Skip to main content

Flowchart of the Accreditation Process

Notification
The Accreditation Administrator (AA) sends the 90-Day Notification Letter to the Health Director to notify them that the health department’s reaccreditation process has begun and that the Health Department Self-Assessment Instrument (HDSAI) and required materials are due within 90 days.

Health Department Self-Assessment
The health department must submit the HDSAI and other required materials to the AA at the North Carolina Institute for Public Health within 90 days after receiving the notification letter.

Site Visit
The AA sends the HDSAI and other required materials to the Site Visit Team (SVT). The SVT reviews the HDSAI and required materials, visits the health department and interviews local health department (LHD) staff and other persons necessary to evaluate compliance with the standards and activities. They also inspect health department facilities as needed to satisfy activity requirements.

Site Visit Team Report
The SVT prepares two reports: 1) an SVT report and 2) a Suggestions for Quality Improvement (SQI) report. The SVT report (word doc) includes a synopsis of missed activities with an associated recommendation for reaccreditation and a narrative of strengths/general observations. The SQI report provides suggestions for quality improvement based on the HDSAI activities; however, the recommendations are not binding and do not affect the accreditation recommendation. Both reports are submitted to the AA and the LHD within 14 days of the end of the site visit.
The AA reviews the reports prior to sending them to the Health Director and Agency Accreditation Coordinator, usually within 1-3 days after receipt of the report.

Local Health Department Options for Response to Report

see NCLHDA Operational Guidelines for additional details (pdf)
Request for review Request for additional review of the evidence No action requested
Written response Error of fact
If the health department disagrees with an assessment finding from the SVT report, they may submit a written response to the AA within 10 business days after receiving the report. If a health department finds an error of fact (an error that is quantifiable, objective and not subject to interpretation in its meaning) in the SVT report, they may submit a request for review to the AA within 10 business days of receiving the report. If the health department receives conditional reaccreditation they may submit a written request for an additional review of evidence to the AA within 10 business days following receipt of the SVT report. The evidence cannot be newly created or revised documentation. It may only be documentation that was in place as of the beginning of the site visit. If no action is requested the report is sent to the NCLHD Accreditation Board (Board).
The AA notifies the Board Chair that a request for review has been received. The AA notifies the Board Chair that a request for review has been received. The AA notifies the Board Chair and Appeals Committee Chair of the written request, and the newly submitted documentation is forwarded to the SVT for review.
The AA investigates as appropriate, with NCLHDA staff, LHD staff, the Health Director, SVT members and the Lead Site Visitor. The AA investigates as appropriate, with NCLHDA staff, LHD staff, the Health Director, SVT members and the Lead Site Visitor. The SVT reviews the documentation in light of the original evidence and the SQI made at the time of the site visit, rescores each “not met” in light of the additional evidence and forwards their findings and recommendations to the AA.
An addendum to the SVT report is developed and is forwarded to the Board, the Appeals Committee Chair and the LHD.
The AA compiles the LHD response and any program response and shares with the LHD, if necessary. Upon conclusion of the investigation, the AA makes a decision and communicates that in writing to the LHD and the Board Chair. If conditional accreditation remains the recommendation to the Board, the Appeals Committee is convened to review the findings. The Appeals Committee reviews all associated documentation and develops a report to the Board with their recommendation for accreditation status.
After initial processing of a Request for Review of the SVT report and the AA’s decision, the LHD may request that the Board review all relevant information and consider a change in decision of the request. This appeal shall not be presented until the Board meeting for which the Request for Review is covered.

NCLHD Accreditation Board Meeting
The report is presented to the Board with the SVT report. The Board or Health Director may choose to discuss the written response and findings during the Board meeting. The Board may choose or choose not to amend the SVT report at that time. The report is presented to the Board with the SVT report for the agency. If the LHD wishes to appeal the decision of the AA they can follow the Review Appeal Procedure. The SVT report, Addendum and Appeals Committee report (if indicated) are presented at the Board meeting. The SVT report is presented at the Board meeting by the Lead Site Visitor.
Continue to Appeals/Extension Process if Needed

Accreditation Status is Awarded by the NCLHD Accreditation Board
Reaccredited Conditionally Reaccredited
If a health department fulfills the defined number of activities within each standard they become reaccredited.

If a health department misses one or fewer activities within each standard, they will receive a Reaccredited with Honors designation.

 If the health department has not fulfilled enough activities to meet one or more of the five standards they become conditionally reaccredited. Continue to conditional reaccreditation process.
Accreditation is awarded for four years.