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North Carolina Local Health Department 
Accreditation Program
Monthly Highlights
July 2019


NCLHD Accreditation Annual Survey – We Want to Hear from You AND Your Team!
Each year the NCLHD Accreditation Program administers a survey to get feedback from local health departments about the program. We want to learn how we can continue to make the program valuable for you and your team members. Please take 10-15 minutes to complete the survey: Please share this link with all your team members so that they can provide their feedback. The survey will remain open until July 10 at 5 p.m.

NCLHD Accreditation Dashboard On-Boarding
Thank YOU all for sending the requested dashboard information! All health departments are expected to have access to their dashboards on July 19. We will send an announcement to all AACs once you have access to the dashboard. We also send information on the training resources that are available to support your use of the dashboard.


NCLHD Accreditation Annual Skills-Building Workshop – Registration Extended to 160 – and Almost Full!

Registration for the annual workshop has been extended to 160 participants. When 160 is hit, the registration system will start a waitlist automatically, so please go to the same registration link to get your name on that list. If we can open for more registrants, we will notify those on the waitlist as soon as possible.

The theme of this year’s workshop is The Life Changing Magic of the NCLHD Accreditation Dashboard. The workshop will be held August 8-9, 2019 at the Conference Center at Guilford Technical Community College, Colfax N.C. The workshop will focus on the AAC’s use of the dashboard; however, other health department staff are welcome to attend.

In addition to learning how to use the dashboard for our program, the workshop will feature stories from health departments that have already started to use the dashboard and a representative from Knowledge Capital Alliance, who created the VMSG Dashboard, will be presenting on the full range of performance management features that are available through the dashboard.

Hotel rooms have been reserved at additional hotels. The information is available on the registration page:

Pictures Please!
Does your health department have a picture of staff celebrating reaccreditation? If so, we would like to include it in the 2018-2019 NCLHD Accreditation Annual Report. Every health department is different, and we want to recognize and celebrate the many people across the state who contribute to accreditation success – any group photos of your staff are welcome! Please send photos to by July 12.

Thank you to those who have sent photos – it is great to see the celebrations!


NCLHD Accreditation Annual Skills-Building Workshop: August 8-9, 2019, Conference Center at Guilford Technical Community College, Colfax N.C.

Accreditation 101: New Agency Accreditation Coordinator Training: September 24, from 9 a.m. – 4 p.m., Greensboro, N.C. Registration will open July 9.

NCLHDA Dashboard Overview: September 27, 2019, 10 a.m. – 11 a.m. Webinar. There is no fee, however, registration is required and will open August 7. The webinar will provide an overview of the NCLHDA dashboard for all users. The webinar will cover content that is being covered at the workshop in August and is aimed at individuals who cannot attend the workshop. We will offer bi-annual webinars to support the use of the dashboard.

NCLHD Accreditation Board meeting: November 22, 2019. 10 a.m. – 3 p.m., Wake County Human Services, Swinburne Training Room #2149, 220 Swinburne St., Raleigh, N.C., 27610.

NCLHD Accreditation Annual Update Webinar: January 21, 2020, 9:30 ‐ 11 a.m. Webinar. There is no fee, however, registration is required and will open in December.


Surry Country – Red Folder Project – Engaging Staff and Keeping Organized

Emily Mayes, RN, BSN
Quality Assurance Coodinator, Agency Accreditation Coordinator, Privacy and Safety Officer
Surry County Health & Nutrition Center

The Surry County Health & Nutrition Center implemented their Red Folder Project in 2016. According to Emily Mayes, the AAC, the goal was to involve each member of the accreditation team in a way that they had not been involved before. They took the following steps to implement the project:

• Assigned each team members the activities they are responsible for
• Made copies of the completed 2015 HDSAI
• Each accreditation team member received a red folder with a copy of the completed activities from the 2015 HDSAI for the activities they had been assigned. They chose red folders because it is an easy color to see on the desk and is a reminder of accreditation responsibilities

The red folders are separated into six sections:

Section 1 – Activities assigned to the team member
Section 2 – Activities due in 2016
Section 3 – Activities due in 2017
Section 4 – Activities due in 2018
Section 5 – Activities due in 2019
Section 6 – Activities due anytime

Separating the sections by year allows team members to focus on one year at time, which helps keep team members from getting overwhelmed collecting evidence. Emily scheduled quarterly face-to-face meetings between 2016 – 2019 with all team members using the red folders to discuss/collect evidence along with way. Team members make notes in their red folders as needed.

Each accreditation team member has an Accreditation Team Assigned Activities form that is kept in their personnel file. After each quarterly meeting, the signature page of this form is signed.

According to Emily, “We are very happy with our red folders! Evidence is collected at a nice, steady rate – even between meetings!” Seeing the red folders on their desks prompts team members to stay focused on collecting evidence between meetings. In addition, many staff have commented that the red folder project helps them understand their role in accreditation.

The Surry County Health & Nutrition Center is using the new NCLHDA Dashboard for their 2019 fall site visit and Emily has continued to use the red folder process. According to Emily, “This process really works for us. We definitely plan to continue using our red folder project for our future reaccreditation cycles!”

If you would like to learn more about the Red Folder Project, contact Emily Mayes at or 336-401-8425.


Share your tips and tricks for accreditation success with other local health departments across the state. If you have a tip or trick that you would like to share, send a summary, no more than 500 words including the activity addressed and any lessons learned. Please send your submission to Stories will be shared via these monthly highlights.

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