Professional Documents
Culture Documents
Table of Contents
I. Introduction ......................................................................................................................................1 A. Community Youth Services Philosophy of PQI .......................................................................................... 1 B. PQI Structure .............................................................................................................................................. 1 C. Definition of Stakeholders ......................................................................................................................... 2 II. Measures and Outcomes .................................................................................................................3
A. Long-term Strategic Goals and Objectives ................................................................................................... 3
B. Management / Operational Performance ................................................................................................... 4 C. Program Results / Service Delivery Quality ................................................................................................. 5 D. Client and Program Outcomes .................................................................................................................... 6 III. PQI Operational Procedures ...........................................................................................................6 A. Data Collection and Aggregation................................................................................................................. 6 1. Case File Review ..................................................................................................................................... 6 2. Safety Review ......................................................................................................................................... 7 3. Administrative Risk Review..................................................................................................................... 8 a. Internal Evaluations ........................................................................................................................... 8 b. External Evaluations ......................................................................................................................... 10 c. Quarterly Program Reviews .............................................................................................................. 10 4. Clinical Review ..................................................................................................................................... 10 B. Data Review and Analysis ......................................................................................................................... 13 C. Communicating Results ............................................................................................................................ 14 D. Using Data for Implementing Improvement ............................................................................................ 15 E. Assessment of the Effectiveness of the PQI Program.............................................................................. 15 IV. Illustrations ................................................................................................................................... 17 V. Operational Procedures Worksheets ............................................................................................ 20
Community Youth Services Strategic Plan is a three year approach effective from July, 2009 through June, 2011 with the intent to extend through June 2012. This design consists of five major areas of development, each having goals to be accomplished over a three to four year period. A. Long-term Strategic Goals and Objectives 1. Goals: d. Implement best practices and strategies that assure that youth and families are successful in achieving their goals. This Goal supports the Mission by: a. Assuring that program services are effective in supporting our participants in meeting their goals for safety, stability, belonging and success. b. Assuring that staff has necessary training, resources, and support to provide a continuum of individualized services and advocacy. e. Expand CYS branding and messaging so that it inspires, cultivates and facilitates additional external, non-governmental relationships, increasing the communitys awareness and revenues received in support of CYS mission. This Goal Supports the Mission by: a. Providing ongoing funding to fully support and staff the agencys services and programs b. Ensuring that CYS is widely recognized and that our mission and vision are embraced throughout our region. c. Develop and implement an agency wide Quality Assurance (QA) Program, which provides a solid foundation for developing, tracking, reporting, and supporting positive outcomes for youth and families. This Goal supports the Mission by: i. Producing outcome data that will help with program development and agency planning. ii. Assuring implementation of approaches that provide best possible services for youth and their families. iii. Giving CYS a competitive advantage because outcomes are documented and can be provided to funders. d. Expand the CYS Continuum of Care, eliminating service gaps for youth within CYS and the community. This Goal Supports the Mission by: i. Closing identified gaps in service, thereby ensuring an accessible sequence of services, available to all populations served that allows participants to progress from an entry point through to successful, independent living. ii. Ensuring that CYS staff is fully aware of service options available to CYS program participants. This will better assist program participants to reach their personal and program goals. e. Ensure CYS is an effective and efficient organization and agency resources support our mission. This Goal Supports the Mission by: i. Ensuring positive youth outcomes while maintaining and enhancing fiscal responsibility. ii. Ensuring administrative structure sufficiently supports agency & program goals. iii. Enhancing agency credibility in community (with donors & funders). 2. Objectives: d. Implement best practices and strategies that assure that youth and families are successful in achieving their goals.
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ii.
iii.
iv.
v.
vi.
b.
