Engaging Tribes in Public Health Accreditation and Quality Nancy Young, MPA

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1 MLC Topical Brief Engaging Tribes in Public Health Accreditation and Quality Nancy Young, MPA Engaging Tribes in Public Health Accreditation and Quality is one of eight topical briefs developed at the MLC s conclusion summarizing key lessons on emergent topic areas. To access these briefs and other stories from the MLC, please visit: accreditation-and-performanceimprovement/resources/stories-andtopical-briefs. Introduction The Multi-State Learning Collaborative: Lead States in Public Health Quality Improvement (MLC) initiative involved work with teams in sixteen states that, over the course of six years, engaged in quality improvement (QI) efforts and prepared for voluntary accreditation. The efforts focused primarily on state and local health departments, with some directed efforts to collaborate with tribal health departments, such as in the state of Wisconsin. This topical brief provides background regarding tribal health in the U.S., discusses tribal health departments progress toward accreditation, and highlights one state s experience, including initial lessons learned from engaging tribes in accreditation and quality efforts. An insert features an interview with a team of tribal public health accreditation leaders. Background There are 565 federally recognized American Indian and Alaska Native tribes located in 35 states. Tribes have sovereign nation status and may form their own governments, create and enforce their own civil and criminal laws, and establish tribal membership requirements. There is a great deal of geographic, demographic, and cultural diversity among tribes located in the U.S. Tribal Public Health Systems 1 Many tribes have created health departments or provided some public health services as part of an overall approach to caring for their communities, but, as in non-tribal jurisdictions, there remains great variation in size, scope, structure, and service mix. Tribal public health systems are complex and include many stakeholders, including tribal epidemiology centers, governments, and colleges; business and industry; state and local health departments with which services are often collaboratively provided; federal agencies; and others. These and other historical, demographic, and policy features present the unique context for tribal public health accreditation efforts. Accreditation is Not New to Tribes but Public Health Accreditation Is The majority of tribes provide clinical services through either hospitals or ambulatory care facilities. In 2009, 100% of tribal hospitals were accredited either by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or certified by the Center for Medicare and Medicaid. Many tribes have sought and obtained accreditation for clinics from either JCAHO or the Accreditation Association for Ambulatory Health Care (AAAHC). Often tribal public health departments partner closely with, or are sometimes divisions or departments within, the same organization as clinical services. Thus, conversation and lessons learned around accreditation processes and preparation can be shared even though the standards, measures, and accrediting body approaches vary significantly. Tribal Health Care Indian Health Service (IHS): Part of the U.S. Department of Health and Human Services, today IHS resources focus on primary health care service delivery with limited public health activity and no current efforts to specifically support public health accreditation.2 Indian Self-Determination and Educational Assistance Act of 1975 PL : Allows Tribes to manage their own health programs by contracting part or all of services or by compacting entire programs. The National Indian Health Board: Non-profit 501c(3) organization that advises a range of agencies and organizations on health care issues of American Indians and Alaska Natives. National Efforts Background In 2008, the National Indian Health Board received support from the Robert Wood Johnson Foundation to assess the feasibility of the promotion of voluntary public health accreditation and public health standards in Indian Country. Through this project, an advisory panel was established to discuss the potential of accreditation, to gather recommendations from Tribal members nationally and to then produce a strategic plan.4 That plan envisioned that tribal public health accreditation will contribute to vibrant, healthy tribal communities through collaboration by all agencies responsible for public health service delivery and the development of accessible, culturally-relevant, competent, accountable, and sustainable public health programs 1 For more information, view the National Indian Health Board Tribal Public Health Profile at 2 U.S. Department of Health and Human Services, Indian Health Service, 3 Id. 4 National Indian Health Board, Exploring Tribal Public Health Accreditation Project,

