Quality. Improvement Plan

Transcription

1 Quality 2017 Improvement Plan

2 Table of Contents Performance and Quality Improvement Philosophy and Plan Overview... 2 Continuous Quality Improvement Cycle... 3 Performance and Quality Improvement Structure... 4 Organizational Performance and Quality Improvement Structure... 5 Performance and Quality Improvement Communication Flow... 7 Stakeholders Involved in the Performance and Quality Improvement Process... 8 The Strategic Initiatives... 9 Objectives/Themes/Overarching Goals... 9 Goals and Action Plans... 9 Ministry & Individual Outcomes Communicating Results Data-informed Decision Making Assessment of the Effectiveness of the Continuous Quality Improvement Process General Individual Case File Audit Process Individual Complaints and Grievances Procedure Staff Complaints and Grievances Procedure Serious Occurrence and Incident Review Risk Management Survey Protocol Ministry Outcomes and Data Collection Procedures QI Plan Evaluation Progress Report on Previous Quality Improvement Plan Glossary of Performance and Quality Improvement Terms Appendix A: The Agency Strategic Initiatives ( Deliverables) Appendix B: Agency File Audit Form May 18, 2017 Page 1

3 Performance and Quality Improvement Philosophy and Plan Overview The Catholic Social Services mission statement is: We are guided by faith to care for and bring hope to people in need with humility, compassion and respect. This mission is at the heart of our work, and our vision for Performance and Quality Improvement is designed to further our mission in the community and our Agency. Our vision is to align our service delivery to the organizational mission, vision, and values while striving to provide the best quality of service to each person in our care. The agency s leadership promotes excellence and creates a culture that fosters continuous quality improvement (CQI). An integral part of our work is having a CQI process in place that: 1) ensures the highest level of professional service, 2) is essential to achieving the best possible outcomes for people in our care, and 3) is most effective when it is a natural part of the way everyday work is done. By designing and implementing CQI methodologies to assess individual outcomes and service and operations processes, we are able to demonstrate effectiveness and efficiency first to the Agency, and then to external funding sources and stakeholders. The CQI cycle the agency has adopted follows. May 18, 2017 Page 2

4 Continuous Quality Improvement Cycle PMF data collected Incidents data collected Satisfaction surveys of the people in our care Staff satisfaction surveys Quarterly service reports Quarterly file audits Performance Measurement Select, collect, align, & integrate data Performance Analysis & Review Anaylze progress & identify opportunities for improvement PMF report, analysis and recommendations Satisfaction of people in our care report, analysis and recommendations Incident and critical incident investigation report, analysis and recommendations File audit gaps idenitifed Knowledge Management Performance Improvement Assess effectiveness & publish & share, findings internally and externally Share best practices & deploy quality improvement strategies Assess effectiveness of corrective actions QI committee distrubutes to services PQI department presents to Executive Teams Executive Teams communicate to services, governance boards, community and funders PMF recommendations implemented by services Quarterly service recommendations implemented File audit gaps closed Best practices implemented by service May 18, 2017 Page 3

5 Performance and Quality Improvement Structure The Agency s Performance and Quality Improvement department facilitates the accomplishment of CQI activities and is integrated into all areas of the Agency s work. This department is responsible for performing risk management and quality improvement activities and ensures agency-wide participation in the CQI process. The Performance and Quality Improvement Department consists of the Director of Performance and Quality Improvement, Policy Analyst, and the Quality Improvement Analyst. The Performance and Quality Improvement Department oversees the CQI structure and they are accountable to the Executive Vice President. The Director of Performance and Quality Improvement is responsible for overseeing the Performance and Quality Improvement activities of the Agency, policy coordination, Agency Accreditation, work flow of the Performance and Quality Improvement Department, chairing the Quality Improvement Committee, and special projects as assigned by the Executive Vice President and the Chief Executive Officer. The Director of the Performance and Quality Improvement Department is also responsible for communicating and liaising with other service areas to increase understanding and participation in the Performance and Quality Improvement activities. The Policy Analyst is responsible for reviewing and processing agreements involving the Agency, working with Agency policy documents as required, Agency Accreditation, process improvement, projects and job duties as defined by the Director of the Performance and Quality Improvement Department. The Quality Improvement Analyst is, Business Intelligence data collection and reporting (i.e. PMF, satisfaction surveys, trends analysis) Agency Accreditation, process improvement, projects and job duties as defined by the Director of the Performance and Quality Improvement Department. The Quality Improvement Analyst will be involved in the Quality Improvement Committee and work in conjunction with various service areas as required completing projects as needed. PQI Staff Policy Analyst and QI Analyst QI Committee PQI Senior Management Director of PQI Department Senior Executive Management Representation Executive Vice President May 18, 2017 Page 4

