DOMAIN 5: Policies and Plans
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- Standard 5.1: Serve as primary and expert resource for establishing and maintaining public health policies, practices, and capacity
- Standard 5.2: Conduct a comprehensive planning process resulting in a Tribal / State / community health improvement plan
- Standard 5.3: Develop and implement a health department organizational strategic plan
Key
(S) = State HD (T) = Tribal HD (L) = Local HD
(S/T) = State/Tribal HD (T/L) = Tribal/Local HD (HAI/AR) = Healthcare Associated Infections/Antibiotic Resistance
PHAB Measures
PHAB Measures
HAI/AR Specific Programs or Activities
HAI/AR Specific Programs or Activities
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Measure 5.1.1:
(All) The monitoring and tracking of public health issues that are being discussed by individuals and entities that set policies and practices that impact on public health
Measure 5.1.1:
(All) The monitoring and tracking of public health issues that are being discussed by individuals and entities that set policies and practices that impact on public health
HAI/AR Programs are expected to monitor and track HAI/AR prevention activities, improved antibiotic use, and HAI/AR outbreaks and report progress to jurisdiction leadership, the multidisciplinary advisory group or other entities that set policies or practice for HAI/AR prevention.
HAI/AR Programs are expected to monitor and track HAI/AR prevention activities, improved antibiotic use, and HAI/AR outbreaks and report progress to jurisdiction leadership, the multidisciplinary advisory group or other entities that set policies or practice for HAI/AR prevention.
Context: HD must document that it stays informed of the public issues that are being discussed by the HD’s governing entity, and by elected officials, individuals, and/or other entities that set policies and practices that impact on the HD or public health.
Opportunity: HAI/AR Programs may have a system or process for tracking interactions or engagements with policymakers or other entities when HAI/AR prevention progress, HAI/AR outbreaks, or antibiotic use information are discussed.
Context: HD must document that it stays informed of the public issues that are being discussed by the HD’s governing entity, and by elected officials, individuals, and/or other entities that set policies and practices that impact on the HD or public health.
Opportunity: HAI/AR Programs may have a system or process for tracking interactions or engagements with policymakers or other entities when HAI/AR prevention progress, HAI/AR outbreaks, or antibiotic use information are discussed.
Measure 5.1.2:
(All) Engagement in activities that contribute to the development and/or modification of policy that impacts health
Measure 5.1.2:
(All) Engagement in activities that contribute to the development and/or modification of policy that impacts health
HAI/AR Programs are encouraged to engage in assessments, evaluations, and stakeholder interviews used to assess policy needs and barriers around HAI, AR and prevention in their jurisdiction. HAI/AR Programs are encouraged to collaborate with legislative liaisons, professional organizations, federal agencies, and other partners to identify and inform HAI and AR policy needs.
HAI/AR Programs are encouraged to engage in assessments, evaluations, and stakeholder interviews used to assess policy needs and barriers around HAI, AR and prevention in their jurisdiction. HAI/AR Programs are encouraged to collaborate with legislative liaisons, professional organizations, federal agencies, and other partners to identify and inform HAI and AR policy needs.
Context: HD must document that it has contributed to deliberations concerning public policy and practice and its impact on public health.
Opportunity: Providing HAI or AR issue briefs, media statements, talking points, fact sheets, public testimony or participating in an HAI advisory committee or work group may support this measure.
Context: HD must document that it has contributed to deliberations concerning public policy and practice and its impact on public health.
Opportunity: Providing HAI or AR issue briefs, media statements, talking points, fact sheets, public testimony or participating in an HAI advisory committee or work group may support this measure.
Measure 5.1.3:
(All) Informed governing entities, elected officials, and/or the public of potential intended or unintended public health impacts from current and/or proposed policies
Measure 5.1.3:
(All) Informed governing entities, elected officials, and/or the public of potential intended or unintended public health impacts from current and/or proposed policies
HAI/AR Programs are encouraged to communicate with governing entities, policymakers, legislative liaisons, professional organizations, federal agencies, the public and other partners about the impacts or potential impacts of existing or proposed policies related to HAI/AR, infection control, or patient safety issues.
HAI/AR Programs are encouraged to communicate with governing entities, policymakers, legislative liaisons, professional organizations, federal agencies, the public and other partners about the impacts or potential impacts of existing or proposed policies related to HAI/AR, infection control, or patient safety issues.
Context: HDs must provide documentation of informing policy makers/public about potential public health impacts of policies being considered or in place – these can be policies implemented by other sectors that impact public health.
Opportunity: This may represent an opportunity for the HD or HAI/AR Program to share policies developed by the state or city/county, or by hospitals and/or healthcare partners.