External Evaluations: i. Licensing Review: On an annual basis the Washington Department of Children and Family Services Licensing division conducts an audit of both residential programs, Haven House and Specialized Foster Care. The Clinical Director and Program Director attends the Exit Interview to discuss risks, challenges and improvement in programs and client care. This information is included in Quarterly Program Reviews. ii. Financial Audit: An accredited Independent Certified Public Accounting firm conducts an annual audit of Community Youth Services financials. The responsibility of the Independent Auditors is to conduct the audit using professional standards to provide an opinion that the financial statements are fairly presented in all material respects in conformity with United States generally accepted accounting principles. As part of the audit, the auditors will review the internal controls of Community Youth Services. This information is brought to the Audit and Investment Committee of the Board of Directors and reviewed and accepted by the Board at the April or May board meetings. After acceptance, it is submitted to funders and the IRS and then posted to the agency website for access by the public. iii. Stakeholder Grievance Report: If a stakeholder grievance is filed, the agency grievance policy and procedures will be followed and Program Directors will include a summary of the issue and steps taken to resolve it in their quarterly report c. Quarterly Program Reviews: Program Reviews are conducted quarterly to assess areas of practice that affect our clients and determine areas of improvement. Each Program Director and Manager reports quarterly findings to the Chief Executive Officer and C.O.O. Program Directors report on data and compare it to historical results to show patterns, trends and qualitative and quantative accomplishments. The C.E.O. & C.O.O review the report to identify patterns and trends in need of attention. Recommendations and suggestions are discussed and documented and then all reports are consolidated and summarized and presented at the Program Planning and Review Committee, a subcommittee of the Board. The report is then made available to the entire board and all staff of CYS. The following PQI data is included in the information gathered: i. Program Statistics and Outputs, including numbers served and exited ii. Incident Reports iii. Participant Satisfaction Survey Results iv. Client Outcomes v. Unit Cost of Analysis and overall budget review vi. Performance, including annual and strategic program goals and status of accomplishment vii. CQI and file review status and results 4. Clinical Review:
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The Board of Directors is ultimately responsible for ensuring that CYS provides the highest quality of care, thus the Board of Directors is the final authority with regard to all Performance and Quality Improvement activities. This authority is delegated to all CYS staff with the C.O.O. as the coordinator for all PQI activities. The Board is kept informed of all PQI activities via their PP&R Committee, who is kept informed by the C.O.O. The mission of every agency committee is to review data and make recommendations for organizational
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CYS utilizes the Plan-Do-Check-Act cycle as the model for Performance Quality Improvement (PQI). Evaluation results are used to target and identify quality improvement initiatives at all levels of the organization. Once needs have been identified, quality improvement committees or teams are developed to address the need. When necessary, the following are the steps taken once the committee/team has been developed: 1. Plan: Create a workable and realistic plan to address identified need. Quality Improvement Plans consist of the following: a. Statement of Need b. Action Steps c. Delineation of Responsibility d. Target Dates e. Follow Up/Completion Status Deploy steps of the plan. Follow up to ensure plan was deployed properly and outcomes are desirable. Management and follow up on quality improvement initiatives and corrective action plans are the responsibility of the program manager/supervisor with the assistance of designated administrative staff (example: Safety Team). CYS Management Team will also review outcome measures on a quarterly basis and offer insight and recommendations for improvement. Plan is fully implemented and cycle begins again. At this time, the issue or need will continued to be measured and reviewed to ensure that the needs were met by the plan and action of the quality improvement team.
2. Do: 3. Check:
4. Act:
E.
CYS is committed to the principles of quantitative analysis in its review of program and service quality performance areas, including:
1.
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Quarterly Program Reviews C.E.O. & C.O.O. Program Directors PP&R Committee Board of Directors
Workforce Development Reviews C.O.O. & C.E.O. Human Resource Manager PP&R Committee Board of Directors
CYS PQI Team Chief Executive Officer & Chief Operations Officer Board of Directors & Subcommittees Audit & Investment, Fund Development & Community Outreach, Program, Planning & Review Program Directors Program Staff Staff Committee Chairs Manager of Organizational Development Clinical Director Human Resource Manager
Stakeholder Satisfaction Surveys C.O.O. Manager of Org. Development Program Directors Program Staff PP& R Committee Board of Directors
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Performance Measure No
Yes
Organizational Change
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Who Will Make Recommendations And To Whom? When Will Recommendations Be Made?
Ensure Complete consistenc and up to y. date Maintain Participant regulatory Case Files complianc e.
Manager of Org. Quarterly. Development will ensure that Teams of case managers reviews occur. and administrative staff, review files quarterly for compliance.
Program-specific The Manager or Org. Quarterly case record review Development reports are forms. Aggregates the data provided to the from staff and C.E.O., C.O.O Forms are Directors every and available to returned to quarter and presents all staff via our Program Directors to C.O.O. document Staff members do not for follow-up with sharing system. review their own cases or staff. Program Directors the cases of staff with also report results whom they work. overview in quarterly Results reviewed program reviews. Supervisors also review quarterly and quarterly for quality recommendations issues. for improvement are made at the time.
Recommendations can be made from the Program Director, file reviewers or Manager of Org Development to case management staff. The C.O.O. and Manager of Org Development may also make recommendations directly to the Program Directors. Reviews and recommendations are made Quarterly.
Quarterly, the Manager or Org. Development and the C.E.O. and C.O.O. review recommendations with the Program Directors who will then review with relevant staff to discuss implementation of any recommended changes.
Who Is Responsible?
How/ Frequency?
Employee Satisfaction Survey Exit Interviews Retention & Turn Over Rates Workforce Stability
When Will In What Collected through Aggregated by HR C.O.O. C.O.O. When Will HR Manager Results Be Recommendations Be Made? Format? Annual Employee Manager and reported C.E.O. C.E.O. C.O.O. Reviewed And The HR Manager collects Satisfaction Survey in Quarterly & Annual Employee Employee Retention C.E.O. Interpreted? data on retention and and on-going report Retention Committee Review Annually and make turnover and shares it in records of Committee PP&R Committee recommendations to the quarterly program employee turnover. PP&R Committee Board of Directors Program Directors review. An annual Board of Program Directors work summary is shared with Exit Interviews are Directors Reviewed at each level with Executive Team to the Board of Directors. used to determine and recommendation implement changes. the reason Reviewed at each made for improvements Annually. employees are level annually leaving and look for and An Employee Satisfaction systemic issues and recommendation survey is conducted by the trends for possible s made for HR Manager and results areas of improvements are shared with the entire improvement. agency including senior staff and the Board of Directors.
