Vocabulary for the NCLHD Accreditation Process
Accessibility. The quality of being at hand when needed.
Accreditation. The process whereby a program of study or an institution is recognized by an external body as meeting certain predetermined benchmarks. Accreditation is often given by organizations created for the purpose of assuring the public of the quality of the accredited institution or program. North Carolina Local Health Department Accreditation refers to when local health departments have satisfied the accreditation Activities adopted by the North Carolina Local Health Department Accreditation Board and applicable rules adopted by the Commission. The initial period of accreditation shall expire four calendar years after initial accreditation is granted.
Accreditation Administrator. The independent entity that, by legislation, manages and facilitates the North Carolina Local Health Department Accreditation process. For the North Carolina Local Health Department Accreditation process, the North Carolina Institute for Public Health serves in this role.
Accreditation Board. The Local Health Department Accreditation Board is established within the North Carolina Institute for Public Health. Read more about the Board.
Accreditation Management Team (AMT). A multidisciplinary team assembled by the local health department to lead the Accreditation process. This team usually includes the Health Director, the personnel and/or finance officer, a director of a personal health service unit, an environmental health specialist, the staff member responsible for the Community Health Assessment and a member of the Board of Health.
Activities. Specific, documentable actions taken by a local health department or a local board of health.
Agency Accreditation Coordinator (AAC). A member of the local health department’s Accreditation Management Team. This individual serves the local health department’s primary liaison to the Accreditation Administrator (AA). The AAC will assure that all necessary Accreditation documentation is complete and that all Accreditation deadlines are met.
Appeal. A written objection made within 10 calendar days of the Accreditation Board’s decision regarding Accreditation status. The appeal should state the specific decision and basis for the objection. The Accreditation Board shall act on the written request within a time period specified by Accreditation Board policy or rule.
Assessment. One of the three core functions of public health as identified by the Institute of Medicine. Assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities. See community assessment.
Assurance. One of the three core functions of public health as identified by the Institute of Medicine. Assuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the quality and effectiveness of that care.
Benchmarks. Predetermined measures illustrated by specific documentable actions taken by a local health department or a local board of health.
Board of Health. A legally designated governing body whose members are appointed or elected to provide advisory functions and/or governing oversight of public health activities, including assessment, assurance, and policy development, for the protection and promotion of health in their community.
Bylaws. Detailed internal rules about how an organization will be governed and conduct business.
Community health assessment. A community health assessment is the process whereby a local health agency and its community engage in assessing the health needs of their community and investigate adverse health effects and health hazards to create a “snap-shot” of a community’s health. Assessments generally serve two functions: they provide useful information for program planning and policy decisions, and can serve as a baseline against which to evaluate the success of interventions.
Community health improvement planning. A series of timely and meaningful action steps that define and direct the distribution of health services and resources to improve your community’s health, or definite strategic action steps to improve health status in the community.
Conditional Accreditation. Conditional Accreditation refers to when the local health department has failed to achieve accreditation as specified by the Laws and Rules and has therefore been granted short-term accreditation subject to conditions specified by the Local Health Department Accreditation Board. The period of Conditional Accreditation shall expire two calendar years after Conditional Accreditation is granted.
Consolidated agreement/Agreement agenda. The contract used by the North Carolina Division of Public Health to distribute state and federal public health funds to local health departments.
Consolidated human services agency. One of the five ways that a county in North Carolina can choose to provide public health services. This type of organization is available to North Carolina counties with populations greater than 425,000. A consolidated human services agency combines public health, mental health, social services, developmental disabilities and substance abuse services and can be governed by either a Consolidated Human Services Board or the board of county commissioners.
Contract with state. One of the five ways that a county in North Carolina can choose to provide public health services. With this type of arrangement, the county arranges with the State to furnish public health services within the county. None of the counties in North Carolina have this arrangement.
Core functions. The three core functions of public health as identified by the Institute of Medicine are assessment, assurance and policy development. State and local public health agencies must perform these functions in order to protect and promote health and prevent disease and injury.
