Accreditation Evidence for Local and Tribal Health Departments

The following list contains examples and resources for completing some of the Public Health Accreditation Board (PHAB) initial accreditation and reaccreditation measures.

Find more information on Standards and Measures Version 2022 on the PHAB website. If your health department is familiar with the previous version, this crosswalk between version 2022 and version 1.5 (PDF) may be helpful in navigating changes.

Also included is information on alignment with Wis. Admin. Code ch. DHS 140 required services for local health departments. This will assist in identifying examples used in the Wisconsin Department of Health Services (DHS) 140 Reviews of local health departments that may be applicable to PHAB accreditation measures.

For more information on the alignment of Wis. Admin. Code ch. DHS 140 sections, contact the DHS 140 calendar inbox at dhscal140reviews@dhs.wisconsin.gov.

PHAB-approved statewide evidence

PHAB has approved the following as Statewide Evidence for local and Tribal health departments in Wisconsin to use during their accreditation process. The evidence will remain as approved until version 2022 is replaced or evidence is no longer current. As part of the Division of Public Health's (DPH) annual report this evidence will be reviewed to ensure it is still current. Statewide Evidence was approved for use 12/10/2024.

Pathways Recognition, Initial Accreditation, or Reaccreditation, Measure 1.2.2 T/L

Example 1: Wisconsin DPH Brief Overview of the Wisconsin Electronic Disease Surveillance System (WEDSS)
Example 2: Wisconsin Immunization Registry Information for Providers and Partners

Pathways Recognition and Initial Accreditation, Measure 2.1.3 A, RD2

Wisconsin State Laboratory of Hygiene Letter to the Health Officer and Screenshot, Lab Certificates, MOU Lab/WIDPH

Initial Accreditation, Measure 2.1.4 A, RD2

Childhood Blood Lead Level Case Management Guidelines

Initial Accreditation, Measure 2.1.7 RD1

Example 1: Report from WEDSS, Chlamydia Trachomatis Infection
Example 2: Report from WEDSS, Gonorrhea Infection

Evidence and resources by domain

Domain 1: Assess and monitor population health status, factors that influence health, and community needs and assets.

Initial and reaccreditation measure 1.1.1: Develop a community health assessment.

This measure requires that data in the community health assessment (CHA) must include secondary data from two or more sources. Data collected by DHS can be found on the Data and Statistics webpage. Data displayed by county include:

Other CHA resources may be found on the CHA and CHIP webpage or through contacting your regional public health strategist.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level III

Wis. Admin. Code § DHS 140.06

Initial accreditation and reaccreditation measure 1.2.2: Participate in data-sharing with other entities.

Local and Tribal health departments (LTHDs) participate in record-level data-sharing with DHS through multiple avenues including the Wisconsin Electronic Disease Surveillance System (WEDSS) and Wisconsin Immunization Registry (WIR). Documentation for this measure could include emails, screen shots documenting data sharing, or data use agreements.

For more information on WEDSS, visit the WEDSS webpage or contact the Division of Public Health (DPH) WEDSS staff at dhswedss@dhs.wisconsin.gov.

For more information on WIR, visit the WIR webpage or contact the WIR Help Desk at dhswirhelp@dhs.wisconsin.gov.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level III

Initial accreditation and reaccreditation measure 1.3.1: Analyze data and draw public health conclusions.

Documentation for this measure may include portions of the state health assessment, provided that some of the data is specific to the populations served by the applicant jurisdiction. The 2020 Wisconsin State Health Assessment (SHA), Painting the Picture of Wisconsin's Health, P-03169 (PDF), contains several analyses of county and regional quantitative data and information on methods. The 2020 SHA also contains examples of qualitative analysis from the Community Health Themes and Strengths Assessment. Information on collecting and analyzing qualitative data can be found in the Qualitative Data Standards Guide (PDF).

Additional resources for quantitative data analysis can be found in County Environmental Health Profiles, which summarize data on the Environmental Public Health Data Tracking portal. Contact the DHS tracking inbox at dhstracking@dhs.wisconsin.gov to request individual 2023 County Environmental Health Profiles.

Initial accreditation measure 1.3.2: Share and review public health findings with stakeholders and the public.

This measure requires examples of resources that present key findings or data visualization, which are also distributed to partners or the public. Data dashboards developed by DHS can be found on our Data and Statistics webpage.

Data displayed by county include:

These resources are open to the public and may be shared with partners and community members.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(a)1.

Level III

Domain 2: Investigate, diagnose, and address health problems and hazards affecting the population.

Initial accreditation measure 2.1.1: Maintain surveillance protocols.

This measure requires a list of surveillance systems used by the health department. Some examples may include the WEDSS, WIR, and Wisconsin State Laboratory of Hygiene wastewater surveillance program.
This measure also requires examples of protocols for surveillance data. Communicable disease case reporting and investigation protocols can be found on disease specific webpages for category I, II, and III reportable diseases and other notifiable conditions. These pages are linked on the Disease Reporting webpage by category.

Initial accreditation measure 2.1.2: Training provided to surveillance sites.