6 All members of the Performance and Quality Improvement Department are required to be able to think critically, be able to quickly learn new skills, and be fluent in the basic functions of computer programs such as Word, Excel, and Outlook. The PQI Department must also be able to communicate, verbally and in written form, in a clear, concise, and professional manner. Members of the PQI Department must be able to work in a collaborative environment but also be capable of self-directed work when required. The Agency also engages the Quality Improvement Committee to bring quality concerns forward to address and disseminate information relating to continuous quality improvement at all levels of the agency. The focus of the Agency s performance and quality improvement structures is using innovative practices, improving processes, using data to identify existing gaps and new opportunities, and finding alternatives that enhance the delivery of desired outcomes. Organizational Performance and Quality Improvement Structure All staff members have a role to play in improving quality throughout the Agency. Each level of responsibility involves different quality improvement activities based on role and level of authority. Direct staff is responsible for providing the best possible service to people in our care, reporting concerns to their supervisor, completing Incident Reports, attending trainings as required, recommending quality improvements and policy improvements, and following procedures and best practices when they are communicated. Supervisors provide direct staff with resources to work through day to day concerns, report concerns which are larger than a day to day level to higher level managers, provide support and guidance during incidents, review Incident Reports, recommend quality improvements and policy improvements, attend trainings as required, ensure staff can attend training as required, follow best practices and procedures as they are communicated, and help in coaching and training front line staff. Managers are responsible for working with supervisors to remove concerns and obstacles on a day to day level, reviewing and signing off on Incident Reports, recommending quality improvements and policy improvements, communicating and gathering information around COA Accreditation, best practices, and innovative practice, attending trainings as required, completing reporting as required, ensuring front line staff and supervisors have resources required to attend trainings and implement procedures and best and innovative practices, and training and coaching both supervisors and staff as required. Directors provide managers with support in dealing with staff concerns, manage the Accreditation process for their areas, review and approve Incident Reports as required, review and create reports as required, communicate information about service expectations, best practices, and innovative practice, recommend quality improvements and policy improvements, work with funders to have appropriate resources in place, communicate concerns to the QI Committee and PQI Department, ensure that managers, supervisors, and frontline staff have adequate resources and training for their job duties, and provide coaching to those under their supervision. Executive Team is responsible for overseeing the Accreditation process, ensuring funding is appropriate and requirements are achievable, recommending quality improvements and policy improvements, reviewing Serious Occurrences and ensuring corrective actions, providing risk management at a service level, reviewing and creating reports as required, bringing forward quality concerns at an executive level, May 18, 2017 Page 5

7 ensuring that appropriate staff are provided to be members of the QI Committee, reviewing policy and ensuring implementation of policy, best practice, and innovative practice. The Performance and Quality Improvement (PQI) Department is responsible for coordinating the Accreditation process, ensuring that funding agreements are reviewed for risk management concerns, trend analysis, the Performance Management Framework (PMF), managing and coordinating consistency projects, coordinating changes to policy, recommending quality improvements and policy improvements, managing quality improvement actions and initiatives, working with the QI Committee to address staff concerns, creating and reviewing reports as required, reviewing and reporting on Serious Occurrences at an agency level, making recommendations to the Senior Executive, and reviewing and helping to implement best and innovative practices throughout the agency. QI Committee members are responsible for attending monthly meetings, completing any work required to participate in monthly meetings, engaging in meetings, communicating QI decisions, recommending quality improvements and policy improvements, activities and results back to various service areas, voicing service and front line quality concerns during meetings, and working with other staff to ensure Quality Improvement Committee initiatives are implemented. The Senior Executive Team has responsibilities which encompass the entire Agency. These two offices provide oversight and risk management functions in two different aspects of Agency business. The CFO provides financial risk management, trend analysis, and is ultimately responsible for ensuring that the Agency is capable of meeting its financial reporting requirements. The CFO is also involved in both the Accreditation process and multiple agency level financial audits, recommending quality improvements and policy improvements, drives financial policy, and ensures that the Agency is following financial best practices. The EVP provides risk management, trend analysis, and is ultimately responsible for ensuring the Agency is able to meet the service and administrative standards, which include reporting and providing service to people in our care. The EVP is involved with the Accreditation process, recommending quality improvements and policy improvements, policy creation, and helps to implement best and innovative practice at an Agency wide level. The EVP also assigns special projects to the PQI department. The Chief Executive Officer (CEO) is responsible for Agency level risk management functions, ensuring the Agency is capable of meeting all its requirements in reporting and service delivery, and creating increased capacity through intentional actions. The CEO guides the Agency through the Accreditation process, reviews trends in incidents and serious occurrences and their associated corrective actions. The CEO also designates resources for quality improvement activities, best and innovative practices, recommends quality improvements and policy improvements, ensures Agency capacity, reports to the Governance Boards, and provides the Agency with direction through an appropriate vision and mission. Governance Boards are responsible for reviewing, questioning, and approving documents, budgets, policies, and reports brought before them as required, appointing a CEO based on the needs of the Agency, providing the Agency with meaningful connections to the community, recommending quality improvements and policy improvements, helping to develop Agency vision and mission, and participating in the Accreditation process of Agency. May 18, 2017 Page 6