County health department. One of the five ways that a county in North Carolina can choose to provide public health services. A county health department covers a single county. In North Carolina, the majority of local health systems are single county health departments.
District health department. One of the five ways that a county in North Carolina can choose to provide public health services. A district health department consists of two or more counties. Usually counties choose to join together to form a district as a way to pool resources and better assure the provision of public health services. In North Carolina, there are districts that range in size from two to seven counties.
E – F
Environmental health. The field of science that studies how the environment influences human health and disease.
Environmental health services. Services having to do with inspections, such as inspections of lodging and institutional sanitation and food safety and sanitation. Environmental health services also cover on-site domestic sewage disposal, safe drinking water and vector control.
Evidence-based health promotions/disease prevention strategies. Endeavors in which there is an informed and explicit use of evidence that has been derived from any of a variety of science and social science research and evaluation methods.
Governance. The legal authority of a board to establish policies that will affect the life and work of the organization while holding the board accountable for the outcome of such decisions.
Guidance document. An informational document for local health departments that are preparing for the completion of the Health Department Self-Assessment Instrument, the Accreditation Site Visit and the Accreditation Review.
Health. A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Health Department Self-Assessment Instrument (HDSAI). An internal review of the local health department’s ability to deliver essential services as indicated by the agency’s performance of a set of prescribed activities. The HDSAI includes 41 Benchmarks and 147 Activities, its completion is a requirement of the North Carolina Local Health Department Accreditation process. Note: The HDSAI is reviewed and may be updated annually.
Health disparities. Differences in morbidity and mortality due to various causes experienced by specific sub-populations. See Morbidity and Mortality.
Health education. Programs designed with a community to help it know about health risks and how to reduce these risks.
Health indicator. A measure that reflects, or indicates, the state of health of persons in a defined population, e.g., the infant mortality rate.
Health promotion. The process of enabling people to increase control over, and to improve, their health.
Health status. The state of health of a specified individual, group or population.
Healthy People 2020. The prevention agenda for the U.S. It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats.
HIPAA. A federal law that created national standards to protect individuals’ medical records and other personal health information. HIPAA is an acronym for “Health Insurance Portability and Accountability Act (HIPAA) of 1996”.
Incidence. The number of new cases of disease in a defined population over a specific time period.
Institute of Medicine (IOM). A private, nonprofit institution that provides objective, timely, authoritative information and advice concerning health and science policy to government, the corporate sector, the professions and the public under a congressional charter. The mission of the IOM is to advance and disseminate scientific knowledge to improve human health.
Intervention. A term used in public health to describe a program or policy designed to have an effect on a health problem. Health interventions include health promotion, specific protection, early case finding and prompt treatment, disability limitation and rehabilitation.
J – K
Jurisdiction. The territorial range of authority or control.
Law (for Accreditation). Senate Bill 804. An act to improve the public health infrastructure by establishing an accreditation system for local health departments, as recommended by the Public Health Task Force 2004.
Lead Site Visitor (LSV). The Site Visit Team member responsible for coordinating the activities of the SVT when on-site, acting as the spokesperson for the SVT, and completing and submitting the Site Visit report to the Accreditation Administrator within 14 days of the completion of the Site Visit. The LSV or another Site Visit Team member will be responsible for the presentation of the Site Visit Team recommendation to the Accreditation Board.
Local. Of or relating to a city, town, or district rather than a larger area: state and local government.
M – N
Mandate. An authoritative command or instruction.
Minutes. Written records of board meetings, including records of actions, attendance, and decisions made by the board. Minutes are considered to be legal documents.
Morbidity. State of being ill or diseased. Morbidity is the occurrence of a disease or condition that alters health or quality of life.
Mortality. Death. Usually the cause (a specific disease, a condition, or an injury) is stated.
North Carolina Institute for Public Health. The North Carolina Institute for Public Health is the Accreditation Administrator as specified in the North Carolina Accreditation Rules.
Objectives. A means to achieve a goal accomplished through implementation of one or more strategies during a specified time frame. This accomplishment should be measurable.