2 and services that promote the health and sovereignty of American Indian and Alaska Native tribes. 5 A Tribal Think Tank hosted by the Public Health Accreditation Board (PHAB) in late 2009 followed the NIHB exploration project and several recommendations resulted, including a suggested model partnership for accreditation that would include tribal, local and state partners consistent with the vision statement set forth in the strategic plan. Benefits of Accreditation as Defined by the National Indian Health Board Exploring Tribal Public Health Accreditation Project Strategic Plan Defines and strengthens the roles and responsibilities of tribal governments in regulating public health in their community Raises the visibility of public health benefits in your tribal community Clarifies how public health includes prevention and wellness to reduce health disparities Assesses strengths and areas for improvement in public health services Encourages stronger partnerships with entities that do public health for our communities, including states, counties, local, tribes, federal, private, non-profits, etc. Leads to more resources for public health, such as grant opportunities and long-term cost savings Provides opportunities for tribal communities to plan for wellness in their communities 7 Unique Context for Tribal Public Health Accreditation Tribal sovereignty (governance, laws, membership) Land bases issues (land base or not, rural or urban, contiguous or non) Government-to-government relationships between states and tribes 6 Shared geography and community health needs with local health departments Direct service from Indian Health Service (IHS) or compacts/contracts Wide variation in public health activities, structures and partnerships An Example from Wisconsin The Wisconsin Department of Health Services (WDHS), governmental leaders of tribes located in Wisconsin, and the Wisconsin tribal health directors group have a history of regular communication and establishment of mutual health-related goals and work plans. In 2008, the Institute for Wisconsin s Health, Inc. and the WDHS began working together to explore tribal public health accreditation readiness as part of the state s MLC award. The initiative, also known in the state as Wisconsin s Public Health Quality Initiative (WIQI), brought together a new group of health departments each year from to form one community of practice around quality and accreditation. The Forest County Potawatomi s community health department joined 39 other project partners in May 2010 and quickly contributed to the WIQI learning community and provided leadership in reaching out to other tribal health departments. The department completed an accreditation self-assessment and began to look at ways in which efforts to obtain AAAHC accreditation for their clinical facility and PHAB accreditation could be complementary. Working with the advice and training expertise of Aleena Hernandez, MPH, of Red Star Innovations LLC, in November of 2010, the Forest County Potawatomi, IWHI and WDHS co-hosted the first Wisconsin Tribal Accreditation Open Forum. The forum provided an introduction to accreditation with an emphasis on dialog. Six of the eleven tribes located in Wisconsin sent representatives to the event. The gathered participants advised IWHI and WDHS on the best ways to support continued efforts. The idea of an inter-tribal accreditation workgroup was conceived. Engagement initiated through support from the MLC continued in 2011 with funding from the Centers for Disease Control and Prevention-supported National Public Health Improvement Initiative (NPHII). In July of 2011, IWHI organized a tribal public health accreditation update webinar followed by a two-day training in August 2011 focused on looking more closely at the PHAB tribal standards and measures and use of the WIQI tribal self-assessment workbook. Representatives from the Forest County Potawatomi, Ho-Chunk Nation, Lac du Flambeau Lake Superior Band of Chippewa, and Oneida Nation attended this training. Each tribe is currently committed to either application for accreditation or serious continued exploration of accreditation and QI through a tribal accreditation work group that plans to meet quarterly at rotating tribal locations. The November 2011 training session hosted by the Ho-Chunk Nation, and co-led by IWHI and WDPH focused on the three accreditation prerequisites. Formal and informal discussions with all eleven tribes continue through WDHS meetings with the Association of Tribal Health Directors and tribal leaders as part of the state-tribal health consultation plan. Lessons Learned: Engaging Tribes in Improvement Efforts for Public Health Services Delivery 1) Identify one or more tribal health department(s) well-positioned to lead. Start a conversation. Is there any interest in exploring public health accreditation or at least improving public health services in a systematic way? If so, might there be interest in working collectively, sharing ideas, and solutions? Listen to what the leadership has to say. 5 Id., p Based on 1994 (reaffirmed in 2009) HHS Tribal Consultation Policy which requires federal departments to consult with tribes in advance. 7 National Indian Health Board, Exploring Tribal Public Health Accreditation Project,

