Catholic Charities Performance and Quality Improvement (PQI) Plan

Transcription

1 Catholic Charities Performance and Quality Improvement (PQI) Plan I. Introduction What is Performance and Quality Improvement? Performance: Refers to the numerical results information obtained from processes, services and products that permit evaluation and comparisons relative to goals, standards, past results, and performance of others. Performance Improvement: Primary result of efforts extended to improve a situation or process; it may be increased output, higher quality, or improved individual learning skills and performance. Quality: Distinguishing characteristics that determine the value or degree of excellence or met expectation. Quality Improvement: All actions taken throughout the organization to increase the effectiveness and efficiency of activities and processes in order to provide added benefits to both the organization and its customers. Together Performance and Quality Improvement is a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, and outcomes of service delivery, effective management practices, and achievement of strategic and program goals. A hallmark of Catholic Charities comprehensive approach to PQI is the promotion of a broad-based, organization-wide process inclusive of staff and stakeholders, as a vital, necessary management tool. The PQI policies and procedures reflect what experts know about what it takes to start, and maintain, a useful quality improvement program. Taken together, the PQI system includes practices that counter the tendency of organizations to place responsibility for quality improvement and results in one or a few individuals. As such, the system recognizes the value of involving staff at all levels of the organization. Quality is never an accident, it is always the result of high intention, sincere effort, intelligent direction and skillful execution. It represents the wise choice of many alternatives. Willa Foster EQUATION for QUALITY: Cost + Satisfaction + Outcomes = Value Quality Improvement (QI) can bring about substantial, lasting, and positive change in your organization. It all begins with identifying the opportunities for improvement. - COA

2 A. Catholic Charities Philosophy of PQI Catholic Charities Performance and Quality Improvement (PQI) Plan directs the use of data to identify areas of needed improvement and implement improvement actions in support of achieving performance targets, program goals, client satisfaction, and positive client outcomes. Elements that define our philosophy include: Commitment to excellence and continuous improvement We understand our work as processes and systems Broad-based, organization-wide, inclusive of staff and stakeholders Includes all programs and services Advances effective services and has a positive impact on persons served Advances effective management practices Supports long-term priorities and goals Addressess organizational performance, quality of services, and client outcomes Implementation of solutions to improve efficiency and deliver accessible, effective services Customer focus/ driven Recovery Oriented Employee Empowerment and Recognition Leadership Involvement

3 Data Informed Practice Use of Statistical Tools Prevention over Correction Trauma Informed Belief that employees want to do important, meaningful work Assumption most errors are due to system, not worker Good enough is not good enough, we can always become better B. PQI Structure Catholic Charities charges the PQI Steering Team with constructive use of data to promote a high-learning, high-performance, results-oriented organization. Staff assigned to the PQI Team have delegated authority from their Department and are qualified by education, experience or interest to: o a. engage people throughout the organization; o b. systematically collect information and analyze data; and o c. communicate results and recommendations to various key audiences. The Director of Quality Improvement is assigned responsibility for implementation and coordination of PQI activities and technical assistance. The PQI Team is accountable to the Senior Management Team and to the Board of Trustees via Quality Improvement and Service Committee. See PQI Activities, Organizational Flow and Structure diagrams below

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5 CATHOLIC CHARITIES PQI STRUCTURE

