Project Description

For Lake Cumberland District Health Department, Accreditation Brings Confidence that ‘We Are Meeting Our Community’s Needs’

By Janae Tucker, RN, CCS-P

The Lake Cumberland District Health Department (LCDHD), covering 10 counties in Kentucky, became PHAB-accredited in March 2017 after several years of preparation. This process gave us an opportunity to evaluate ourselves utilizing a set of national standards for local health departments. We have always maintained a high level of quality, while at the same time striving for excellence, so this was a perfect opportunity to validate our past work and enhance our future activities.

The path to accreditation was an incredible learning journey. Analyzing the standards and measures made us look at everything we do. We realized there were some things we were doing well and that there were areas of needed improvement. Thus we began to plan, literally!  We worked on a strategic plan, a quality improvement plan, community health improvement plan, a workforce development plan, etc. Also, we realized we needed to place a much greater emphasis on documentation.  One of our most significant weaknesses wasn’t that we were not doing many of the required activities but that we were not documenting very well what we did. Thanks to accreditation we realized how important it was to not only document all the valuable services we provide, but to also clearly document our improvement efforts. This practice has developed into a way of life across all departments. One of the first questions you hear when we sit down at a meeting now is, “Who is taking minutes?” or “How can we document or measure?”

Prior to the application for PHAB accreditation, there wasn’t a broad, agency-wide acceptance of quality improvement and performance management. Initial efforts to implement PM/QI processes were met with resistance and viewed as “one more thing to do,” but as we moved through the accreditation process it became apparent how valuable these systems are to the organization. So, now we have a performance management and quality improvement system in place that is effective and continues to evolve to meet our agency’s needs.

Our executive team, which has a representative from each department, became our QI leadership committee. Now our daily operations incorporate quality improvement and performance management, allowing us to easily identify areas for improvement in our services, programs, projects, processes, policies and plans.

Becoming a PHAB-accredited health department has assured that we are achieving our vision of being a “progressive leader providing innovative solutions to achieve optimal health status for our communities.”  As we face new challenges and emerging health issues, we have greater confidence in our ability to continue meeting the public health needs of our communities.

Lake Cumberland District Health Department in Somerset, Kentucky was awarded national accreditation through the Public Health Accreditation Board on March 14, 2017.

About the author: Janae Tucker, RN, CCS-P, is LHN Specialist at Lake Cumberland District Health Department in Somerset, Kentucky. Contact her at [email protected]

⇒ Other major benefits gained as a result of going through the accreditation process:

  • Implementation of a data analysis committee
  • Strengths/Weaknesses: clear vision of strengths and opportunities for improvement as identified by all staff and the governing board of health.
  • Improving communication with our governing entity/board of health
  • Identified gaps between strategic plan, performance management and quality improvement; the department has been working to ensure that the major plans align with each other and are part of our PM system