Quarterly.
Incidents
Determine Incident the cause Report of the Database unsafe situations and correct where possible
Ongoing each report is Incident Report examined as it is entered Database into database Quarterly trends & commonalities Annually trends & commonalities
Database allows C.O.O. Any group may reports to be run on Clinical Director recommend changes to types of incidents, C.E.O. improve safety at any locations and Safety Committee time. staff/participants PP&R Committee Implementation is involved. Board of immediate when Aggregated quarterly Directors needed. and reported through Reviewed at each charts/graphs to PP&R level and Committee & Board of recommendation Directors made for improvements
Who Is Responsible?
How/ Frequency?
Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted?
Who Will Make Recommendations And To Whom? When Will Recommendations Be Made?
Participant Satisfaction
Program Outputs
Why Participant Program Staff participant Satisfaction are or are Survey not satisfied with the services provided. This includes facilities, interaction s with staff and confidenti ality Track VariousProgram program program Directors specific specific activities that indicate program effectiven ess
Different for each program, as they vary in length and intensity of service provided, as well as service population. Common timeframes include at: Entrance Exit Quarterly Summary Annual Summary Quarterly
Participant Program Directors Satisfaction Survey aggregate data and paper and online present in Annual Program Summaries
Program C.O.O. Program Directors Directors Clinical Director Program Staff C.O.O. Make recommendations Clinical Director to Program Directors Quarterly Reports and Staff annually to Executive Team
Participant Reported via Quarterly C.O.O. interview, Reports and Annual C.E.O. documentation in Summaries case files, collection of proof of outcome (i.e. copy of diploma , pay stub, assessment result or self report)
C.O.O. C.E.O. recommends necessary changes during Quarterly Program Report presentations
Program Directors
Who Is Responsible?
How/ Frequency?
Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted?
Who Will Make Recommendations And To Whom? When Will Recommendations Be Made?
Participant Review goals Case Managers s will on and Program exhibit Individualized Staff, Program improved Service Plan. Directors outcomes Assessments Participant such as Outcomes/Cli as per program CFARS, nical goals CASAS, Ansell Casey Assessment
Varies by program, due to different participants, services offered, intensity and duration.
Summarize in Excel Program Director tracking spreadsheets will review, interpret and report results
Program Staff, to Program Director Program Director, as participant prepares to exit / meet outcome
Who Is Responsible?
How/ Frequency?
Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted? C.O.O. will
Who Will Make Recommendations And To Whom? When Will Recommendations Be Made?
Risk is Risk COO assessed Management to help set Program priorities Standards and and determine Assessment urgency Process, and Insurance priority. coverage Regulatory review, Policy complianc and Risk & e is Procedure Regulatory examined review, Management as it Unemployme pertains to nt and L&I contractua claims l review, requireme Annual nts property inspections, Conflict of interest annual renewal
Normal agency Quarterly reports for Executive staff will C.O.O. reporting processes Employee Retention receive and review results and make and during staff and Safety Committee, interpret results recommendations. meetings. COO will Audit & Investment as they are review Risk Committee meet generated. Management Plan quarterly. and ask for input. Monthly review of agency financials. Properties inspected semi-annually. Policies and procedures updated as needed or minimum every 3 years. Insurance coverage reviewed every 3 years. Unemployment claims and L&I claims reviewed quarterly. Conflict of interest reviewed annually.
Who Is Responsible?
How/ Frequency?
Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted?
Who Will Make Recommendations And To Whom? When Will Recommendations Be Made?
To Implementati C.O.O. determine on Plan, progress is Committee being Reports, made on Quarterly Strategic Plan plan. Reports. L Outcomes Measurable results were included in the Strategic Plan. Monthly Compare C.O.O. reports of with previous financial month and performan year results ce, Quarterly Investmen Financial t Review, Viability Annual Budget Creation, Annual A133 Audit
Twice a year
Implementation Implementation Plan C.E.O and Board Plan Program Excel Worksheet of Directors Directors will report results.
C.O.O. will make C.O.O. recommendations to C.E.O. and Board of Directors. Recommendations will be made at annual board retreat.
FundWare C.O.O. generates C.E.O. Accounting Monthly Financial Board of Software and Excel Reports Annual BudgetDirectors Spreadsheets. Program Agency auditor Directors Agency auditor generates A-133 audit, based on staff work
C.O.O. will make recommendations to C.E.O. and Board of Directors. C.E.O. Board of Directors
C.O.O.