6 C. Stakeholder Involvement in PQI: In this section Catholic Charities defines its stakeholders and how they will be involved in its PQI system. Stakeholders are the people who have an interest or "stake" in Catholic Charities success at achieving its mission. Stakeholders may include the Board, staff, person services, funders, community, courts, etc. Potential stakeholders include: o Persons Served, their Families, and Advocates o Board of Trustees o Personnel; all levels, employees, volunteers and consultants o Funders and Regulators o Partner Organizations / Other Service Providers / Provider Associations o Other Community Representatives o Business, faith-based, volunteer civic organizations o Courts / Probation / Parole o Public Agencies o Organizations Providing Services Under Contract o Elected Officials o Consumer advocates Inclusion of external and internal stakeholders; work together to: a. develop key outcomes and outputs; b. develop relevant qualitative and quantitative indicators; and c. identify data sources, including measurement tools and instruments. How can we involve our stakeholders? Here are just a few of the many ways to involve stakeholders in our PQI process: Sit on our PQI Committee Participate in ad hoc or ongoing work groups Partner with staff to develop outcomes and indicators Review reports and provide feedback Help identify positive practices Recommend improvements when necessary Work with the Board and management on short- and long-term planning Have staff administer measurement tools and collect data Conduct surveys and/or focus groups Ask for input at regular meetings of our community partners Internal and external stakeholders review performance data and outcomes results in order to: a. identify strengths and areas of positive practice; and b. provide feedback about areas of needed improvement. Catholic Charities leadership, including board or advisory members, and PQI personnel communicate with staff and stakeholders about achievements relative to desired outcomes, indicators, and benchmarks or targets. Please refer to the Core Policy and Procedure Manual for guidance: PQI 1, PQI 2.03, PQI 4.01, and PQI 6.04 (below).

7 PQI 1: Catholic Charities leadership demonstrates a clear commitment to fostering a culture of excellence and continual improvement by: a. using quality improvement results to build capacity and improve practice; b. allocating resources for an organization-wide PQI system; c. making data-informed decisions. PQI 2.03: The PQI plan: a. defines the organization's/program s stakeholders; and b. specifies how a broad range of internal and external stakeholder groups will be involved in the PQI process. PQI 4.01: Staff throughout the organization and stakeholders work together to identify key outputs and outcomes, and related: a. quantitative and qualitative indicators; b. data sources, including measurement tools and instruments for each identified output and outcome; and c. performance targets PQI 6.04: Internal and external stakeholders review performance data and outcome results in order to: a. identify strengths and areas of positive practice; and b. provide feedback about areas in need of improvement. D. Overview of the Improvement Cycle Fundamental questions are: o Methods for obtaining feedback about findings from stakeholders o Actions in response to PQI findings and feedback o Determination if an implemented change is an improvement See steps in the improvement cycle below. See detail procedures in Part III and PQI Procedure Manual. Please refer to the Core Policy and Procedure Manual for guidance: PQI 6.01, PQI 6.02, PQI 6.03, PQI 6.04, PQI 7.01, PQI 7.02, and PQI PQI 6.01: Procedures for reviewing and aggregating PQI data: a. ensure data integrity and reliability; and b. facilitate the development of aggregate data reports for analysis. PQI 6.02: The programs (with PQI assistance) analyzes PQI data to: a. track and monitor identified measures; b. identify patterns and trends; c. compare performance over time; d. compare data against the results of internal benchmarks; and e. compare data against the results of external benchmarks, if available. PQI 6.03: Summary reports of PQI information (via PQI Team): a. are distributed in a timeframe and format that facilitates review and analysis; and b. consider concerns related to the confidentiality of service recipients. PQI 6.04: Internal and external stakeholders review performance data and outcome results in order to: a. identify strengths and areas of positive practice; and b. provide feedback about areas in need of improvement. PQI 7.01: Catholic Charities (via Senior Management with PQI Team assistance) takes action based on the findings and feedback to: a. develop solutions; b. replicate good practice; c. recognize and motivate staff; d. improve organizational systems, processes, polices, and procedures; e. improve services; and f. eliminate or reduce identified problems.

8 PQI 7.02: Catholic Charities (via Senior Management with PQI Team assistance) monitors the effectiveness of actions taken and modifies implemented improvements, as needed. PQI 7.03: Catholic Charities leaders, senior managers, program directors, and supervisors: a. keep PQI on the agenda of board, management, and staff meetings; b. regularly evaluate the need for and uses of data; and c. evaluates the PQI system, infrastructure, processes and procedures.