8 Performance and Quality Improvement Communication Flow Service Delivery Review policy and implement best practice Planning, coordinate and implement quality initiatives Risk Management Participate Accreditation process Senior Executive Agency level risk management Review agency level trends in incidents Participate in accreditation process Finance/IT/IAM Planning, coordinate and implement quality initiatives Review policy and implement best practice Risk Management Participate Accreditation process Human Resources Planning, coordinate and implement quality initiatives Review policy and implement best practice Risk Management Participate Accreditation process Performance Quality Improvement Facilitate QI committee Manage PQI actions and initiatives Coordinate accreditation process Maintain organization wide policy and procedure Contract approval/ Development Special projects management Risk Management CEO Agency level risk management Guiding accreditation agency wide Ensuring resources for best and innovative practices Community Engagement Planning, coordinate and implement quality initiatives Review policy and implement best practice Risk Management Participate Accreditation process Governance Boards Review policies and documents brought Appoint CEO Provide community connections May 18, 2017 Page 7

9 Stakeholders Involved in the Performance and Quality Improvement Process Catholic Social Services involves all stakeholders in performance activities. The agency defines stakeholders as individuals or groups who have a vested interested in the organization and its mission. This includes staff, people in our care and their families/guardians/trustees, the Board of Governors, donors, and community members. Stakeholder participation in the performance and quality improvement processes may take the form of committee work, focus groups, interviews, and surveys, among other methods. Catholic Social Services firmly believes that stakeholder feedback is a valuable tool for providing reliable data that is used to shape the ministries and services that best meet the needs of people in our care. In order to ensure that our services are responsive to our key individual and stakeholder groups, we survey them on an annual basis to understand their expectations of us. These groups and their current expectations are as follows: Key Group People in our Care Members of the family or caregiver system Professionals who work with challenging individuals Funders/Donors Referral sources Expectations for our Services Safe ministries in which they are treated in fairly and appropriate ways by caring and respectful staff. They want to feel successful and make progress towards their goals Be accessible, inclusive, and responsive to meeting the needs of people in our care. Be courteous, knowledgeable, culturally sensitive, and respectful of their choices for individuals they are responsible for. Be knowledgeable and impart practical tips/strategies for working with people in our care. Fees must be equal to or lower than the competition; staff must be accessible, reliable, and dependable Be effective and efficient stewards of resources, transparent, responsive, and accountable to reporting/administration of funds. Seek ways to partner or collaborate to reduce costs. Be accessible, flexible, accountable to, and up-to-date with regulatory and system requirements. Maintain adequate capacity and be collaborative. Catholic Social Services has a systematic and documented process for managing data collection mechanisms, as shown in the chart below. Data from surveys, phone calls, and the Performance Management Framework identify strengths, opportunities for improvement, and trends. Overall, all of the data collected is used to improve and evaluate our delivery of service. Data Collection Mechanism Purpose/Data Received Maximum Frequency Satisfaction Survey For People In Our Care Loyalty Annually Performance Management Framework (PMF) Quarterly ShareVision Quarterly Serious Occurrences Quarterly Key: Assess Satisfaction Identify improvement areas Assess Progress Assess Needs May 18, 2017 Page 8