Context: HDs must provide documentation of informing policy makers/public about potential public health impacts of policies being considered or in place – these can be policies implemented by other sectors that impact public health.
Opportunity: This may represent an opportunity for the HD or HAI/AR Program to share policies developed by the state or city/county, or by hospitals and/or healthcare partners.
PHAB Measures
PHAB Measures
HAI/AR Specific Programs or Activities
HAI/AR Specific Programs or Activities
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Measure 5.2.1:
(All) A process to develop a state/community/Tribal health improvement plan
Measure 5.2.1:
(All) A process to develop a state/community/Tribal health improvement plan
HAI/AR Programs develop plans, set priorities, guide prevention efforts and facilitate multidisciplinary HAI/AR advisory groups about HAI and AR prevention activities.
HAI/AR Programs develop plans, set priorities, guide prevention efforts and facilitate multidisciplinary HAI/AR advisory groups about HAI and AR prevention activities.
Context: HDs must complete a health improvement planning process. This must include involving public health system partners, use of data to establish priorities (drawing from the state/community health assessment), identification of assets and resources, and a process to set priorities.
Opportunity: HAI/AR Programs or its partners, including HAI/AR Multidisciplinary Advisory Groups, may contribute strategic planning or recommendations to the broader health improvement planning process and provide data to be analyzed in establishing state/community/Tribal health priorities.
Context: HDs must complete a health improvement planning process. This must include involving public health system partners, use of data to establish priorities (drawing from the state/community health assessment), identification of assets and resources, and a process to set priorities.
Opportunity: HAI/AR Programs or its partners, including HAI/AR Multidisciplinary Advisory Groups, may contribute strategic planning or recommendations to the broader health improvement planning process and provide data to be analyzed in establishing state/community/Tribal health priorities.
Measure 5.2.2:
(All) State/community/Tribal health improvement plan adopted as a result of the health improvement planning process
Measure 5.2.2:
(All) State/community/Tribal health improvement plan adopted as a result of the health improvement planning process
HAI/AR Programs develop plans, set priorities, guide prevention efforts and facilitate multidisciplinary HAI/AR advisory groups about HAI and AR prevention activities.
HAI/AR Programs develop plans, set priorities, guide prevention efforts and facilitate multidisciplinary HAI/AR advisory groups about HAI and AR prevention activities.
Context: The state/community health improvement plan should include measureable outcomes or indicators, policy changes needed to accomplish objectives, partners that will implement strategies, and consideration of priorities of other jurisdictions, as appropriate (national, state, local, and Tribal).
Opportunity: This may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
Context: The state/community health improvement plan should include measureable outcomes or indicators, policy changes needed to accomplish objectives, partners that will implement strategies, and consideration of priorities of other jurisdictions, as appropriate (national, state, local, and Tribal).
Opportunity: This may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
Measure 5.2.3:
(All) Elements and strategies of the health improvement plan implemented in partnership with others
Measure 5.2.3:
(All) Elements and strategies of the health improvement plan implemented in partnership with others
HAI/AR Programs are expected to collaborate with health agencies, healthcare facilities, healthcare organizations, state and local health partners, and other AR partners to set HAI/AR and appropriate antibiotic use goals and objectives and monitor progress towards these goals.
HAI/AR Programs are expected to collaborate with health agencies, healthcare facilities, healthcare organizations, state and local health partners, and other AR partners to set HAI/AR and appropriate antibiotic use goals and objectives and monitor progress towards these goals.
Context: HDs must demonstrate plan implementation with monitoring of results.
Opportunity: This measure may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
Context: HDs must demonstrate plan implementation with monitoring of results.
Opportunity: This measure may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
Measure 5.2.4:
(All) Monitor and revise as needed the strategies in the community health improvement plan, in collaboration with broad participation from stakeholders and partners
Measure 5.2.4:
(All) Monitor and revise as needed the strategies in the community health improvement plan, in collaboration with broad participation from stakeholders and partners
HAI/AR programs collaborate with other health agencies, healthcare facilities, healthcare organizations, state and local health partners, and other partners to make and monitor progress towards national HAI/AR prevention targets.
HAI/AR programs collaborate with other health agencies, healthcare facilities, healthcare organizations, state and local health partners, and other partners to make and monitor progress towards national HAI/AR prevention targets.
Context: HDs must demonstrate annual evaluation of progress toward health improvement plan goals.
Opportunity: This measure may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
Context: HDs must demonstrate annual evaluation of progress toward health improvement plan goals.
Opportunity: This measure may be relevant if HAI/AR priorities are included as part of the adopted state/community health improvement plan.