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10 II. Measures and Outcomes A. Client Outcomes Examples of client outcomes include: change in functional status; health, welfare, and safety; permanency of life situation; quality of life; achievement of individual service goals; and other outcomes as appropriate to the program or service population. See individual program quarterly PQI reports for detailed list of client outcomes. Please refer to the Core Policy and Procedure Manual for guidance: PQI 4.01 and PQI 4.01: Staff throughout the organization and stakeholders work together to identify key outputs and outcomes, and related: a. quantitative and qualitative indicators; b. data sources, including measurement tools and instruments for each identified output and outcome; and c. performance targets. PQI 4.02: On an ongoing basis, each of Catholic Charities programs (with assistance from PQI Team) measures client outcomes, including two of the following areas: a. change in clinical status; b. change in functional status; c. health, welfare, and safety; d. permanency of life situation; e. quality of life; f. achievement of individual service goals; and g. other outcomes as appropriate to the program or service population. B. Program Results/ Service Delivery Quality Describes what is monitored relating to the quality of our services. This includes: o Outreach, intake, assessment, and service planning and delivery processes o Data from risk management reviews of immediate and ongoing risks related to service delivery o Consumer satisfaction Widely accepted dimensions of service quality that the programs may choose to measure include: accessibility, availability, efficiency, continuity, safety, timeliness, and respectfulness. Please refer to the Core Policy and Procedure Manual for guidance: PQI 4.03, PQI 5.02, and RPM 2.02 and COA's requirements related to outreach, intake, assessment, and service planning and delivery processes vary by service and are found in the Service Standards Section of the Core Manual which are assigned to each of your programs. PQI 4.03: At least annually, the organization/program (via RPM Committee and PQI Team) examines its service delivery processes to plan, manage, and evaluate the quality of its services, including: a. outreach, intake, assessment, and service planning and delivery processes; b. review of immediate and ongoing risks related to service delivery; and c. consumer satisfaction. PQI 5.02: Catholic Charities (via programs and PQI assistance) aggregates data from case records for monitoring the quality of services, including, as appropriate to the program: a. timeliness and comprehensiveness of individualized assessments, b. length of service; c. need for continued service; d. family involvement; and

11 e. achievement of service goals. RPM 2.02: Catholic Charities Special Incidents Review Committee, a sub-committee of the RPM Committee, conducts a quarterly review of immediate and ongoing risks that includes a review of incidents, critical incidents, accidents, and grievances related to: a. administering, dispensing, or prescribing medications; b. service modalities or other organizational practices that involve risk or limit freedom of choice; c. the use of restrictive behavior management interventions, such as seclusion and restraint; d. facility safety issues; e. situations where a person was determined to be a danger to himself/herself or others; and f. serious injuries and deaths. Incidents are to be reported by staff consistent with the Untoward Incident Process and based on the Incident Reporting Guide, Incident Severity Rating Scale and documented on the Incident Reporting & Tracking Forms (See RPM Appendix). RPM 2.03: Catholic Charities Special Incidents Review Committee reviews all incidents and accidents that involve the threat of or actual harm, serious injuries, and deaths, and review procedures: a. establish timeframes for investigation and review; b. require solicitation of statements from all involved individuals; c. ensure an independent review; d. require timely implementation and documentation of all actions taken; e. address ongoing monitoring if actions are required and determine their effectiveness; and f. address applicable reporting requirements. C. Management / Operations Performance Describes what Catholic Charities is monitoring related to its management and operational performance that are intended to strengthen our organization and build capacity. Measures include: o progress toward achieving Catholic Charities strategic goals and objectives o o operational functions that influence the capacity to deliver services risk Numerous examples of the types of data that can be collected, and that are directly related to various COA standards are described in the Clarification to PQI Please refer to the Core Policy and Procedure Manual for guidance: PQI 4.04, GOV 7.02, GOV 7.03, and RPM PQI 4.04:Clarification: Examples of operations and management performance measures can include: - Efficiency in the allocation and utilization of its human and financial resources in furthering or impeding the achievement of organizational objectives (HR 2); - Effectiveness of risk prevention measures (See RPM 2.01, RPM 2.02); - Staff retention/turnover and satisfaction (See HR 4.03, HR 4.04); - The cost of delivering a unit of service as compared to similar programs/the relationship of service delivery costs to the benefits derived by consumers of service (See FIN 5.06); - Costs v. benefits of fundraising efforts (See ETH 3.03); - Achievement of budgetary objectives (FIN 5); - Effectiveness of community education and outreach (See GOV 4.04);and - Efforts to diversify the governing body (See GOC 4.04) PQI 4.04: Catholic Charities (via Senior Management and PQI Team) collects and monitors data on management and operational performance to: a. strengthen and build organizational capacity;

