PQI Plan

Performance and Quality Improvement (PQI) Plan
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
Developed by Trudy Soucoup for: Community Youth Services, 2011
Community Youth Services PQI Plan

I. Introduction The Performance and Quality Improvement (PQI) program of Community Youth Services promotes excellence and continuous improvement in all areas of participant care and support services including any form of contracted service. Management endorses the collection and constructive use of data to promote high learning/high performance results. Performance and outcome expectations are communicated in a supportive manner and ensure protection for employees who identify areas of needed improvement. The PQI plan is broad-based and includes all employees and Board of Directors. With input from stakeholders, the Board of Directors and staff establish strategic priorities and goals. Key performance objectives are delineated for all services, and performance and participant outcomes are measured in each program area. These key objectives include those that have the greatest impact on the quality of care/service the participant ultimately receives. Priority is given to functions which are performed frequently, which can be high risk or problematic. Data is used to help the staff better understand if we are meeting program objectives and standards. A. Community Youth Services Philosophy of PQI Community Youth Services has a track record of providing quality services to participants since 1970. We consistently work to improve service delivery and operations. The Community Youth Services Performance and Quality Improvement standards promote excellence and a culture that values efficient and effective delivery of services, as well as a commitment to the continual improvement of program services, performance, and positive results. This is accomplished through both short-term and long-term planning, the systematic collection and review of service delivery data, and through continual efforts to communicate outcomes and recommendations for improvements. Community Youth Services leadership, including members of the Board of Directors, the senior management team, staff members, volunteers, participants and members of the community, work together to identify strengths and areas of positive practice, and to communicate these achievements throughout the organization. Regular training and support are given to all staff in order to increase the capacity of the agency to sustain and improve performance and quality improvement activities. The PQI Plan not only defines the framework and function of the organization and its commitment to maintaining positive results, but also conveys the agencys dedication to excellence and continual improvement of all programs and services. B. PQI Structure (see Fig. 1) The Chief Operations Officer (C.O.O.) is responsible for overseeing the PQI process. The Clinical Director, Human Resource Manager and the Manager of Organizational Development organize and coordinate all PQI activities. These activities include the review of management outcomes, client outcomes, program/service delivery effectiveness and risk prevention activities. Three subcommittees of the Board of Directors - The Program Planning & Review Committee (PP&R Committee), The Audit & Investment Committee and the Fund Development and Community Outreach Committee, review all policies prior to their presentation to the full Board. The PP&R Committee also participates in a one-and-a -half - hour quarterly meeting to receive reports and elicit questions related to important performance improvement issues including quarterly program reports, incident reports and workforce development. At each meeting, the C.O.O. reports on the quality improvement issues and actions taken in the quarter. The PP&R Committee consists of select members of the Board of Directors
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and is staffed by the C.O.O. and the Manager of Organizational Development. The PP&R Committee meets during the third week following the end of each quarter (March, June, September, and December). Quarterly, the C.O.O. submits a comprehensive report which includes an action plan regarding performance improvement issues to the Chief Executive Officer (C.E.O.) and Board of Directors. This quarterly summary compiled by each program includes a report of program statistics, outputs and outcomes, participant outcomes and survey results, program/service delivery activities and risk prevention activities. The quarterly report summaries are also available to all staff for review. An annual report is available to all stakeholders in the first quarter of each year. CYS also has three staff-led committees that are included in the PQI Process Best Practices, Employee Retention & Training, and Safety. These committees generally include staff members from all programs in the organization. They meet on a monthly basis to examine the strategic plan, organizational goals and objectives, and make recommendations on progress and system improvements. To support PQI processes, the organization analyzes the agency-wide data in relation to: Consumers (Participant Outcomes, Demographics) Program/services (Program Outcomes, Service Delivery) Performance (Client and Employee Satisfaction) Risk management Financial viability C. Definition of Stakeholders CYS stakeholders include board members, executive team, staff members, volunteers, partners in the community, and participants. Stakeholders are involved in the PQI process at various levels: Staff, which includes volunteers, is regularly involved in the planning and implementation of various strategic outcomes. Board members and the Executive Team are included at the highest level of PQI planning, including the development of the long-term strategic plan. The Executive Team include the C.E.O., C.O.O, Clinical Director, Director of Development and Community Outreach and the Human Resources Manager. Partners in the community are involved PQI process through surveys, CYS staff involvement in community organizations and contract monitoring where applicable. Partners can include: partnering community organizations, courts, elected officials, other service providers, funders and regulators. Participants, their families and advocates are involved in PQI through on-going agency and program specific quality of service surveys. Here are just a few of the many ways we involve stakeholders in our PQI process: Sit on the Board of Directors or a Board Sub 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 strategic planning Have staff administer measurement tools and collect data