10 The Strategic Initiatives The agency s long-term strategic goals and objectives are set forth in the Agency Strategic Initiatives, attached in Appendix A. Catholic Social Services uses the Agency Strategic Initiatives document to plan and execute a strategic course for the organization through a one year cycle. These cycles are designed advance Catholic Social Services capacities so that more complex Initiatives can be introduced the following year. Data is gathered through meetings and surveys from stakeholder groups as necessary, informing the team of important environmental trends and considerations necessary to complete a thorough situational analysis. Objectives/Themes/Overarching Goals Catholic Social Services is continually working to improve the experience for people in our care and reduce inefficiency throughout the organization. Overall the goal of Catholic Social Services is to provide the best quality of care and grow to serve vulnerable and underrepresented groups. Goals and Action Plans Catholic Social Services used an inclusive and systematic process that delivers the following key documents: Purpose Principles Mission Agency Strategic Initiatives Clearly and succinctly states why the organization exists Statement of beliefs and intents that guide the behavior of the organization and its staff in carrying out the strategy. A targeted call-to-action that identifies specific strategies for the organization to pursue. A map of overall objective, goals, strategies and measures, target and owners. This document guides Catholic Social Services growth and capacity building each year. The Strategic Initiatives Document is "audited" by the Senior Executive on a quarterly basis. Audits involve the team's review of the Strategic Initiatives Document with emphasis on measures that ARE NOT on track. The whys of any measures that are off track are discussed and the entire team determines what the organization must do in order to get the measure back on track. Audits also review and reaffirm the organization's capacity to carry out the strategy as currently defined by the Agency Strategic Initiatives. An example of an objective which is part of the Agency s Strategic Initiatives is the Performance Management Framework. Objective Create a functional and meaningful Performance Management Framework Goal 1 Define metrics to be measured, frequency and scope of reporting, and parties responsible Goal 2 Collect and analyze data on an ongoing basis Goal 3 Compare data from multiple reporting periods to establish trends and areas of improvement May 18, 2017 Page 9

11 Catholic Social Services employs a variety of systems to ensure the organization stays on plan and aligned to strategic objectives. Some key systems include: System Purpose Use Financial Review Review of Strategic Initiatives Performance Management Framework (PMF) Monthly review of performance and variance analysis Quarterly audit of strategic measures, tactics, and targets. A system for collecting quantitative and qualitative ministry information-outcomes, goals, demographics, highlights/success stories, etc. Notable variances to financial plans are addressed through an annual audit and monthly reviews. Any off track item is addressed through a QAP. Data informs and evaluates service delivery. Any off-track outcomes are addressed through a QAP. Please see Appendix A for current Annual Agency Strategic Initiatives. Ministry & Individual Outcomes Catholic Social Services offers ministries in many different areas. In doing so, Catholic Social Services is dedicated to meeting the emerging needs of vulnerable groups in the communities we serve. In order to fulfill the mission of the agency, Catholic Social Services is dedicated to monitoring and responding to changing needs in a proactive way when possible. The agency conducts internally generated data analyses on a regular basis to determine patterns of use, ministry effectiveness, and demographic information as related to services and outcomes for people in our care. Individual information is gathered from ShareVision. These analyses are evaluated by the Performance and Quality Improvement Department and the Quality Improvement Committee and presented to the Governance Boards, Executive and Senior Executive teams, with recommendations made regarding ministry development, improvement, and changes. Catholic Social Services designs and uses long-term and short-term performance measures and outcomes to drive and monitor organizational effectiveness and to evaluate actual results with the expected results of standards of success. Communicating Results The communication of results is part of the agency s knowledge management process and is inclusive of both internal and external stakeholders. Results of quality improvement activities, outcome measures, and strategic initiatives are shared internally in regular meetings, such as departmental, Senior Executive Team, Executive Team, Governance Board Meetings and Quality Improvement Committee meetings. Agency leaders are responsible for ensuring that all staff receive information appropriate for their role and function. The Performance and Quality Improvement Department also generates regular reports for leadership, direct staff, and the Board. Examples of such reports include the Incidents Report Summaries, Performance Management Framework Results, Satisfaction Survey for People in Our Care Report, and an Agency Serious Occurrence Report. These reports illustrate the impact that the services have on those we serve. On a regular basis, the Executive Vice President will provide a written summary of May 18, 2017 Page 10