12 b. measure progress toward achieving its strategic goals and objectives; c. evaluate operational functions that influence the capacity to deliver services; and d. identify and mitigate risk. RPM 2.01: Management, through the Risk Prevention and Management (RPM) Committee with the involvement of the Board Audit, Finance and Services Committees conducts an internal assessment of overall risk at least annually that includes: a. compliance with legal requirements; b. insurance and liability; c. health and safety; d. human resources practices; e. contracting practices and compliance; f. client rights and confidentiality issues; g. financial risks; and h. conflicts of interest. C. Compliance with External Regulatory Requirements and Other External Reviews Reviews include, as applicable i. licensing and other reviews related to federal, state, and local requirements; ii. government and other funder audits; iii. accreditation reviews; and iv. other reviews, where appropriate. Please refer to the Core Policy and Procedure Manual for guidance: PQI 4.05, PQI 5.01, and RPM PQI 4.05: Catholic Charities (via RPM Committee with assistance from PQI Team) reviews and addresses the findings and recommendations of external review processes, including, as applicable: a. licensing and other reviews related to federal, state, and local requirements; b. government and other funder audits; c. accreditation reviews; and d. other reviews, where appropriate. PQI 5.01: Quarterly reviews of case records evaluate the presence, clarity, quality, continuity, and completeness of required documents. III. PQI Operational Procedures and the Improvement Cycle A. PQI Data Management Procedures 1. Data Collection and Aggregation Describe in detail the how data for each of the things being measured or monitored in Section II is collected, aggregated, and reviewed. See PQI Procedure manual for details. Include case record review procedures in this section. Procedures should describe sampling methods. See PQI 5.03 for guidance. PQI 5.03: The quarterly case record review process: a. includes a random sample of both open and recently closed cases; b. uses uniform data collection tools to ensure consistency and permit comparison of data; and

13 c. maintains objectivity by ensuring that reviewers do not review cases in which they have been directly involved as a service provider or supervisor. 2. Data Review and Analysis Procedures include: The process for ensuring data integrity and reliability Types of data analysis being conducted Report formats Timeframes for dissemination and review Review procedures including detailed procedures for stakeholder review Analysis of stakeholder feedback Please refer to the Core Policy and Procedure Manual for guidance: PQI 6.01, PQI 6.02, PQI 6.03, PQI 6.04, RPM 5.01, RPM 5.03, and RPM PQI 6.01: Procedures for reviewing and aggregating PQI data: a. ensure data integrity and reliability; and b. facilitate the development of aggregate data reports for analysis. PQI 6.02: The programs (with PQI assistance) analyzes PQI data to: a. track and monitor identified measures; b. identify patterns and trends; c. compare performance over time; d. compare data against the results of internal benchmarks; and e. compare data against the results of external benchmarks, if available. PQI 6.03: Summary reports of PQI information (via PQI Team): a. are distributed in a timeframe and format that facilitates review and analysis; and b. consider concerns related to the confidentiality of service recipients. PQI 6.04: Internal and external stakeholders review performance data and outcome results in order to: a. identify strengths and areas of positive practice; and b. provide feedback about areas in need of improvement. RPM 5.01: Authorized Personnel can rapidly access paper and electronic information. RPM 5.03: Catholic Charities has a computer-based management information system appropriate to its size and complexity, that permits: a. timely access to information about persons served by any part of the organization, or by other practitioners within Catholic Charities, to support continuity and integration of care across settings and services; b. capturing, tracking, and reporting of financial, compliance, and other business information; c. longitudinal reporting and comparison of performance over time; and the use of clear and consistent formats and methods for reporting and disseminating data. RPM 6.01: Catholic Charities Privacy Office assures confidential and other sensitive information from theft, unauthorized use, damage, or destruction by: a. limiting access to authorized personnel on a need-to-know basis; b. backing up electronic data copies for 10 days, with copies maintained off premises; c. using firewalls, anti-virus and related software, and other appropriate safeguards; and d. maintaining paper records in a secure location. B. Using Data Describe how the organization responds to findings and feedback and uses data to build capacity, improve services, and have a positive impact on the persons and families it