Conduct surveys and/or focus groups Ask for input at meetings of our community partners
II. Measures and Outcomes
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.

a. Complete a program specific needs assessment related to program enhancement and effectiveness. b. Research best practice models and strategies. c. Create and define a best practice theoretical approach that has been implemented across all CYS programs that provide direct services. d. Staff has been trained to utilize best practice approaches. e. Clinical support for CYS programs is regularly provided. Clinical supervision improves case manager skills and provides more options for effective interventions. f. Program specific outcome measurements have been created that evaluate best practice strategies, including the Childrens Functional Assessment Rating Scale (CFARS) & contract outcomes. 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 the CYS mission. a. Community awareness of CYS & its programs has increased and has become more effective. b. Agency funding has increased and is more diversified. 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. i. A support infrastructure for Quality Assurance (QA) is in place at CYS. ii. Data collection and management systems for programs and agency-wide are more consistent, accurate, and produce meaningful data that document the impact of the service measured. iii. Data collected by programs is organized, summarized and accessible and informs program development and improvement. iv. Potential strategies and tools have been assessed and selected for use that benefits program and agency performance. d. Expand the CYS Continuum of Care, eliminating service gaps for youth within CYS and the community. i. The needs for various youth services in our community have been assessed. ii. The CYS Continuum of Care has been expanded and strengthened. iii. The CYS continuum of services is easily identified and access is understood by staff and participants. e. CYS is an effective and efficient organization and agency resources support our mission. i. Strengthen financial health ii. Effectively deliver program services by ensuring that CYS has a highly trained and capable workforce. iii. Agency information is effectively delivered to staff. B. Management / Operational Performance The Executive Team establishes periodic reviews of essential management and service delivery processes consistent with quality priorities. Staff throughout CYS and partners and contractors, work together to: a. develop key outcomes and outputs b. develop relevant qualitative and quantitative indicators c. identify data sources, including measurement tools and instruments
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CYS selects performance measurement indicators that relate to operations and management, program results, and client outcomes. Possible management operations outcomes and data sources include: a. Financial Viability i. Monthly reports of financial performance (FIN 5.04a and b) ii. Cost analysis of services (FIN5.05; 5.06) b. Workforce Stability i. Workforce gap analysis (HR 2a) ii. Staff satisfaction surveys (HR 4.03; 4.04) iii. Staff retention data(HR 4.03; 4.04) iv. Analysis of employment patterns (HR 5.04) v. Workload / caseload size reviews (Service Sections) c. Board Effectiveness i. Program Review (GOV 6) ii. Risk Assessment (GOV 6.08) d. Board Governance & Recruitment ii. Community Representation (GOV 2.02) iii. Governance Expertise (GOV 2.03) e. Safety and Security i. Accidents, incidences and grievances reports (RPM 2.02) ii. Monthly facility Maintenance Reports (ASE 4; 6.01; 6.02) iii. Risk management reviews (RPM 2.01) f. Effective Fund-raising i. Ethical fundraising practices (ETH 3) ii. Stable income (FIN 4) iii. Resource development (GOV 6.05) a. Overview of legal, regulatory, and funder mandates regarding measurement of outputs and outcomes All contracts are negotiated and reviewed for outcomes and outputs. Each program sets up case files and develops a process to collect required information from program participants and a system to consolidate, track and report data. Data is reported quarterly to funders and to agency leadership through quarterly reporting. Reports compare performance status against benchmarked goals typically set by funders or in the grant development process. In addition, data may be inputted into a state or federal database to indicate progress toward required results. Often, federal and state agencies compare this data to other programs accomplishments, or to a set minimum standard. Contracts typically also include all laws and regulations that must be followed while carrying out the contracted services. These are reviewed by agency staff and training on contract provisions is provided as needed. Furthermore, these contractual standards are used, in addition to legal requirements, accreditation standards and review of best practices, to develop program policies and procedures that guide the way services are provided. C. Program Results / Service Delivery Quality CYS selects performance measurement indicators that relate to operations and management, program results, and participant outcomes. The PQI plan:

a. assigns responsibility for implementation and coordination of PQI activities and technical assistance with the Manager of Organizational Development b. sets forth the purpose and scope of PQI activities as defined in Section I.A c. establishes a periodic review of essential management and service delivery processes consistent with quality priorities d. outlines methods and timeframes for monitoring and reporting results e. includes provision for an assessment of the PQI programs utility, including any barriers to and supports for implementation The PQI plan describes how valid, reliable data will be obtained and used on a regular basis to advance monitoring of actual versus desired: a. functioning of operations, that influence CYSs capacity to deliver services b. quality of service delivery c. program results d. participant satisfaction e. participant outcomes Collection of service delivery information focuses on key quality factors, including accessibility, appropriateness, availability, continuity, efficiency, effectiveness, safety, timeliness, and respectfulness or any of the other dimensions of quality. D. Client and Program Outcomes CYS measures participant and program level outcomes on an on-going basis for every program according to the goals of the program. Each outcome measured falls into one of the following categories: a. change in clinical and/or functional status, b. achievement of goals, such as permanency of living situation, acquisition of skills, acquiring GED or diploma, reading level improvement, becoming employed, or avoidance of negative outcomes (incarceration, suicide attempts) c. client satisfaction, or d. health, welfare and safety III. PQI Operational Procedures CYS uses data to identify areas of needed improvement and to implement improvement plans in support of achieving performance targets, program goals, participant satisfaction, and positive outcomes. To accomplish these goals the following processes are used: A. Data Collection and Aggregation 1. Case File Review It is the responsibility of all Community Youth Services staff to ensure that all participant files contain the documents that are legally and programmatically required. A File Review is conducted quarterly to analyze and evaluate clarity, content and continuity of open/closed records and to determine if participants needs and strengths are being assessed appropriately. In the Level 1 Review, the File Review Team, consisting of peers from various programs, collects a random selection of files from each program area. The number of files to review per quarter is determined by the standard produced by the Council on Accreditation.
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Peer reviewers examine cases in which they have not been directly involved or for which there is no conflict of interest. All records reviewed are subject to the Case File Confidentiality Policy of Community Youth Services and the Washington Department of Family and Protective Services. Peer Reviewers look for evidence to show agency leadership, stakeholders and funding agencies that programs are effective and in conformance with their service, legal, and fiscal requirements. Additionally, they are looking to see that all required documents are placed in the file in a timely and consistent manner and filled out accurately. Documents should be in the same place in each file. Using the program-specific Case File Review Checklist, peer reviewers conduct the case review during the last weeks of March, June, September and December. The Manager of Organizational Development reviews each report to determine patterns and/or trends in the case records. Concerns and recommendations are reported on a summary report to Program Directors and discussed with the Directors as needed. In the Level 2 Review, the Case File Reviews are performed by Program Directors (PD) and are
directly related to the quality of the services provided and documented.

Quality issues could differ for open and closed cases, especially in programs where client characteristics, program participation, length of stay, or other factors may be related to positive outcomes. Criteria for evaluating the appropriateness, necessity, and effectiveness of services include: a. appropriate & current services needed and provided or obtained (ISP) b. length of service c. changes in status or level of service d. need for continued service e. compliance with mandated review indicators f. timeframes g. case note accuracy and quality h. service plan development timeliness i. evidence that the program participant has been involved in the development of the service plan j. evidence that the program participant has signed all required grievance, client rights and responsibilities and confidentiality or information disclosure documents. Level 2 Case File Reviews happen on an ongoing basis over each quarter. Program Directors review the same number of files as the Level 1 Review requirements but do not necessary need to review the same files as will be reviewed by the Level 1 Case File Reviewers. Directors file the Level 2 Case File Review Checklist for future reference. Directors provide feedback and consultation to case managers for follow up. 2. Safety Review: The Safety Committee conducts a quarterly review of all issues regarding employee and client safety by focusing on facilities and risk management. The Safety Committee utilizes representatives from administration, human resources, and program staff. Committee members meet to discuss safety issues, licensing audits and reports as related to safety and risk management. Data and reports are gathered by the responsible committee members and brought to the meeting for review. These reports assist in making a determination of areas that are in need of improvement. Reports gathered for assessment include:

a. Health and Fire inspections: The Safety Committee Co-Chair presents the Safety and Health Inspection as well as the Fire Inspection to the committee. The committee inspects records of emergency evacuation drills and policies and procedures pertaining to dealing with emergency situations, including disruptive individuals. Current inspections reports are reviewed and examined for areas that need attention. b. Licensing reviews and monitoring visits as it pertains to facilities management: The current licensing reviews and reports are gathered by the Business Manager or appropriate Program Director and examined for any improvements that need to be made. They are copied to the applicable contract or property file and reported to Executive Staff during the quarterly reporting process. c. Incident reports regarding staff and participant accidents and injury reports: Incident reports that involve any safety issues are retrieved from the database by the C.O.O. and Clinical Director and examined to determine if the cause of the unsafe situation was identified and corrected. d. Environmental, Health and Safety/Physical Plant Audit: The environmental/physical plant audit is conducted by the Safety Committee members, and Program Directors using the Environmental, Health and Safety/Physical Plant checklist. The data is compiled and used to determine where improvements are needed. Audits include: i. Review of medication storage and record keeping are examined and any issues discovered are discussed and recommendations are made in areas in need of improvement. ii. Vehicle Accident reports are gathered by the Business Manager and reviewed and recommendations are made regarding improvements. iii. Facility Maintenance Reports will be reviewed by the Business Manager to determine areas of needed improvement and recommendations will be made and presented. iv. Training materials are reviewed by the Employee Retention Committee for appropriateness to all levels of staff to include new equipment or change in standards/regulations. Staff training is also evaluated regards to areas of risk. Patterns and/or trends are examined in the reports listed above. The Safety Committees responsibility is to stay abreast of safety issues by reviewing potential risks and making recommendations to address them, preparing emergency action plans and carrying out risk reduction strategies. Previous implementation and recommendations are reviewed and determination of effectiveness is examined. The C.O.O. completes an annual comprehensive report and presents it to the Board of Directors. 3. Administrative Risk Review: Administrative Risk Reviews are conducted at least annually to assess areas that pertain to administration of Community Youth Services. The Program Planning and Review (PP&R) and the Audit & Investment sub-committees of the Board of Directors meets quarterly with representatives from the Executive Staff, Organizational Development Manager, and other staff as needed to review processes and specific documents to identify patterns/trends in need of attention. Recommendations and suggestions will be discussed and documented in the meeting minutes and submitted at the quarterly Board of Directors meeting. a. Internal Evaluations: i. Employee Satisfaction Survey: Annually, the Human Resource Manager distributes an Employee Satisfaction Survey to all staff to identify areas of satisfaction and areas in need of improvement. Components of the survey include: 1. mission and purpose
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2. quality of services and client focus 3. compensation 4. respect for employees 5. staff satisfaction 6. staff engagement 7. communication 8. opportunities for growth 9. workplace resources 10. supervision This data is collected and shared with all staff. Program Directors address areas of needed improvement with individual programs and develop an action plan. This process and attached information is included in the March Administrative Quarterly Report submitted to the PP&R Committee and reviewed at the following board meeting. Staff grievances: The Human Resource Manager addresses staff grievances according to agency policy. If a grievance is filed, information about the grievance and the resulting actions are discussed by Executive Staff. Trends are analyzed and recommendations are included in the Quarterly Program Review report to be submitted to the PP&R Committee. Stakeholder Surveys: An Annual Stakeholder Survey is conducted in October of each year to solicit input from the broader community on the quality of the agency and how to improve. Stakeholders are defined as advocates, alumni, funding sources, referring agents and community supporters. Components of the survey include: 