12 performance and quality improvement activities to the Board of Governors and other appropriate bodies, such as funders. Data-informed Decision Making Catholic Social Services uses a process of data-informed decision making as quantitative data is not the only factor which is considered when a decision is made. Data is collected to give the agency insight into areas where improvements will allow for the agency to better meet its Strategic Initiatives, develop capacity, manage risk, implement correct actions, or provide better service to the people in our care. In short, quantitative data is mixed with qualitative data, experience in various fields, community need, and other driving factors to allow Catholic Social Services to make the best overall decision. The agency promotes the collection and analysis of data to guide services and improve operations. The framework which supports data-informed decision making includes: 1) leadership for improvement and the use of data; 2) support for generating actionable data; 3) formal structures and time set aside for analyzing and interpreting data by the PQI department; 4) professional development and technical support for data interpretation by the PQI department; 5) tools for acting on data. The Performance and Quality Improvement department is responsible for the collection, evaluation, and comparison of data. Data may be compared to previous data in the same service area or may be benchmarked against similar organizations. The Performance and Quality Improvement department uses the collected and analyzed data to inform recommendations made to the Senior Executive Team. The Senior Executive team then makes a decision based on the data presented, the current environment, and the mission, vision, and goals of Catholic Social Services. From the decision made, actions and goals will be created. The results of these actions and goals will be reviewed on a quarterly basis where their impact will be evaluated and new strategies will be put into place if required. Assessment of the Effectiveness of the Continuous Quality Improvement Process On a regular basis, the Performance and Quality Improvement Department will review the effectiveness of the Quality Improvement Plan activities. The review will include: 1) Achievement of the plan s overall goals and objectives; 2) Achievement of accepted professional standards of practice; 3) Resolution of identified problems; 4) Assessment of the efficiency of QI activities and the adequacy of corrective actions; May 18, 2017 Page 11

13 5) Improvement of the service delivery system; 6) Appropriate communication of findings All ministries of Catholic Social Services are subject to review and monitoring by a variety of internal and external, independent authorities. Currently, the agency is reviewed by the Council on Accreditation and provincial bodies. General Individual Case File Audit Process 1) Each service will identify a number of case files to review. This number should comply, at minimum, with COA standards. a. Ministries are to review cases on a quarterly basis. For example, a ministry may choose to review 25% of selected case files each quarter. b. Upon closing each case file, a review is to be conducted. 2) Staff member completing the review will review case records and complete Agency File Audit Form making sure to include: a. Individual name; b. Date of review; c. Name of staff completing the review; and d. Responses for each item, either Yes or No or NA. e. Asses the quality of file (i.e. outcome measures and individual goals) f. Indicate any outstanding concerns g. Indicate if required follow up was completed, not to exceed the quarter following. 3) Hard copies of report are maintained in the individual file. The Performance and Quality Improvement Department and the Quality Improvement Committee will evaluate the effectiveness of the process on a regular basis. Individual Complaints and Grievances Procedure If a grievance is lodged against a staff person or Catholic Social Services and it cannot be resolved by the Team Leader or Manager, the service Vice President is notified and the individual is given assistance, if needed, in filing a formal written grievance. The service Vice President investigates the grievance on behalf of the individual. If the individual is dissatisfied with the review, he/she may request a further investigation by the CEO or appointed designate or inquiry team. The CEO assesses the validity of the grievance, ascertains the facts in the situation, and responds to the appeal within ten working days of receipt. The CEO has final authority for grievance resolution. Formal Complaints and grievances are monitored by the Service Vice President as per the Client Right of Appeal Policy found in Section 2: Client Service Delivery of the agency policy manual. They are May 18, 2017 Page 12

14 reviewed during the quarterly service team meetings for the service receiving the complaint or grievance. The Performance and Quality Improvement Department presents a summary report of complaints/grievances to the Senior Executive and Executive Teams quarterly. The goal of the grievance procedure is to achieve fairness, dignity, and opportunities for reconciliation in an atmosphere of mutual respect. It is the intent that all individuals are provided someone to hear their complaints fairly, should they choose to address their concern through a formal process. Staff Complaints and Grievances Procedure There shall be absolutely no reprisals against anyone, including Catholic Social Services staff, making a complaint or filing a formal grievance as outlined in the Protection of Reporters of Suspected Misconduct Policy found in Section 5: Human Resources. Making a complaint or filing a formal grievance shall in no way have any bearing on the continuance of services to the individual or the individual s family or employment with Catholic Social Services. Further information around the filing and management staff complaints and grievances can be found in the Agency Policy Manual Section 5: Human Resources under Right of Appeal Policy. Serious Occurrence and Incident Review Purpose The purpose of establishing an internal system of reporting incidents that occur on or off the agency s premises that may involve staff, people in our care, or visitors, is to: 1) Determine patterns and trends for managing and improving the care of persons served; 2) Determine and mitigate internal and external system and service gaps 3) Develop an internal and external communication system for incidents, and 4) To manage risk. Catholic Social Services will ensure: 1) That all incidents (as defined in the Critical and Non-Critical Incidents Policy found in Section 2: Client Service Delivery) are reported to the proper authorities as required by administrative rule and statute; 2) That all reports are completed, accurate and factual; 3) That follow-up and/or corrective action is taken as needed; 4) That all reports are reviewed and analyzed for patterns and trends as part of Catholic Social Services quality improvement process, and that this information is incorporated into revision of operational practices, as warranted, and 5) That all staff receive training during orientation on the reporting process for incidents, including specific reporting requirements for allegations of abuse and neglect. For purposes of this Policy May 18, 2017 Page 13