14 serves. Procedures include (see PQI Manual for details): How decisions are made about appropriate actions to take based on PQI findings and stakeholder feedback various methods will be used to complete an analysis; these will include root cause analysis, affinity diagrams, run and control charts, use of charters, and other quality analysis methods. Criteria for development corrective action or improvement plans will be based on external audits, cost-benefit analysis, strategic planning relative to mission, flow charting, process mapping, etc How the organization monitors implemented improvements and makes decisions about modifying implemented improvements action teams, departments, and programs will develop charters or plans of action which will detail milestones, goals and objectives and report on them periodically. Expectations for leaders, and other personnel about sharing PQI results at staff and other meetings of internal stakeholders it is expected that, as a learning organization, we all can contribute and learn from our successes and challenges. Please refer to the Core Policy and Procedure Manual for guidance: PQI 1, PQI 7.01, PQI 7.02, and PQI 7.03(a). PQI 1: Catholic Charities leadership demonstrates a clear commitment to fostering a culture of excellence and continual improvement by: a. using quality improvement results to build capacity and improve practice; b. allocating resources for an organization-wide PQI system; c. making data-informed decisions. PQI 7.01: Catholic Charities (via Senior Management with PQI Team assistance) takes action based on the findings and feedback to: a. develop solutions; b. replicate good practice; c. recognize and motivate staff; d. improve organizational systems, processes, polices, and procedures; e. improve services; and f. eliminate or reduce identified problems. PQI 7.02: Catholic Charities (via Senior Management with PQI Team assistance) monitors the effectiveness of actions taken and modifies implemented improvements, as needed. PQI 7.03: Catholic Charities leaders, senior managers, program directors, and supervisors: a. keep PQI on the agenda of board, management, and staff meetings; C. Assessment of the Effectiveness of the PQI System Describe the process by which the organization evaluates the effectiveness of its PQI system in order to ensure its ongoing viability and long term sustainability; The process for evaluating the need for and uses of data Evaluating the PQI system as a whole including infrastructure, processes and procedures

15 The review of the effectiveness of the PQI system will occur though out the year and will be based on findings from the annual report, staff and consumer surveys, compliance with COA PQI standards, cost-benefit analysis, and as other data is available. Please refer to the Core Policy and Procedure Manual for guidance: PQI 1 and PQI 7.03 (b)(c). PQI 1: Catholic Charities leadership demonstrates a clear commitment to fostering a culture of excellence and continual improvement by: a. using quality improvement results to build capacity and improve practice; b. allocating resources for an organization-wide PQI system; c. making data-informed decisions. PQI 7.03: Catholic Charities leaders, senior managers, program directors, and supervisors: a. keep PQI on the agenda of board, management, and staff meetings; b. regularly evaluate the need for and uses of data; IV. Planning Ahead Describe the process by which the organization develops and shares it annual PQI Report including: Timeframes and process for reviewing results of key PQI activities and holdover issues from prior reports and determining if they merit inclusion in the report How priorities and goals for the coming year are determined The PQI Annual Report is produced after all departments have submitted their 4 th quarter PQI report (due by Feb 10 th of each year). Additionally the PQI Team will itemize the year-end status of the elements of the annual plan. Priorities and goals for the annual PQI plan will be determined by taking into account the strategic plan, PQI Team member items, Department requests, and by results of data from surveys and reports received. Additionally carry over issues will be reviewed. Please refer to the following standards for guidance: PQI PQI 7.04: Catholic Charities (via PQI Team) develops an annual PQI Report for the governing body and staff that: a. summarizes key PQI activities that are ongoing, have been resolved, or that need further intervention; b. reviews holdover issues from prior PQI annual reports; and c. identifies PQI priorities and goals for the coming year.