07/23/14 — Health Department meets standard

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Health Department meets standard

By Phyllis Moore
Published in News on July 23, 2014 1:46 PM

The Wayne County Health Department has been re-accredited by the North Carolina Local Health Department Accreditation Board.

The status must be renewed every four years.

The local department received its first accreditation in 2009.

Prior to 2008, it was done voluntarily and Wayne County was among those that participated in that capacity. Then it became a mandatory requirement of the state for health departments to go through the accreditation process, said Health Director Davin Madden.

"The law required everyone go through the initial accreditation process by no later than 2014," Madden said. "The national model, it's voluntary but their model is actually developed off the North Carolina model."

The new accreditation format was developed in 2009 when the state Division of Public Health and the N.C. Association of Local Health Directors created a mandatory, standards-based system for accrediting local departments throughout the state.

The process examines department policies and procedures in all program areas, with 41 benchmarks and 148 individual activities on the list of requirements. A health department must have a compliance rate of 95 percent or higher to receive accreditation status.

Wayne County's score was 97 percent, Madden said.

Departments that don't pass the benchmark with a successful 95 percent can be granted a conditional approval and are given 12 months to make corrections, he explained. Upon subsequent review, the department will either receive full accreditation -- if they miss no more than eight out of the 148 requirements -- or be considered unaccredited.

"Accreditation is an arduous process that ultimately demonstrates the high quality of services and commitment provided by our health department to their community," Madden said. "It's no easy task to accomplish the volume of measures required yearly over a four-year period, but our dedicated staff has made it happen and I am very proud of the work they do each and every day."

Because of the time and effort involved in achieving accreditation, it is a prestigious distinction, the health director said.

"It's a quality improvement tool that we have to go through, looking at all of our policies and procedures, making sure that you're engaging the public and our partners and using proper standards of care," he said. "It's kind of a recognition that we're doing a good job in providing the services and trying to work with the community to fulfill our mission with the partners.

"It's just a validation that the work that we're doing is paying off and we're meeting the standards."

Among the areas checked during the accreditation team's two-day site visit, Madden said, are communicable diseases, staff development and privacy issues.

"We were applauded for our efforts in how we monitored and responded to communicable diseases in the area," he said. "We were commended for staff development. We work hard to try to teach leadership and just build quality workers within the health department and have good skills.

"We have 130 employees, multiplied by the number of turnover that you have in a four-year period. Documentation is so important but it's also extremely strenuous."

The issue of privacy is multi-layered, he said.

"There were multiple things about privacy -- (they mentioned doors not being locked in our records room, but we have staff in there all the time monitoring the room," Madden said. "They come in and evaluate how your records room is kept, how you monitor records, all these things to protect patient information."

The accreditation process has been a very involved and time-consuming one for the health director, hired in the role in 2012.

"It's not just something that happens because we're here. It really does require us to be conscious about the way we're doing business," he said.

It was also a team effort, he said, recognizing the leadership of Director of Nursing Evelyn Coley, lead accreditation coordinator, and Administrative Assistant Star Baker, assistant coordinator.

"They did a fantastic job," he said. "It requires all the staff and coordinators to pull together to make sure we have all the policies and procedures in place."