1. knowledge of the organizations mission 2. community need and continuum of care 3. agency status through distribution of agency materials 4. review of the organizations overall performance in relation to established expectations The data is collected by the Manager of Organizational Development and brought to the Executive Staff. Consolidated data is presented at the PP&R Committee meeting and the Quarterly All-Agency Meeting in December. Recommendations are made for quality improvement of organizational performance based on the results of the data. Demographic Profile: A demographic profile of the community is created in January of each year that includes the following: 1. gender; age 2. racial/ethnic composition 3. language choice 4. length of participation in programs This process and attached information is included in the January Program Review report to the PP&R Committee. Staff Exit Interview: An exit interview is conducted by the Human Resource Manager for all employees leaving the organization. Results of the interviews are brought to the HR Quarterly Review meeting to identify risks and opportunities for organizational performance. Structural issues to be addressed will be included in the quarterly report to the PP&R Committee. Feedback to Program Directors will be provided as appropriate. Staff Retention: The Human Resource Manager collects data regarding staff retention within the agency. The data is reviewed during Program Quarterly Reports, trends and/or patterns are examined and included in the quarterly report to the Board of Directors.
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vii. Financial Health: The C.O.O. prepares and reviews the monthly revenue and expense reports and balance sheet for the agency and each program. Trend charts are created which track cash balances, accounts receivable, grant balances, % utilized compared to year to date projections, etc. Patterns and trends are reviewed to assess financial viability and indication of a need for action. Financial reports are posted on the intranet for access by program management and submitted to the Board of Directors at their monthly meetings
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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Community Youth Services has identified three best practice models that can be utilized to facilitate clinical review across the continuum of programs that are provided at CYS. Those best practice models are: 1. Positive Youth Development 2. Solution Focused Case Management 3. Wraparound Core Competencies of these models include: 1. Individual/Family Voice & Choice 2. Team-based Approach to Providing Services and Supports 3. Natural and Community Supports for a Family that Will Sustain Progress When CYS Services Have Ended 4. Team Collaboration, Cooperation and Communication 5. Cultural Competence 6. Community Based 7. Solution-Focused and Strength-Based 8. Individualized 9. Outcome Based These three models are used throughout the continuum of care and adapted to each program to suit the needs of the participants and the requirements of the program. a. Therapeutic Foster Care Program is designed to work with youth in the foster care system that are often referred to as multi-systems youth experiences challenges in most domains of their lives. Most youth referred to the CYS Therapeutic Foster Care Program meet the criteria for Behavioral Rehabilitation Services (BRS). The Therapeutic Foster Care team meets weekly to discuss cases and consult about program goals specifically related to placement stability, school stability, improved mental health, improved behavioral functioning and planning for permanency. The Therapeutic Foster Care team also consults about cases during weekly staff meetings. Each case manager has the opportunity to discuss cases on an individual basis as needed with the CYS Clinical Director and the Therapeutic Foster Care Program Director as well as presenting cases for per review during weekly staff meetings. The CYS Clinical Director and the Therapeutic Foster Care Director are on call for the Therapeutic Foster Care Program staff 24 hours a day, 7 days a week for emergent clinical consultation. b. Family Preservation Services at Community Youth Services provides in-home, school and community based services to families who are at risk for child abuse and neglect and who may be at risk of losing custody of their children to out-of-home care. CYS utilizes licensed contract therapists to provide Family Preservation Services. The focus of clinical consultation for CYS contract therapists is to support the achievement of the goals identified by the Division of Children and Family Services as well as achieving the goals identified by the family.