3 2) By listening, you will learn what the interests, realities and concerns are for that health department. Each tribal health department is different. 3) Though every tribe and tribal health department is different, there is common ground that makes inter-tribal work groups a particularly promising approach. 4) The primary purpose of an inter-tribal public health workgroup should be to support improved public health service delivery quality. Exploration of accreditation can be secondary. 5) The workgroup should function in a way that makes sense to the participants. 6) Participants at all levels of interest and engagement should be welcomed with trainings delivered from a tribal perspective. 7) Many health departments are experiencing cutbacks and having to do more with limited resources. Convening multiple tribes may mean that some may have to travel significant distances to attend meetings. 8) Consider providing technical assistance and support through a variety of means (webinar, one-on-one, travel stipends). 9) Relationships are critical and require a long-term commitment. Consistency in communications, meetings, and services is critical. 10) The essential services and PHAB standards and measures provide many opportunities for discussions among tribal, state, and local partners about collaboratively increasing capacity. Interview with A Leader: The Forest County Potawatomi The Forest County Potawatomi Community Health Department became engaged with Wisconsin s Public Health Quality Initiative in early MLC support was key to the Tribe s initial efforts to explore and prepare for accreditation. The Forest County Potawatomi have a strong clinical and public health presence in the community. The Community Health Department s Health and Wellness Center serves Native and non-native people in north-central Wisconsin. In 2011, the Center achieved both accreditation recognition from the Accreditation Association for Ambulatory Health Care (AAAHC) and recognition from the National Committee for Quality Assurance Patient-Centered Medical Home (NCQA-PCMH). 8 The Community Health Department is preparing for public health accreditation and expects to submit a letter of intent to PHAB by the end of Clinical and public health staff are working together to identify ways in which accreditation and QI processes complement efforts to meet standards and measures in clinical and public health settings. The author interviewed Lorrie Shepard, Community Health Nursing Supervisor, and Linda Sturnot, Compliance Coordinator at the Health and Wellness Center, to gain their insights. Q. What do you see as the drivers for Tribal public health accreditation? A. Accountability is a primary driver. We believe in being held accountable to our employer for the delivery high-quality, cost-effective health care services to the Forest County Potawatomi Community. And accreditation provides us with an opportunity to look at how we do things through a different lens to objectively evaluate what we are doing. Are we ready to meet national public health standards? If not, what do we need to do to improve? Accreditation aligns with our Health and Wellness Center strategic plan, which includes AAAHC accreditation standards and Patient-Centered Medical Home concepts of care. Q. How did involvement in the MLC impact your efforts to become accredited? A. We learned about QI through an Indian Health Services pilot project so the concept of plan-do-study-act wasn t foreign to us. The QI training and tools we got as part of WIQI 9 were an important step. The training allowed us to buy into QI and apply it in all service areas. We built a QI tool box that all staff can access. The WIQI agency self-assessment tool 10 helped us evaluate whether we had the capacity to seek accreditation and also was great for use in preparing for AAAHC accreditation. We adapted it for AAAHC standards and measures. The interest that WIQI demonstrated in pulling Tribes together to help us lend support to each other has been our guiding force. WIQI has been very responsive to our questions and concerns and very supportive in helping us understand what we needed to do to prepare for and attain accreditation. 8 The majority of, though not all, tribes provide both clinical and public health services. 9 WIQI is a project of the Institute for Wisconsin s Health. WIQI was funded initially by the Robert Wood Johnson Foundation and is now supported in part by the CDC Public Health Improvement Initiative. The Wisconsin Division of Public Health has been the lead fiscal agency for both awards and the IWHI/WDPH partnership has been critical to the success of these efforts. 10 The WIQI Agency Self-Assessment tool is an Excel-based workbook that allows departments to self score capacity in each standard and measure on a 0-4 scale.