15 and Procedure, the Performance and Quality Improvement Department is responsible for monitoring the incident reporting system. Incident Reporting Procedure 1) All reports are to be made on the most current revision of the agency s Incident Report (IR) which is found on ShareVision. 2) When an incident occurs, the staff person observing or discovering the incident is responsible for completing the IR as soon as possible, preferably immediately, after responding to the situation. The staff person will also contact his/her immediate supervisor or on call supervisor to make a verbal report to a person of the incident and to seek further instructions, as necessary. The staff person is to complete and submit the IR to his/her supervisor or designee before ending their shift or no later than 24 hours after. 3) The Supervisor (or designee) will: a. Review and sign off on the IR; b. Initiate other reporting processes, as needed (e.g., Protection for Persons in Care, etc. (within 24 hours), etc.); and c. Submit the completed original IR to Manager. 4) The Manager (or designee) will: a. Review and sign off on the IR; b. Indicate whether or not the incident is Critical and requires Service Vice President Review. c. Ensure any corrective actions required are taken. 5) Incidents of alleged abuse or neglect of any person in our care will be reported internally using the agency s Abuse Allegations and Reporting Policy found in Section 2: Client Service Delivery and shall also be reported to local authorities and enforcement agencies as appropriate. 6) For all incidents, the Manager or designee will ensure that any necessary immediate or long-term follow-up steps or corrective actions are taken, and that documentation of such is made in the appropriate place on the IR. 7) Managers are responsible for ensuring that all departmental staff receive training during their orientation in the implementation of this procedure, and receive thorough instructions on how to complete an IR. 8) The IR will serve as documentation for: a. Incidents involving loss of or damage to agency or personal property as outlined in the Critical and Non-Critical Incidents Policy found in Section 2: Client Service Delivery. b. Incidents involving people in the care of Catholic Social Services. 9) Upon receipt, the Performance and Quality Improvement Department will: May 18, 2017 Page 14

16 a. Review IR data at an agency level; b. Identify trends; Risk Management c. Make recommendations to the Senior Executive based on data. The agency s risk management practices aim to prevent risk and reduce the impact of loss and liability. All staff play some role in risk identification and mitigation. However, the agency has formal structures and activities in place to strengthen the organization and prevent unnecessary risks. These structures are outlined in the agency policy manual Section 8: Risk Management. This section of the agency policy manual contains several policies which are designed to limit risk and liability for Catholic Social Services. These policies include the Risk Management Policy, and Security Identity Card Policy. Section 2: Client Service Delivery contains several policies which help to mitigate risk as well. These include the Abuse Allegations and Reporting Policy, and Critical and Non-Critical Incidents Policy. Survey Protocol The Performance and Quality Improvement department will maintain and administer surveys related to satisfaction of people in our care, volunteer satisfaction, and staff satisfaction at an agency wide level. Following is the survey protocol for surveys distributed by Performance and Quality Improvement Department: Survey Distribution For satisfaction surveys for people in our care, a multi-mode method of survey distribution will be made available to the appropriate services. These modes will include both paper and electronic distribution. Staff and volunteer satisfaction surveys will be sent via to the appropriate areas. Survey Analysis Survey results are analyzed by the Performance and Quality Improvement department. The survey report (including raw data, summary, and outcomes related data) is placed in the Performance and Quality Improvement department folder under a suitable folder name. The summary report of the findings of the survey is presented to the Executive and Senior Executive Teams, Governance Boards, and all relevant stakeholders. The Executive and Senior Executive teams review the survey report and determine strengths and necessary improvements based off Performance and Quality Improvement and Human Resources Department recommendations. Survey Results The Performance and Quality Improvement department shall create a summary of results within an appropriate timeframe of receiving the survey data. The summary may include what was learned from the results, a list of strengths as well as opportunities for improvement, and suggested actions to be taken as May 18, 2017 Page 15

