To maintain the overall credibility of the national public health accreditation process, the Public Health Accreditation Board (PHAB) uses information from various sources to monitor the sustained capacity and quality of the health departments that it accredits. Therefore, PHAB has established policies and procedures for receiving and addressing written complaints about an accredited
health department.

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PHAB Complaint Policy and Procedures

Policy

PHAB accepts only written complaints about an accredited health department that are specific to a possible lack of conformity with PHAB Standards & Measures under which the health department was accredited or reaccredited. PHAB does not address complaints or disputes between individuals and health departments; environmental conditions or hazards; professional licensing or practice; or any state, local, or Tribal regulations. PHAB does not mediate disputes between the accredited health department and any party.

Procedures

Complaints must be made by either email or U.S. mail addressed to PHAB’s President & CEO. Before filing a complaint with PHAB, the person or persons intending to file a complaint (the Complainant) must use and exhaust the administrative procedures available to them through the accredited health department. A complaint must be filed in writing on the PHAB complaint form below. The Complainant must specify the health department (the Respondent) and the accreditation measure(s) with which the Respondent is purportedly out of conformity. The Complainant should provide a brief narrative explaining the background and context of the complaint. In addition to the complaint form and brief narrative, the Complainant must provide evidence (copies of letters or emails) substantiating that administrative remedies made available by the Respondent to address complaints have been pursued and exhausted.

File a Complaint

Once PHAB receives a properly filed complaint, the following procedures will be followed:

  1. Within five (5) business days, the PHAB President & CEO, or their designated representative, will respond in writing to the Complainant to acknowledge receiving the complaint. In the acknowledgement communication, the President & CEO, or their designated representative, may request more information from the Complainant; dismiss the complaint as being outside of PHAB’s complaint policy; or accept the complaint for further review and adjudication.
  2. Within five (5) business days of accepting the complaint for further review and adjudication, PHAB’s President & CEO, or their designated representative, will notify in writing the Health Department Director and the Accreditation Coordinator of the Respondent that the Respondent is the subject of a complaint. A copy of the complaint and supporting documentation will be shared with the Respondent. The Respondent must respond in writing to the PHAB President & CEO and address the substance of the complaint within twenty (20) business days of receiving notice and a copy of the complaint and supporting documentation.
  3. Concurrent with notifying the Respondent, the President & CEO, or their designated representative, will notify the PHAB Board Chair that a complaint has been received and provide to the Chair a copy of the complaint and supporting documentation. The Board Chair and the President & CEO will confer and select up to two (2) additional members of the PHAB Board that have no conflicts of interest with the Respondent or the Complainant to serve with them as an ad hoc panel to review the complaint with them.
  4. Within ten (10) business days of the receipt of the health department’s written response, the Board Chair will convene the ad hoc panel to review the complaint. The ad hoc panel will review all the materials provided both by the Complainant and the Respondent and take one or more of the following actions:
    1. Dismiss the complaint based on the evidence received. Dismissal will result in no change to the Respondent’s accreditation status.
    2. Determine that further investigation of the complaint is warranted. If the ad hoc panel makes this determination, trained PHAB peer reviewers (the Peer Reviewers) who, if possible, have previously reviewed the Respondent for its initial or reaccreditation application(s) will be requested to review the
      Respondent for conformity with the specific standard(s) and measure(s) cited in the complaint. The Peer Reviewers will conduct their review in a timely fashion so that it is completed within sixty (60) days of the ad hoc panel’s request. The Peer Reviewers will be assisted by PHAB’s Director of Accreditation and may request additional documentation and/or conduct necessary interviews with the Respondent’s relevant personnel and/or the Complainant, either in person or by videoconference, to adequately assess the Respondent’s conformity with the specific standard(s) and measure(s) cited in the complaint. The Peer Reviewers will summarize their findings in a written report to the ad hoc panel and may be requested to discuss their findings with the ad hoc panel at the discretion of the PHAB Board Chair and/
      or President & CEO.
  5. Within five (5) business days of receiving the written report from the Peer Reviewers, the ad hoc panel will convene and take one of the following actions:
    1. Dismiss the complaint based on the evidence received and the peer review. This will result in no change to the Respondent’s accreditation status.
    2. Conduct additional interviews with the Respondent’s relevant personnel and/or the Complainant through convening a hearing via video conference. If the ad hoc panel chooses this option, it must notify the Complainant and the Respondent of its decision to do so in writing. The ad hoc panel shall explain that the hearing is not an adversarial proceeding but one that is seeking additional information or clarification of information received through the Peer Reviewers. The hearing must be conducted within twenty
      (20) business days of the notification being provided to the Complainant and the Respondent.
  6. If the Respondent does not provide a written response (step 2) or participate in any required further investigation (step 4 or 5), the ad hoc panel will document the Respondent’s lack of cooperation in its report (step 7). The Respondent may request an extension of up to fifteen (15) business days from the ad hoc panel to respond to the ad hoc panel’s
    request(s) if the Respondent is dealing with a public health emergency or other significant event outside of its control that directly impacts its ability to provide a written response to the complaint in a timely manner. The PHAB Board Chair and/or President & CEO shall grant or deny the extension request in their sole discretion.
  7. At the conclusion of its fact-finding process (outlined in steps 4 and 5 above), the ad hoc panel will summarize its findings in a written report along with either its dismissal of the complaint or its recommendations for further actions. The report will be addressed to the PHAB Accreditation Committee in a timely fashion so the Accreditation Committee can deliberate and act on the report at its next regularly scheduled meeting.

Final Resolution of the Complaint

The report from the ad hoc panel will be reviewed and deliberated upon by the Accreditation Committee at its next regularly scheduled meeting. The Accreditation Committee shall be the final decision-making body for all complaints. Based on the Accreditation Committee’s deliberations, the following actions may be taken:

  1. Continue the accreditation status of the Respondent without change;
  2. Continue the accreditation status of the Respondent but require the Respondent in its next annual report(s) to detail its remediation efforts and compliance with the specific standard(s) and measure(s) identified by the Accreditation Committee as being deficient to maintain the Respondent’s accreditation status, or, in the case of a Respondent in its fourth year of an accreditation status, in the Respondent’s application for reaccreditation;
  3. Place the Respondent on probation for a period not to exceed twelve (12) months during which time specific follow-up actions, such as regular reporting or a repeat peer review will be required, and the Respondent’s probationary status will be noted on the PHAB website during the probationary period; or
  4. Revoke the Respondent’s accreditation.

The Complainant and the Respondent will be advised of the Accreditation Committee’s decision on the complaint, a summary of the process taken to investigate the complaint, and a summary of the findings of the investigation within ten (10) business days of the Accreditation Committee’s decision. No other materials related to the complaint will be provided to the Complainant.

All complaints that result in the naming of an ad hoc panel for investigation, and their associated outcomes, will be reported to the full Board of Directors quarterly.

Complaints, and all associated documentation, will be maintained in PHAB records associated with the Respondent for the remainder of that Respondent’s accreditation cycle, or no longer than five years.

PHAB will not publicly release the complaints received nor the results of the complaint assessments except as they may be compelled to do so by legal process. De-identified complaint data may be used by PHAB to inform its efforts to improve its services and those of accredited health departments.