A portion of this measure details reporting requirements and a list of reportable diseases and conditions, which can be found on the Disease Reporting webpage. A PDF of disease reporting categories, Reportable Communicable Disease Conditions in Wisconsin, P-03305 (PDF), is also available.

Initial accreditation measure 2.1.3 and reaccreditation measure 2.1.2: Ensure 24/7 access to resources for rapid detection, investigation, containment, and mitigation of health problems and environmental public health hazards.

A portion of this measure requires accreditation information for testing sites used by the health department. Accreditation information for The Wisconsin State Laboratory of Hygiene can be found on the compliance webpage.

Initial accreditation measure 2.1.4 and reaccreditation measure 2.1.3: Maintain protocols for investigation of public health issues.

Case reporting and investigation protocols for foodborne illnesses and vaccine preventable diseases can be found under disease specific tabs.

Initial accreditation measure 2.1.7: Use surveillance data to guide improvements.

A portion of this measure requires reports generated from WEDSS. For assistance in generating WEDSS reports review documents on the WEDSS SharePoint site, contact DPH WEDSS staff at dhswedss@wisconsin.gov.

State Lab of Hygiene Letters
These letters can be used as supplemental evidence for health departments.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(a)2.

Level III

Initial and reaccreditation measure 2.2.2: Ensure continuity of operations during response.

For information on continuity of operations plans and training opportunities, visit the Continuity of Operations / Continuity of Government (COOP/COG) webpage from the Department of Administration. Partner Communications and Alerting (PCA) portal has examples of COOP plans and a DHS 140 and PHEP Capabilities Connections document. The PHEP Operational Readiness Review (PDF) provides guidance on what should be included in a COOP plan.

Initial accreditation measure 2.2.6 and reaccreditation measure 2.2.5: Maintain and implement a process for urgent 24/7 communications with response partners.

DHS maintains communication with local and Tribal health departments and other response partners through the PCA portal. This system may serve as an example for this measure.

Initial and reaccreditation measure 2.2.7: Conduct exercises and use After Action Reports (AARs) to improve preparedness and response.

A portion of this measure requires after action reports (AARs) showing collaboration with other health departments. AARs are available for statewide or regional emergency preparedness exercises from your Healthcare Emergency Readiness Coalition (HERC) or the PCA Portal.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Domain 3: Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.

Initial and reaccreditation measure 3.1.1: Maintain procedures to provide ongoing, non-emergency communication outside the health department.

Part of this measure requires demonstrating capacity to communicate with individuals who are non-English speaking, deaf or hard of hearing, and blind or have low vision. DHS provides resources for locating:

DHS also provides information on Braille Transcribers and accessible content creation.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(a)4.

Initial accreditation measure 3.2.2: Implement health communication strategies to encourage actions to promote health.

Required documentation for this measure includes an example of unified messaging with other health departments. DHS occasionally distributes communications toolkits and talking points on key issues to local and Tribal health departments for the purpose of unified messaging.

Examples of ideas that locals may have shared that DHS created:

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(a)1.

Domain 4: Strengthen, support, and mobilize communities and partnerships to improve health.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level III

Wis. Admin. Code § DHS 140.06(6)

Domain 5: Create, champion, and implement policies, plans, and laws that impact health.

Initial and reaccreditation measure 5.1.1: Maintain awareness of public health issues that are being discussed by those who set policies and practices that impact on public health.

Information on policy changes may be received through DHS news releases, the Wisconsin Association of Local Health Departments and Boards (WALHDAB), newsletters, and meetings.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level III

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(a)1.

Level III

Domain 6: Utilize legal and regulatory actions designed to improve and protect the public’s health.

Initial accreditation measure 6.1.4: Conduct enforcement actions.

This measure requires that information has been provided to regulated entities about their responsibilities related to public health laws. This may be met in a variety of ways. One example may include communication with the food service industry about Wisconsin Food Code. The Department of Agriculture, Trade and Consumer Protection Food Code Fact Sheets can aid in this communication.

Initial accreditation measure 6.1.7 and reaccreditation measure 6.1.3: Identify and implement improvement opportunities to increase compliance.

Communications of regulations required by this measure may include communications with the public about investigations or compliance checks. Compliance checks through the Tobacco Prevention and Control Program would be one example.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Wis. Admin. Code § DHS 140.05(1)(c)

Level III

Domain 7: Contribute to an effective system that enables equitable access to the individual services and care needed to be healthy.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Wis. Admin. Code § DHS 140.04(1)(c)3.

Initial and reaccreditation measure 7.2.1: Collaborate with other sectors to improve access to social services.

Local and Tribal health departments participated in the development of the Wisconsin Integrated HIV Prevention and Care Plan through involvement with the Wisconsin Statewide Action Planning Group (SAPG) and in regional partner services provider meetings during the planning process in 2022.

Initial and reaccreditation measure 7.2.2: Collaborate with other sectors to ensure access to care during service disruptions.

For information on continuity of operations plans and training opportunities, visit the COOP/COG webpage from the Department of Administration.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 section:

Level I

Wis. Admin. Code § DHS 140.04 (1)(c)2.