17 appropriate. Once the summary is complete, results shall be communicated to stakeholders through the Executive Team, Senior Executive Team, and Quality Improvement Committee. Evaluation To promote and ensure continuous quality improvement throughout the Agency, the survey protocol shall be evaluated and tracked by Performance and Quality Improvement. Necessary reminders shall be communicated to ensure timely dissemination of survey results, creation of summary reports and adherence to deadlines Ministry Outcomes and Data Collection Procedures Catholic Social Services collects and analyzes appropriate data quarterly and annually to determine the performance and effectiveness of ministries and to identify potential improvement opportunities. This includes data generated by measuring and monitoring activities and other relevant sources. The data is analyzed to provide information on: 1) Customer satisfaction and/or dissatisfaction; 2) Conformance to organization, legal and individual requirements; 3) Characteristics of processes, services and their trends; 4) Overall performance and impact on the people in our care Performance measures are determined at a service level. Outcome and Outputs to be measured for successful completion are developed at a ministry specific level. Quarterly and annual performance is monitored through the following categories in the Performance Management Framework (PMF): Measure Bed Nights Outreach Hours Number of Individuals Served Satisfaction of People in Our Care % of Successful Outcomes % of Successful Outputs Data Tracked The number of nights an individual is in our care and the number of funded nights available to each ministry. The number of hours of service provided by each ministry and the number of funded hours available to be provided. The number of individuals served by a ministry compared to what each ministry has been funded to serve on an annual basis. The percentage of people in our care who report being satisfied with services in the annual Agency Satisfaction Survey. The percentage of individual outcomes which successfully reach the ministry set targets based on the total number of outputs and outcomes measured. An average percentage is used. An outcome is defined as benefits for individuals during or after ministry activities. These may include increased skills or independence or new knowledge. The percentage of individual outputs which successfully reach the ministry set targets based on the total number of outputs and outcomes measured. An average percentage is used. An output is defined as the direct products of ministry activities. These may include the number of classes offered or number of counselling sessions completed. May 18, 2017 Page 16

18 Catholic Social Services monitors long term progress of the ministries and the organizational performance. The Performance Management Framework collects and reports out key metrics specific to ministry performance. Aggregation, Reporting, and Interpretation The Performance and Quality Improvement Department is responsible for the aggregation of the quarterly Performance Management Data. The Performance and Quality Improvement Department is also responsible for the agency wide satisfaction survey which is distributed to people in our care. This involves the collection, calculation, and analysis of the data. Results are reported to the ministries through Performance and Quality Improvement Department and Quality Improvement Committee meetings. The Performance Management Framework is presented to the Senior Executive Team, Executive Team, and Quality Improvement Committee by the Performance and Quality Improvement Director. The Executive Vice President reports the Performance Management Framework results to the Board of Governors. Review & Recommendations Performance and Quality Improvement Department, relevant ministry personnel, the Executive team, the Senior Executive Team, and the Board review the outcomes data and propose changes, improvements, and monitoring actions for the outcomes. The data is also utilized to promote the organization and its results. This data is key in business development. QI Plan Evaluation The Quality Improvement (QI) Plan is to be reviewed on an annual basis by the Performance and Quality Improvement Department to ensure the QI Plan is effective and efficient in meeting its stated goal of guiding Performance and Quality Improvement activities. If modifications need to be made to the plan to increase efficiency or effectiveness, these recommendations will be made to the Senior Executive. The PQI Department will submit its recommendations to the Senior Executive. The Performance and Quality Improvement department will also consider changes made to the COA standards, provincial standards, best practice, and innovative practice when making recommendations The QI Plan will also be reviewed annually by the Senior Executive Team to ensure the QI Plan is still aligned with the vision of Catholic Social Services and is congruent with the growth and betterment of the agency as outlined in the Strategic Initiatives. The Senior Executive will consider any recommendations made by the PQI department in a timely manner. Progress Report on Previous Quality Improvement Plan Catholic Social Services has drafted the Quality Improvement Plan in a new format. This new format includes more specific information around quality improvement activities, timelines, responsibilities, and reporting. This increased level of specificity will allow for a greater understanding of gaps and areas which require improvement based on a data-informed decision making model. This new format of QI Plan replaces the previous format which has been converted into a Quality Improvement Terms of Reference document. May 18, 2017 Page 17