Each therapist is offered clinical consultation with the CYS Clinical Director weekly or as needed based on the challenges of each familys situation. Additionally, CYS contracted therapists are provided 24 hours per day, 7 days per week emergent clinical consultation by the CYS Clinical Director. c. Crisis Family Intervention Services at Community Youth Services provides brief in-home, school and community based therapeutic services to families who are experiencing a current crisis, family conflict, school related problems or families who experience challenges accessing community supports due to isolation and/or poverty. CYS utilizes licensed contract therapists to provide Crisis Family Intervention Services. Each therapist is offered clinical consultation with the CYS Clinical Director weekly or as needed based on the challenges of each familys situation. Additionally, CYS contracted therapists are provided 24 hours per day, 7 days per week emergent clinical consultation by the CYS Clinical Director. d. Haven House is a co-educational, residential program that provides safety, stabilization and assessment and referral services for youth who are in immediate crisis and with no other housing option. Youth are referred to Haven House by: Childrens Protection Services social workers, law enforcement officers, and schools. Additionally, youth can refer themselves to Haven House through the Safe Shelter program if these youth feel they are in imminent danger within their own families. Many of the youth referred to Haven House are identified as Behavior Rehabilitation Services youth (described above) who are often in behavior, emotional and mental health crises. The Haven House team meets daily to discuss each youth in care. Clinical supervision is provided by the Haven House director, the Program Coordinator and the CYS Clinical Director. Clinical supervision is also provided, daily, on an as needed basis for Haven House program staff. The Haven House director, the program manager, and the CYS Clinical Director are also on call 24 hours per day, 7 days per week to offer clinical support to staff when there is a crisis within the residential center. e. Foster Care Assessment Program provides standardized assessments of foster youth who have been in out-of-home care for long periods of time; have incomplete diagnostic information; who experience physical, emotional or mental health needs which have created barriers to permanency and who do not have a viable plan for permanency. The Foster Care Assessment Team meets weekly to discuss current cases with the CYS Clinical Director. Additionally, the CYS Clinical Director is available to meet with the members of the FCAP team at any time to support the development of the permanency and service plan. When an initial report has been developed by the FCAP staff, each case is reviewed by a community based review team that includes: the CYS Clinical Director, a University of Washington/Harborview Hospital FCAP team member, the CYS FCAP team and an FCAP evaluator from another region in Washington State. Following this review, the CYS FCAP evaluator writes a final report to submit to the referring social worker for implementation. f. Comprehensive Assessment Program provides standardized evaluations and service recommendations for families who are at risk of child abuse and neglect as identified by
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Childrens Protection Services. Referred families also may have a history of CPS referrals, challenges with mental health, and/or substance abuse. The Comprehensive Assessment Program also conducts structured interviews with the referred parents, children and with the referring CPS social worker; reviews existing records for the referred family; and meets with collateral contacts of the family. The Comprehensive Assessment Program team meets weekly to discuss current cases with CYS Clinical Director. Additionally, the CYS Clinical Director is available to meet with the members of the Comprehensive Assessment Program team at any time to support the development of the service plan. Each of the clinical programs listed above are provided weekly clinical consultation that addresses specific cases as well as the implementation of the practice models listed above. Clinical supervision can include individual meetings with program staff or can be inclusive of entire teams. In addition to our CYS-staffed programs, Behavioral Health Resources (BHR), a community mental health agency in Thurston and Mason counties, has developed a collaborate relationship with Community Youth Services. A BHR Mental Health Specialist is located at CYS to be a single contact referral and assessment for CYS participants. Benefits of this clinical collaboration is that the BHR Mental Health Specialist can see any CYS participate regardless of age, the Mental Health Specialist can see enrolled participants in the participants homes, community or school and each CYS enrolled participant has access to the full array of BHR services including group therapy, evidence based programs, and medication management. The BHR Mental Health Specialist can also participate on the wraparound team that is identified by the participant and their CYS case manager. g. Community Youth Services Best Practices committee also addresses the need to provide consistent and regular clinical consultation to other CYS programs. The Best Practices Committee is currently providing overview training in Wraparound, Solution Based Case Management and Positive Youth Development to all CYS staff. The Best Practices Committee works with CYS program managers to develop regular consultation practices within each of their programs. B. Data Review and Analysis (see Fig. 2) The process for the collection, processing, analysis and feedback of agency data are as follows: 1. Quality Assurance: The collection of data is for fulfilling the mission, values and mandates of CYS and to assure that services provided meet set standards. Both quantitative and qualitative means of data collection are utilized. Data is in the form of internal and external reports, generated or received from regulating bodies, stakeholders, staff and residents. 2. Performance Measurement: Quantitative internal data collection tools include but are not limited to the participant progress assessments, individualized service plan results, financial reports, training records, surveys, employee records, and various excel spreadsheets and databases that collect and track participant demographics, assessment results and accomplishments. Qualitative internal data collection tools include incident / accident reports, b behavioral contracts, progress report forms, case record reviews, grievances, agency logs, facility reviews, and program Annual plans and

