DOMAIN 1

Conduct and disseminate assessments focused on population health status and public health issues facing the community
Standard 1.1: Participate in or lead a collaborative process resulting in a comprehensive community health assessment

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 1.1.1:

(S) A state partnership that develops a comprehensive state community health assessment of the population of the state.

(T/L) Tribal/local partnership that develops a comprehensive community health assessment of the population served by the health department.

HAI/AR Specific Programs or Activities

HAI/AR programs or responsible parties in HDs build capacity for HAI and AR prevention. They coordinate and collaborate with multi-disciplinary advisory groups and various healthcare and community partners to facilitate HAI/AR surveillance and prevention activities. Assessments and robust partnerships are key components for all HAI/AR programs, including improving antibiotic use across healthcare and the community.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: A comprehensive community health assessment includes many stakeholders and participation from a variety of sectors. HAI/AR surveillance and prevention activities, as well as improving antibiotic use across healthcare and the community, are areas that rely on engagement and relationships with different partners to ensure quality data and evidence-based decision-making.

Opportunity: A HD’s HAI/AR partnerships and assessment activities can be drawn from or incorporated into broader community health assessment activities.

PHAB Measures

Measure 1.1.2:

(S) A state level community health assessment.

(T/L) A Tribal/local community health assessment.

HAI/AR Specific Programs or Activities

HAI/AR Programs work with PH, healthcare, academic and laboratory partners to enhance surveillance capacity to track HAI/AR, monitor antibiotic use, and analyze data reported by facilities to allow for a comprehensive assessment of HAI/AR in facilities, regions and states.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: The HD must have a comprehensive state or community health assessment of the population of the state. The state/community health assessment includes the identification and description of the jurisdiction’s health and areas of health improvement, the factors that contribute to the health challenges, and the existing resources that can be mobilized to address them.

Opportunity: HAI/AR data, including antibiotic use data, can be part of the broad-based data used to inform the community health assessment process including a narrative description of health challenges in the state and discussion of the contributing causes of health challenges. Also, a listing of assets/resources that can be mobilized and employed to address specific health challenges, such as HAI/AR prevention, can be considered.

PHAB Measures

Measure 1.1.3:

(All) Accessibility of community health assessment to agencies, organizations, and the general public

HAI/AR Specific Programs or Activities

HAI/AR Programs are expected to collaborate with other programs and other HDs, healthcare facilities, laboratories, academic centers, and other governmental and external HAI/AR partners to increase awareness, education, and use of available data for HAI/AR.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: The state/community health assessment is a resource for all partners and should be made available so that it can be used in collaborations and for priority-setting, planning, program development, grant applications, and coordination of resources.

Opportunity: The community health assessment can be shared with HAI/AR partners; this may be especially relevant where HAI/AR and improving antibiotic use in healthcare and the community is identified as a priority health issue or included within the community health assessment.

Standard 1.2: Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on the health status of the population

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 1.2.1:

(All) 24/7 surveillance system or set of program surveillance systems

HAI/AR Specific Programs or Activities

HAI/AR Programs can access and use data form the NHSN which collects HAI/AR and other patient safety data directly from healthcare facilities. Programs also access HAI/AR data through the NNDSS, ARLN, EIP, or other surveillance systems. Data sources such as electronic laboratory records, antibiotic use data, and administrative data, such as hospital discharge or readmissions data, are also available.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: public health surveillance systems can serve as an early warning system for impending issues or help to monitor and clarify the epidemiology of health problems. HDs work with a variety of surveillance systems, some of which are very relevant to HAI/AR programs.

Opportunity: Examples for documentation related to surveillance systems can draw from a variety of HAI/AR program surveillance sources. Annual state HAI and AR reports, CMS Compare, or other sources of HAI/AR surveillance data, administrative data, laboratory data, or antibiotic use data may be considered as examples of documentation for this measure.

PHAB Measures

Measure 1.2.2:

(All) Communication with surveillance sites

HAI/AR Specific Programs or Activities

HAI/AR Programs work with a variety of healthcare facilities and laboratories to educate and promote surveillance data submission and validation. For example, HAI/AR programs offer NHSN surveillance training including facility and group enrollment, data collection, management, and analysis.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must keep a list of the individuals or organizations that provide surveillance data, which may include hospitals, outpatient facilities, nursing homes, clinical laboratories reporting HAI and AR data. HDs must also provide at least one example of a training or meeting with surveillance sites regarding reporting processes, reportable diseases/conditions and timeframes. HDs must document trainings or meetings held with surveillance site members regarding relevant reporting requirements, reportable diseases/conditions, and timeframes. HDs must provide documentation of the distribution of surveillance data to partners/stakeholders,

Opportunity: Documentation could include education and training conducted by HAI/AR programs to facilities covering reporting requirements specific to their state, NHSN data submission and analysis, or laboratory specific training.

PHAB Measures

Measure 1.2.3:

(All) Primary data

HAI/AR Specific Programs or Activities

HAI/AR Programs review and analyze primary data to target HAI and AR prevention efforts and antibiotic stewardship activities.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must provide two examples of standardized primary data collection (quantitative and qualitative) as well as data collection instruments that are used.

Opportunity: If the HAI/AR program has information/primary data collected from healthcare facilities or the public, for example, (via focus groups, surveys, etc.), this may meet this requirement for HDs.

PHAB Measures

Measure 1.2.4:

(S) Data provided to Tribal and local HDs located in the state.

(L) The provision of data to the state health department and to a Tribal HD (if one or more is located in the jurisdiction the local HD is authorized to serve).