19 Glossary of Performance and Quality Improvement Terms Goals: Tasks or actions which are required to further Objectives. Goals can be interconnected. For example, the one goal may be to solicit information on the experience of people in our care, a second to analyze the information, and a third to create a series of actions to correct gaps. Each goal is a unique piece, but they can also be integrated to affect larger objectives. Incident Report (IR): A report found on ShareVision which is to be completed based on criteria found in the Agency s Critical and Non-Critical Incident Identification and Reporting Policy. This report is to be completed according to the Serious Occurrence and Critical Incident Review procedures. Ministry: A program or service as defined by Catholic Social Services. Objectives, Themes, or Overarching Goals: An unifying idea or concept which ties together many smaller actions in an attempt to achieve a larger scale action. Examples include improved experience for the people in our care or the reduction of inefficiency. Performance and Quality Improvement (PQI) Department: An administrative department charged with management of performance and quality improvement activities, projects designated by the Executive Vice President, and advised by the QI Committee. The department is composed of a Director of PQI, a Research and Policy Manager, and PQI Coordinators. Performance Management Framework (PMF): A system of quarterly reporting used to provide information of key metrics consistently, analyze trends, and inform decision making. These reports are produced by each ministry. Quality Action Plan (QAP): A sequence of steps that must be taken, or activities that must be performed well, for a strategy to improve the quality of a designated goal to succeed. An action plan has three major elements (1) Specific tasks: what will be done and by whom. (2) Time horizon: when will it be done (3) Information on the success or failure of the specific tasks. Quality Improvement (QI) Committee: Provides clear expectations and guidelines regarding quality improvement review criteria and best practices. Members regularly review ministries, monitor quality of service provided, and provide consultation and assistance to the Agency in the interests of improving effectiveness and efficiency. Quality Improvement (QI) Plan: A document created which outlines the quality improvement activities, structures and processes, and roles and responsibilities of the Agency. It is for use by Agency staff and stakeholders. ShareVision: A system of reporting and storing individual information used by Catholic Social Services. Stakeholders: Individuals or groups who have a vested interested in the organization and its mission. This includes staff, people in our care and their families/guardians/trustees, the Board of Governors, donors, and community members. Strategic Initiatives: Long-term planning goals as outlined in the Strategic Initiatives document created by the Executive and Senior Executive teams with input and recommendations from other sources as required. May 18, 2017 Page 18

20 Vision: A guiding statement which directs the future of the organization. The Catholic Social Services vision is Inspired by God's love, our communities will be transformed through service to people of all faiths and cultures. The Strategic Initiatives are designed to help support the fulfilment of the vision. May 18, 2017 Page 19

21 Appendix A: The Agency Strategic Initiatives ( Deliverables) AGENCY INITIATIVES ( ) IDENTITY: Advance the identity of our Agency Incorporate the celebration of Feast Days across the Agency. Open two new ministries, one in Edmonton and one in Central Region. Align Agency communication efforts with the Archdiocese of Edmonton. Improve Agency aligned recruitment processes to identify appropriate candidates for employment. INTEGRITY: Advance our work with greater compassion and increased competence Create a Leadership Development framework to build our leadership competencies and support succession management. Develop an operations manual to ensure operational practices in direct care ministries. Migrate our Performance Management Framework to an integrated electronic reporting platform. Review Disability and Children s Service Ministries to identify changes in demographics and needs of the people in our care. Implement consistent Agency wide confidentiality and privacy training. Review legal risk management checklist and address identified issues. Complete alignment of CC/CSS fiscal years. Investigate options and select a new scheduling/time & attendance system. STEWARDSHIP: Continue to build our competencies in the stewardship of the people, finances and capital assets entrusted to our care. Identify and prioritize property renovations and upgrades required to meet the needs of people in our care. Relocate Immigration Services to newly renovated office building. Complete design and construction of Borden Park transitional residence. Build an integrated fundraising framework in consideration of changing donor demographics, community engagement and longer term sustainability. Conduct an Employee survey to measure and identify actions to improve engagement of our employees. Provide all of our people in residential care with wireless internet access. Upgrade all Agency Exchange Servers. Review pension and benefit plans and providers. Review learning development and training platforms and identify opportunities for improvements. May 18, 2017 Page 20

22 Appendix B: Agency File Audit Form May 18, 2017 Page 21