employee evaluations. External data collection tools received and reviewed by CYS include corrective action plans received by the Washington State Department of License Review, stakeholder surveys and site reviews by the Department of Social and Health and Services and other contracting agencies whether state or federal. 3. Performance Evaluation: Processing and statistical analysis of data is performed by the various agency staff or contracting entities. Data is compiled into forms consistent with presentation in the PQI process. External reports are received by the C.E.O. and / or C.O.O. for analysis and presentation preparation. Data analysis may involve board members, a treatment team, case managers, youth care workers, administrative staff, contracting entities, and regulating bodies or stakeholders. 4. Presentation: Quarterly reports are made to the C.E.O & C.O.O. by Program Directors on the following areas: Program accomplishments, case file review, program data, incidents, outcomes data, accidents, grievances, participant satisfaction surveys, human resources, financial, facility, administrative, other internal reports and external reports. The summarized information is presented to the PP&R Committee by the C.O.O. 5. Recommendations for Improvement: The C.E.O. & C.O.O and/or PP&R committee will conclude either satisfaction or deficiency with the various results. If recommendations for improvement are necessary to ensure quality performance, the committee shall move to the next step. 6. Define Improvement Goals and Objectives: Each identified deficiency shall be turned into a goal with an objective consistent with measurement using the data collection tool of the deficiencys origin. The Executive Staff will establish success criteria, based on contractual goals and accreditation standards. 7. Analyze the Process under Study: The Executive Staff evaluates the improvement plan for feasibility and period and submit to the Chief Executive Officer for approval. 8. Plan, Test, and Pilot Improvement Ideas: When improvement plans involve extensive cost, time, risk of harm, or radical systemic change, a pilot of the improvement idea is performed to minimize consequence of failure. 9. Organizational Change: Improvement plans, goals, objectives and general recommendations are communicated throughout the agency via the staff meeting process. Meetings include - general agency staff meetings, treatment team, case manager meetings, executive staff meetings, youth care worker team meetings, counselor supervision and the reports of the Chief Executive Officer to the Board of Directors. 10. Performance Measurement: The process begins again. C. Communicating Results
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