P – Q
Personal health services. Refers to services offered at some health departments such as family planning, maternal and child health, immunizations, school health, adult health, dental public health, chronic disease control, communicable disease control, Sexually Transmitted Diseases (STD) counseling and treatment, Tuberculosis, and HIV/AIDS.
PHRST. Public Health Regional Surveillance Teams.
Policy. A plan or course of action, as of a government, political party, or business, intended to influence and determine decisions, actions and other matters.
Policy development. Policy development is one of the three core functions of public health as defined by the Institute of Medicine. Policy development is formulating public policies, in collaboration with community and government leaders, designed to solve identified local and national health problems and priorities.
Population. A group or number of people living within a specified area or sharing similar characteristics (such as occupation or age).
Prevalence. The number of existing disease cases in a defined population during a specific time period.
Prevention. Actions that reduce exposure or other risks, keep people from getting sick, or keep disease from getting worse.
Primary care. Basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system.
Public health. Activities that society does collectively to assure the conditions in which people can be healthy. This includes organized community efforts to prevent, identify, preempt and counter threats to the public’s health.
Public health authority. One of the five ways that a county in North Carolina can choose to provide public health services. Similar to a district health department (two or more counties), a public health authority may include more than one county and require a board and a director.
Public health practice. Organizational practices or processes that are necessary and sufficient to assure that the core functions of public health are being carried out effectively.
Regulation. An authoritative rule. Standards specify what those covered by a law must do to meet the law’s requirements.
Remediation. A process for a local health department that has been deemed “Conditionally Accredited” to create and implement a corrective action plan in reference to the “Not Met” Standards/Benchmarks. If the corrective action plan meets the Accreditation Standards/Benchmarks, the Accreditation Board shall determine the local health department to be Accredited.
Risk. The likelihood or probability that an individual will experience a certain event.
Rule-making (also referred to as rulemaking or rule making). The development of regulations for future enforcement. Rule-making describes what is expected in general terms and is done apart from and before any particular instances of failure to comply with regulations.
Rules (for Accreditation). The rules establish the process for local health departments to become accredited pursuant to G.S. 130A-34.1.
Site visit. An on-site visit of the health department by a team of experts to clarify, verify, and amplify the information in the self‑assessment and the organization’s ability to meet a set of public health standards. The site visit team reviews the self-assessment instrument and supporting documentation, interviews the local health department staff and other persons necessary to evaluate compliance with the standards and inspects the facilities in accordance with the standards.
Site visit team (SVT). The team of healthcare professionals who are responsible for ensuring that the local health departments have a fair, equitable assessment and that the Health Department Self-Assessment Instrument (HDSAI) is clarified, verified and amplified. The team includes:
- A Local Health Department Director
- A Public Health Nurse/Quality Assurance Representative
- An Environmental Health Professional
- A Board of Health Representative
- A Site Administrator from the Administrative Agency
Standards. The standards for North Carolina Local Health Department Accreditation are as follows:
- Standard 1: Agency Core Functions and Essential Services
- Standard 2: Facilities and Administrative Services
- Standard 3: Governance/Board of Health
Statute. A law enacted by a legislature.
Strategic plan. A planning process that seeks to define where an organization is going over the next year or more, how it is going to get there and how it will know if it got there or not. The focus of a strategic plan is usually on the entire organization, while the focus of a business plan is usually on a particular product, service or program.
Ten essential services. The ten essential services provide a working definition for the practice of public health and are the framework within which all public health activities occur. The essential services are–monitoring health status to identify community problems; diagnosing and investigating health problems in the community; informing, educating, and empowering people about health issues; mobilizing community partnerships to identify and solve health problems; developing policies and plans that support individual and community health efforts; enforcing laws and regulations that protect health and ensure safety; linking people to needed personal health services and assuring the provision of health care when otherwise unavailable; assuring a competent public health and personal health care workforce; evaluating effectiveness, accessibility, and quality of personal and population-based health services; and conducting research for new insights and innovative solutions to health problems.
U – V
Unaccredited. Unaccredited refers to local health departments that have failed to meet one or more accreditation benchmarks after a period of conditional accreditation.
W – X – Y – Z
WHO. World Health Organization