PHAB Measures
PHAB Measures
Connections
Connections
Measure 5.3.1:
(All) Department strategic planning process
Measure 5.3.2:
(All) Adopted department strategic plan
Measure 5.3.3:
(All) Implemented department strategic plan
Measure 5.3.1:
(All) Department strategic planning process
Measure 5.3.2:
(All) Adopted department strategic plan
Measure 5.3.3:
(All) Implemented department strategic plan
A HD strategic plan defines and determines an organization’s roles, priorities, and direction over three to five years. While the plans are not program-specific, all programs and staff, including those dedicated to HAI/AR should be engaged and be able to connect their work to the broader strategic plan.
These three measures assess the process, the existence of an adopted plan, and the implementation of the plan. HAI/AR staff and the program should ideally be aware and engaged in all steps.
A HD strategic plan defines and determines an organization’s roles, priorities, and direction over three to five years. While the plans are not program-specific, all programs and staff, including those dedicated to HAI/AR should be engaged and be able to connect their work to the broader strategic plan.
These three measures assess the process, the existence of an adopted plan, and the implementation of the plan. HAI/AR staff and the program should ideally be aware and engaged in all steps.
PHAB Measures
PHAB Measures
HAI/AR Specific Programs or Activities
HAI/AR Specific Programs or Activities
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Opportunities / Considerations For Connections Between HAI/AR and Accreditation
Measure 5.4.1:
(All) Process for the development and maintenance of an All Hazards Emergency Operations Plan (EOP)
Measure 5.4.1:
(All) Process for the development and maintenance of an All Hazards Emergency Operations Plan (EOP)
HAI/AR Programs are expected to collaborate and communicate with their HD’s emergency preparedness programs related to outbreak responses, infection control and preventing transmission of infections in healthcare and community settings and consider how the HAI/AR Program may be incorporated into the process of developing an all Hazards Emergency Operations Plan.
HAI/AR Programs are expected to collaborate and communicate with their HD’s emergency preparedness programs related to outbreak responses, infection control and preventing transmission of infections in healthcare and community settings and consider how the HAI/AR Program may be incorporated into the process of developing an all Hazards Emergency Operations Plan.
Context: HD must document that it participates in preparedness meetings with other government agencies and other levels of HDs, participates in drills, exercises, or actual implementation of the All Hazards Emergency Operations Plan and document collaboration in revising emergency plans.
Opportunity: While the documentation will likely be produced from preparedness staff, HAI/AR staff should be aware of and involved in the process for developing and testing the EOP, where it addresses detection and response to HAI/AR and other infection control and patient safety issues, as appropriate.
Context: HD must document that it participates in preparedness meetings with other government agencies and other levels of HDs, participates in drills, exercises, or actual implementation of the All Hazards Emergency Operations Plan and document collaboration in revising emergency plans.
Opportunity: While the documentation will likely be produced from preparedness staff, HAI/AR staff should be aware of and involved in the process for developing and testing the EOP, where it addresses detection and response to HAI/AR and other infection control and patient safety issues, as appropriate.
Measure 5.4.2:
(All) Public health Emergency Operations Plan (EOP)
Measure 5.4.2:
(All) Public health Emergency Operations Plan (EOP)
HAI/AR Programs are expected to collaborate and communicate with the HDs’ emergency preparedness programs related to outbreak responses, infection control and preventing transmission of infections in healthcare and community settings and consider how HAI/AR Program may be incorporated into the process of developing an all Hazards Emergency Operations Plan.
HAI/AR Programs are expected to collaborate and communicate with the HDs’ emergency preparedness programs related to outbreak responses, infection control and preventing transmission of infections in healthcare and community settings and consider how HAI/AR Program may be incorporated into the process of developing an all Hazards Emergency Operations Plan.
Context: The HD must provide an EOP which outlines roles and responsibilities for all-hazards responses, communication networks, and continuity of operations. The HD must also provide documentation of testing and revision of the EOP.
Opportunity: HAI/AR programs may engage in EOP activities and the EOP may be activated or tested to address HAI/AR –related issues such as outbreak containment and response.
Context: The HD must provide an EOP which outlines roles and responsibilities for all-hazards responses, communication networks, and continuity of operations. The HD must also provide documentation of testing and revision of the EOP.
Opportunity: HAI/AR programs may engage in EOP activities and the EOP may be activated or tested to address HAI/AR –related issues such as outbreak containment and response.
Measure 5.4.3:
(S) Consultation and/or technical assistance provided to Tribal and local HDs in the state regarding evidence-based and/or promising practices / templates in EOP development and testing
Measure 5.4.3:
(S) Consultation and/or technical assistance provided to Tribal and local HDs in the state regarding evidence-based and/or promising practices / templates in EOP development and testing
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