Domain 8: Build and support a diverse and skilled public health workforce.

Initial accreditation measure 8.1.2: Recruit a qualified and diverse health department workforce.

DHS staff have developed guidelines for hiring local health officers and public health nurses to ensure the positions meet statute. Additionally, a training page provides resources for on-boarding staff to the public health system and continuing education. Local and Tribal health departments will need to demonstrate the use of these resources.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Wis. Admin. Code § DHS 140.04 (1)(h)6.

Level II

Wis. Admin. Code § DHS 140.05(1)(b)1.

Initial accreditation measure 8.2.1: Develop a workforce development plan that assesses workforce capacity and includes strategies for improvement.

The second required document for this measure is a list of learning or educational opportunities that relate to the gaps in workforce capacity or capabilities which must include training on equity.

DHS has a listing of recorded health equity trainings that can could be used by local and Tribal health departments for staff education.

The 2023 Wisconsin Public Health Workforce Assessment could be used as part of this measure if the following points are in place: there was sufficient participation in the assessment for your agency; results were reviewed at an agency level; and results influence workforce development activities or plan.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Domain 9: Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.

Initial accreditation measure 9.1.1: Establish a performance management system.

The Public Health Foundation (PHF) website includes performance management resources that are helpful in the development of a performance management system, including information on the Public Health Performance Management System Framework.

Initial accreditation measure 9.1.4 and reaccreditation measure 9.1.2: Establish a process that guides health department quality improvement efforts across the department.

The following resources provide information on how to create a Quality Improvement (QI) Plan and put QI into practice:

Reaccreditation measure 9.1.4: Nurture a culture of quality across the health department.

The NACCHO QI Roadmap provides information on the phases of a culture of quality and a self-assessment tool for health departments to determine which phase they are in.

Initial and Reaccreditation measure 9.1.6 RD4: The intent of this requirement is to provide evidence that learning opportunities have been delivered to staff on performance management or QI.

DPH provides performance excellence resources on the DHS Training for Public Health Employees in Wisconsin website. One of these is the “Wisconsin Public Health - Performance Excellence” three-part training that is available via search on the TRAIN Learning Network website or using the direct links below:

Wisconsin Public Health - Performance Excellence Part 1: Performance Excellence Overview (Course ID: 1120101)
Wisconsin Public Health - Performance Excellence Part 2: Results-Based Accountability (Course ID: 1120104)
Wisconsin Public Health - Performance Excellence Part 3: Turn the Curve Thinking (Course ID: 1120109)

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Level III

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Level III

Domain 10: Build and maintain a strong organizational infrastructure for public health.

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Wis. Admin. Code § DHS 140.04 (1)(h)2.

Level II

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Level II

Level III

Wis. Admin. Code § DHS 140.06(5)(d)

This standard is aligned with the following Wis. Admin. Code ch. DHS 140 sections:

Level I

Wis. Admin. Code § DHS 140.04 (1)(h)3.

Level II

Level III

Wis. Admin. Code § DHS 140.06(2)

PHAB-approved statewide evidence

Evidence and resources by domain

Standard 1.1: Participate in or lead a collaborative process resulting in a comprehensive community health assessment.

Level I

Level III

Standard 1.2: Collect and share data that provide information on conditions of public health importance and on the health status of the population.

Level III

Standard 1.3: Analyze public health data and share and use the results to improve population health.

Level I

Level II

Level III

Standard 2.1: Anticipate, prevent, and mitigate health threats through surveillance and investigation of health problems and environmental hazards.

Level I

Level II

Level III

Standard 2.2: Prepare for and respond to emergencies.

Level I

Standard 3.1: Provide information on public health issues and public health functions through multiple methods to a variety of audiences.

Level I

Level II

Standard 3.2: Use health communication strategies to support prevention, health, and well-being.

Level I

Level II

Standard 4.1: Engage with the public health system and the community in identifying and addressing health problems through collaborative processes.

Level I

Level III

Standard 5.1: Serve as a primary and expert resource for establishing and maintaining health policies and laws.

Level I

Level III

Standard 5.2: Develop and implement community health improvement strategies collaboratively.

Level I

Level II

Level III

Standard 6.1: Promote compliance with public health laws.

Level I

Level II

Level III

Standard 7.1: Engage with partners in the health care system to assess and improve health service availability.

Level I

Standard 7.2: Connect the population to services that support the whole person.

Level I

Standard 8.1: Encourage the development and recruitment of qualified public health workers.

Level I

Level II

Standard 8.2: Build a competent public health workforce and leadership that practices cultural humility.

Level I

Level II

Standard 9.1: Build and foster a culture of quality.

Level I

Level II

Level III

Standard 9.2: Use and contribute to developing research, evidence, practice-based insights, and other forms of information for decision making.

Level I

Level II

Level III

Standard 10.1: Employ strategic planning skills.

Level I

Level II

Standard 10.2: Manage financial, information management, and human resources effectively.

Level I

Level II

Level III

Standard 10.3: Foster accountability and transparency within the organizational infrastructure to support ethical practice, decision-making, and governance.

Level I

Level II

Level III

Glossary