial statements                                         Examples of Documentation
Required Documentation   Documentation/Guidance
                                                        2. Two program reports                                                  •Audited financial statements •Program reports

                                                                                                                                Maintain written agreements with entities providing processes,
                                                        Maintain written agreements with entities providing processes,
Measure 11.2.2 All       Measure A2.2 B                                                                                         programs and/or interventions delegated or purchased by the public
                                                        programs and/or interventions delegated or purchased by the
                                                                                                                                health agency
                                                        public health department
                                                                                                                        Required Documentation
                                                                                                                        •Two examples of current written contracts/MOUs, MOAs for
                                                        1. Current written contracts/MOUs/ MOAs for processes, programs
Required Documentation   Documentation/Guidance                                                                         processes, programs and/or interventions
                                                        and/or interventions
                                                                                                                        See Domain 9 for program evaluation of delegated/contracted
                                                                                                                        service providers
Measure 11.2.3 All       Measure A2.3 B           Yes
                                                                                                                                Required Documentation
                                                                                                                                •Annual agency budget approved by governing entity
                                                                                                                                •Two examples of financial reports (at least quarterly)
                                                                                                                                •Audited financial statements
                                                        1. Approved health department budget
Required Documentation   Documentation/Guidance                                                                                 Other Examples of Documentation
                                                        2. Quarterly financial reports
                                                                                                                                •Documentation that audit has been reviewed by the governing
                                                                                                                                entity and/or key agency staff
                                                                                                                                •Documentation that financial reports reviewed by the governing
                                                                                                                                entity and/or key agency staff
Measure 11.2.4 All       Measure A2.4 B           Yes
                                                                                                                                Examples of Documentation
                                                        1. Grant applications and or examples of leveraging funds to increase   •Annual budget submission •Budget revisions •Additional funding
                                                        resources                                                               requests •Grant applications and fundraising •Newspaper
Required Documentation   Documentation/Guidance
                                                        2. Appropriate communications with others concerning the need for       articles/letters to the editor on the need for improvement in public
                                                        improvement in public health                                            health (can be issues specific) •Public Health meeting discussing
                                                                                                                                public health funding
                                    CROSSWALK FOR PUBLIC HEALTH ACCREDITATION BOARD (STANDARDS & MEASURES)
    Element [Updated                              Only Coding
                              Element [Beta]                                          Updated Workbook (1.0)                                                                      Beta
     Workbook (1.0)]                               Changed

                         [Was 2nd part of PART
                                                                Maintain Capacity to Engage the Public Health Governing
Domain 12                A, which is now                                                                                [No domain title]
                                                                Entity
                         Domain 11 & 12]
                                                                Maintain current operational definitions and statements of the public         Maintain current operational definitions and statements of the public
Standard 12.1            Standard A3B
                                                                health roles, responsibilities, and authorities                               health roles and responsibilities of specific authorities

Measure 12.1.1 All       Measure A3.1B                          Provide mandated public health operations, programs, and services             Provide mandated public health operations and services
                                                                                                                                              Required Documentation
                                                                                                                                              •Applicable laws and regulations and/or statewide listing of mandated public
                                                                1. Authority to conduct public health
Required Documentation   Documentation/Guidance                                                                                               health services
                                                                2. Description of operations that reflect authorities
                                                                                                                                              •Description of operations that reflect authorities (e.g., service descriptions,
                                                                                                                                              annual reports, meeting minutes)
                                                                                                                                              Demonstrate that the governing entity complies with regulations regarding
Measure 12.1.2 All       Measure A3.2B                          Maintain current operational definitions and/or statements of the public
                                                                                                                                              governing entities
                                                                health governing entity’s roles and responsibilities
                                                                                                                                              Examples of Documentation
                                                                1. Authority of the governing entity                                          •Applicable laws and regulations •Governing entity operating rules •Self
Required Documentation   Documentation/Guidance
                                                                2. Description of governing entity                                            assessment of performance in compliance with applicable laws, regulations
                                                                                                                                              and operating rules
                                                                Provide information to the governing entity regarding
                                                                                                                                              Provide orientation and regular information to members of the governing
Standard 12.2            Standard A4B                           public health and the official responsibilities of the health department
                                                                                                                                              entity regarding their responsibilities and those of the public health agency
                                                                and of the governing entity.
                                                                Communicate with the governing entity regarding the responsibilities of the   Provide orientation and regular information to the governing entity
Measure 12.2.1 All       Measure A4.1 B
                                                                public health department                                                      regarding the responsibilities of the public health agency

                                                                                                                                              Examples of Documentation
                                                                1. Two examples of communications provided to the governing entity
                                                                                                                                              •Sample of training packets •Attendance records for governance member
Required Documentation   Documentation/Guidance                 regarding the responsibilities of the public health
                                                                                                                                              orientation meeting •Governing entity minutes •Documentation of
                                                                department
                                                                                                                                              governing entity member attendance at related informational sessions

                                                                                                                                            Provide orientation and regular information to the governing entity
Measure 12.2.2 All       Measure A4.2 B                         Communicate with the governing entity regarding the responsibilities of the
                                                                                                                                            regarding their responsibilities
                                                                governing entity

                                                                                                                                              Examples of Documentation
                                                                                                                                              •Governing entity meeting minutes with actions
                                                                1. One example of a communication with the governing entity about their       •Governing entity policies memos, NALBOH news briefs or other documents
Required Documentation   Documentation/Guidance                 operational definitions and/or statements of the public                       •Documentation of governing entity member attendance at related
                                                                health governing entity’s roles and responsibilities                          informational sessions •Examples of governing entity action on
                                                                                                                                              responsibilities, including championship of community and political support
                                                                                                                                              for public health

DELETED FROM
                         Measure A3.3 B                         DELETED FROM WORKBOOK/NOT IN 1.0                                              Demonstrate the evaluation of the agency director by the governing entity
WORKBOOK/NOT IN 1.0
                                                                                                                                              Required Documentation
DELETED FROM                                                                                                                                  •Position description and qualifications for agency director •Current
                         Documentation/Guidance                 DELETED FROM WORKBOOK/NOT IN 1.0
WORKBOOK/NOT IN 1.0                                                                                                                           evaluation of the agency director
                                                                                                                                              See Domain 8 for evaluation of agency staff
                                                                Encourage the governing entity’s engagement in the public health
Standard 12.3            New/not in beta                                                                                                      New/not in beta
                                                                department’s overall obligations and responsibilities.
                                            Provide the governing entity with information about important public
Measure 12.3.1 All       New/not in beta   health issues facing the health department and/or the recent actions of the    New/not in beta
                                           health department
                                           1. Two examples of communications with the governing entity regarding
Required Documentation   New/not in beta   important public health issues and/or recent actions of the health             New/not in beta
                                           department
Measure 12.3.2 All       New/not in beta   Track actions taken by the governing entity                                    New/not in beta
                                           1. Review issues discussed, actions taken, and policies set by the governing
Required Documentation   New/not in beta   entity at                                                                      New/not in beta
                                           least annually
                                           Communicate with the governing entity about assessing and improving the
Measure 12.3.3 All       New/not in beta                                                                                  New/not in beta
                                           performance of the health department

                                           1. Two examples of communication with the governing entity concerning
                                           assessment of the health department’s performance
Required Documentation   New/not in beta                                                                                  New/not in beta
                                           2. Two examples of communication with the governing entity concerning
                                           the improvement of the health department’s performance

				
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