improvement based upon that data. Each committee communicates about projects and results through regular CYS meetings and media. Their quarterly report is summarized in the agency quarterly report and provided to the PP & R Committee. The PP&R Committee reviews agency summary performance data and new or updated policies. In addition, input from program directors, Council on Accreditation standards, licensing requirements, information technology requirements, regulatory and contractual requirements, and child welfare and other industry best practice standards (such as Child Welfare League of America) inform our decision making processes and strategies for communicating. Once a decision is reached by the Program Directors/Manager, the decision is communicated to all staff. The C.O.O. ensures that all approved revisions replace or enhance existing agency policies and procedures. At least one member of the Executive Team attends each quarterly meeting of the Boards PP&R Committee to provide and receive input on PQI activities and decisions. D. Using Data for Implementing Improvement
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.
Assessment of the Effectiveness of the PQI Program
CYS is committed to the principles of quantitative analysis in its review of program and service quality performance areas, including:
1.
Management and Operations Measures

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The agency has identified reviews of its financial viability status, workforce stability levels, and safety and security procedures as priorities. Through the ongoing work of the Safety, Employee Retention and the Audit & Investment Committees, oversight of all management and operations measures is provided and reported regularly to the Executive Staff and Board of Directors. 2. Strategic Plan Measures The Strategic Plan, based on a three year planning cycle, mandates the achievement of selective performance goals and outcomes, including strategies for goal attainment and the development of performance improvement plans. In 2008, we spent the year developing a new strategic plan. This was created with staff and board input, built off of the successes and unfinished items from the previous strategic plan. We used online surveys and focus groups to develop priorities and organize them into common themes. The board approved the strategic plan in March 2009 and we continue to track progress through the implementation plan and annual work plan. The five content areas include: Implementing Best Practices, Community Relations and Fund Development, Quality Assurance, Continuum of Care and Organizational Effectiveness and Efficiency. 3. Service Effectiveness/Participant Outcome Measures Methods of measuring and evaluating service quality include case record reviews, client satisfaction surveys and client outcomes data. We track outcomes and outputs consistently across programs via our updated quarterly report formats and update consumer surveys. This makes it easier to understand organizational and program effectiveness, review the impact of program and staffing changes and provides better information to senior management and the board for our quarterly and annual reporting process. 4. Performance and Quality Improvement Plan The agency Performance and Quality Improvement Plan is updated annually and is designed to be comprehensive in its approach to performance assessment. Both staff and stakeholders collaborate on the development of outcome measures, jointly review results, and monitor efforts by the agency to improve programs and professional practice. In 2010-2011, all program and departmental policies and procedures were reviewed and updated to reflect current practices and standards. Transfer to a new, more readable format that provides additional context. Quarterly program report formats and required content were updated. CQI areas such as incident reports, consumer survey data and file review results were added. The format change added more consistency in reporting across programs and make process of gathering data more efficient.
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Fig. 1 - CYS PQI Structure
Participant File Review Program Staff Program Directors Manager of Org. Development
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
Clinical Review Clinical Director Program Directors Program Staff C.O.O.
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Fig. 2 - Data Review and Analyses
Quality Assurance
Set/Review Performance Measurement/s
Performance Measure No
Yes
Area Being Studied: Need to Improve?
Recommendations for Improvement
Define Improvement Goals and Objectives
Analyze the Process Being Studied
Organizational Change
Plan, Test, and Pilot Improvement Ideas
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Fig. 3 PQI Process and Timeline
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CYS Overview of QI Data Collection Process
What Is Being Measured? Why Is It Being Measured? Indicators and Data Sources Who Is Responsible? How/ Frequency? Tools - How Will Data Be Collected? How Will Data Be Aggregated and Reports Generated? In What Format? Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted? Who Will Implement/ Oversee Recommended Changes?
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.
Quality of Case Records
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.
What Is Being Measured?
Why Is It Being Measured?
Indicators and Data Sources
Who Is Responsible?
How/ Frequency?
Tools - How Will Data Be Collected?
How Will Data Be Aggregated and Reports Generated?
Who Will Review and Interpret Results?
Who Will Make Recommendations And To Whom?
Employee Satisfaction Survey Exit Interviews Retention & Turn Over Rates Workforce Stability
Human Resource Manager, The Executive Team, The Board of Directors
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.
Who Will Implement/ Oversee Recommended Changes?
Quarterly.
Incidents
Determine Incident the cause Report of the Database unsafe situations and correct where possible
Program Directors C.O.O. Clinical Director PP&R Committee Board of Directors
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
C.O.O. Clinical Director Program Director Safety Committee Chair
Who Is Responsible?
How/ Frequency?
How Will Data Be Aggregated and Reports Generated? In What Format?
Who Will Review and Interpret Results? When Will Results Be Reviewed And Interpreted?
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?
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.
Interview, Assessment, Survey, Review external data
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
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
Varies by type of assessment / review, but typically annually or quarterly
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?
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.
Monthly Quarterly Annually
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.

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Performance and Quality Improvement (PQI) Plan

Developed by Trudy Soucoup for: Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services PQI Plan

Community Youth Services PQI Plan

II. Measures and Outcomes

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

directly related to the quality of the services provided and documented.

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services PQI Plan

Community Youth Services PQI Plan

Assessment of the Effectiveness of the PQI Program

Management and Operations Measures

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Clinical Review Clinical Director Program Directors Program Staff C.O.O.

Community Youth Services, 2011

Community Youth Services PQI Plan

Set/Review Performance Measurement/s

Area Being Studied: Need to Improve?

Recommendations for Improvement

Define Improvement Goals and Objectives

Analyze the Process Being Studied

Plan, Test, and Pilot Improvement Ideas

Community Youth Services, 2011

Community Youth Services PQI Plan

Community Youth Services, 2011

Community Youth Services PQI Plan

Quality of Case Records

What Is Being Measured?

Why Is It Being Measured?

Indicators and Data Sources

Tools - How Will Data Be Collected?

How Will Data Be Aggregated and Reports Generated?

Who Will Review and Interpret Results?

Who Will Make Recommendations And To Whom?

Human Resource Manager, The Executive Team, The Board of Directors

Who Will Implement/ Oversee Recommended Changes?

Program Directors C.O.O. Clinical Director PP&R Committee Board of Directors

C.O.O. Clinical Director Program Director Safety Committee Chair

Community Youth Services, 2011

What Is Being Measured?

Why Is It Being Measured?

Indicators and Data Sources

Tools - How Will Data Be Collected?

How Will Data Be Aggregated and Reports Generated? In What Format?

Who Will Implement/ Oversee Recommended Changes?

Community Youth Services, 2011