(T) The provision of data to the state health department and to a local HD.

HAI/AR Specific Programs or Activities

Through state HAI reports, some HAI/AR programs are developing tailored reports of data analyses for localities or regions. Many are also making risk-adjusted HAI data available via these reports or online so comparisons can be made among hospitals.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

For the state standard: An example for the State Measure could include state reports of aggregate HAI/AR or antibiotic use data at local or regional level which are distributed to tribal and local HDs.

Tribal/Local Measure an example could include HAI data that tribal/local HDs provide to the state HD or to other HDs.

Standard 1.3: Analyze public health data to identify trends in health problems, environmental public health hazards, and social and economic factors that affect the public's health

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 1.3.1:

(All) Data analyzed and public health conclusions drawn

HAI/AR Specific Programs or Activities

HAI/AR Programs use quantitative and qualitative HAI/AR data to conduct and review outbreak investigations, target prevention efforts to inform public health practice, and to develop programs and policies. Many programs develop and disseminate annual HAI reports of data analyses for their state or region. HAI/AR Programs also use national HAI reports that include risk-adjusted HAI/AR data to make comparisons between hospitals, measure progress toward HAI/AR prevention goals, identify facilities in need of improvement, and direct program strategy and prevention efforts.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must provide two examples of reports, each containing analysis and conclusions drawn from the data in the report (one quantitative and one qualitative). HDs must also provide documentation of the review of data analysis, whether internal or with partners or coalitions

Opportunity: Documentation may include outbreak investigations and follow up, reports of hospital or other healthcare facility data, reports of performance measures for program improvement and progress towards goals and objectives. Reports that demonstrate an analysis of the required outcome data or findings in assessments of incidence and prevalence or burden in a particular region could be used as examples.

PHAB Measures

Measure 1.3.2:

(S) Statewide public health data and their analysis provided to various audiences on a variety of public health issues

(L) Public health data provided to various audiences on a variety of public health issues.

(T) Public health data provided to the Tribal community on a variety of public health issues.

HAI/AR Specific Programs or Activities

HAI/AR Programs develop and disseminate tailored reports (annual HAI/AR reports) of data analyses for their state or region. CDC produces national and state progress reports that make risk-adjusted HAI/AR data available enabling state agencies to make comparisons between hospitals, measure progress toward HAI/AR prevention goals, identify facilities in need of improvement, and implement prevention efforts. Much of the programs’ NHSN and antibiotic use data are available in the CDC Patient Safety Atlas.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must document the distribution of two analytic public health reports from two separate years, on one or more public health issues, to specific audiences in the jurisdiction. Distribution may be via mail, email, presentation, etc.

Opportunity: HAI/AR Programs can use and distribute their own state developed reports and/or CDC-prepared annual state HAI reports or other available resources to share data with public health partners, providers and the public.

Standard 1.4: Provide and use the results of health data analysis to develop recommendations regarding public health policy, processes, programs or interventions

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 1.4.1:

(All) Data used to recommend and inform public health policy, processes, programs, and/or interventions

HAI/AR Specific Programs or Activities

HAI/AR Programs use HAI/AR surveillance data to assess needs within the state and identify priority facilities (those with high rates of infections). After identifying facilities with high HAI/AR infection rates and developing plans to reduce infections, these jurisdictions continue to monitor progress and make improvement. Jurisdictions support HAI prevention collaboratives or antibiotic stewardship collaboratives that use NHSN or other data to target prevention practices and promote adherence to CDC guidelines and other recommendations to reduce HAIs and improve antibiotic use. Additionally, jurisdictions use HAI/AR data to inform licensure, accreditation and inspection processes as well as state or local policy makers.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must demonstrate the use of data to impact policy, processes, programs or intervention (or revision thereof).

Opportunity: HAI/AR Programs can document how they use HAI/AR outbreak and surveillance data to identify prevention priorities, target facilities with high rates of infections or that are more likely to put patients at risk due to the nature of their services, contain emerging resistant pathogens, and assess interventions and HAI reductions.

PHAB Measures

Measure 1.4.2:

(S) Statewide summaries or fact sheets of data to support health improvement planning processes at the state level.

(T/L) Tribal / community summaries or fact sheets of data to support public health improvement planning processes at the Tribal or local level.

HAI/AR Specific Programs or Activities

HAI/AR Programs develop and disseminate tailored reports (Annual HAI reports) of data analyses for the state or region. Additionally, jurisdictions use HAI surveillance data to set priorities, guide and assess prevention efforts and inform public health practice and develop policy.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must provide two examples of health-issue or program-specific data summaries. The HD must also demonstrate the dissemination of the data summaries.

Opportunity: HAI/AR programs may have state specific data reports identifying the prevention initiatives within the jurisdiction, the number of facilities enrolled in each HAI/AR prevention activity. These reports can be considered as an example.

PHAB Measures

Measure 1.4.3:

(S) Support provided to Tribal and local health departments in the state concerning the development and use of summaries of community data

HAI/AR Specific Programs or Activities

HAI/AR Programs are expected to collaborate with state, local, and tribal partners to provide education and support for identifying and assessing HAI/AR prevention gaps within the state and address priority areas based on the data. Many HAI/AR Programs also compile HAI/AR data into reports or online data portals that can be shared.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: State HDs must document two examples of providing data tools, guidance, and/or data summaries to Tribal and local HDs. Distribution may be via mail, email, presentation, etc. States must also document the provision of technical assistance in analyzing and understanding the data.

Opportunity: Documentation can include how programs distribute and assist Tribal and local HDs in using HAI/AR-related data or summaries of data.