4 And we should mention that the initial encouragement to get involved with WIQI came from Terri Timmers, the director of the Wisconsin Division of Public Health Northern Region office, who thought we were ready to consider this and be part of a statewide project. Q. What if any special challenges and/or barriers have you encountered in preparing for accreditation application? A. There are so many resources (e.g. WIQI, NACCHO, NIHB, the Wisconsin Division of Public Health) one big challenge is just to chose the best ones and then organize them to create a workplan for accreditation preparation. It is also a challenge to block off time to meet regularly and to get the right staff involved and engaged. The initial reaction of staff can be, Oh no not another project! But the right people can see how this brings everything together. We needed to demonstrate to our administration how public health accreditation fits in with the Health and Wellness Center s mission, vision, and strategic plan. We did, and are now developing a Community Health Department strategic plan that aligns with the Center plan, so the pieces are coming together. One barrier has been our own belief that we are not moving fast enough. Also, as a Sovereign Indian Nation, we have found that some of the standards may not apply to us and/or that our Tribe is not obligated to follow a certain rule or law. For example, our Tribe does not have public health laws per se. We are grappling with how to document this and still meet the spirit of the standards. Q. How about successes so far things to celebrate? A. We are really enjoying the challenge of this the opportunity to excel and take our services to the next level! Our staff is engaged now and excited about the prospect of becoming accredited. And we like the fact that we are exploring new ground and working across departments to meet standards. We completed our agency self-assessment using the WIQI workbook as a team and we have progressed as a team. Q: Do you have any observations about preparing for AAAHC and PHAB accreditation? A. The processes of preparing are very similar, so some of the same organizing strategies can be used. We adapted the WIQI agency self-assessment tool for use with AAAHC standards because the format and self-scoring approach was helpful. We found that many of the standards have a shared intent so our efforts to prepare weren t duplicating at all but actually complementary. As an example, the QI projects we have completed can be used to meet compliance with both PHAB and AAAHC QI standards. AAAHC requires a QI study in five focus areas every three years. Our Community Health Department just completed a case management template and this project can be used as evidence for both accrediting bodies. We are also establishing care teams that involve community health department and clinical staff as part of our NCQA Patient Centered Medical Home assurance efforts, and we will be monitoring the effectiveness of those. So, we are responding to accrediting and recognition bodies, but most importantly, we are forming teams to care for our community members in a high quality way. Q: What would your advice be to other Tribes who are just now beginning to think about accreditation? A: First, do some solid brainstorming before meeting with Tribal leadership about how the initiative aligns with the facility or Tribal strategic plan, mission, and vision and how this accreditation will help improve quality services provided. We loved the fact that the PHAB standards were reviewed by the National Indian Health Board and that Tribes, including the Forest County Potawatomi, had input in the development of the standards. And having the intent of the standards defined as is the case with Version 1.0, is very helpful. Those considering accreditation should definitely look at the intent documentation. Evaluate your resources honestly including staff and their skills to work on large projects or facilitate meetings, computer support and software, and familiarity with QI tools that can support the initiative. And identify outside resources that may be available, including grant opportunities and others who might be willing to share their experiences.

5 Related Links National Indian Health Board Exploring Tribal Public Health Accreditation Project: PHAB and NIHB Partnership Information Sheet: PHAB Tribal Think Tank Report. Will be posted on PHAB website when finalized at IWHI s Self-Assessment Workbook for Tribal Public Health Departments: The Multi-State Learning Collaborative: Lead States in Public Health Quality Improvement (MLC) brought state and local health departments together with other stakeholders including public health institutes, health care providers, and universities to improve public health services and the health of their community by implementing quality improvement (QI) practices. During the project s six years, QI teams in each of the 16 participant states Florida, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Montana, New Hampshire, New Jersey, North Carolina, Oklahoma, South Carolina, Washington, and Wisconsin prepared for public health accreditation and applied QI practices to specific health outcomes and processes. The MLC was managed by the National Network of Public Health Institutes with support from the Robert Wood Johnson Foundation. The Multi-State Learning Collaborative: Lead States in Public Health Quality Improvement (MLC) was managed by the National Network of Public Health Institutes (NNPHI) and supported by the Robert Wood Johnson Foundation (RWJF). For more information on the MLC go to