Performance and Quality Improvement Plan
Connections for Kids (CFK) is a nonprofit organization in South Portland Maine that provides mental health, residential and educational services to children.
Our Mission is to create better futures for children, youths, and families. We specialized in developing relationships, building individual and family strengths, and using treatment and education that works. Connections for Kids engages children, youth and families in healthy activities and educational programs.
Core values drive all treatment intervention: Safety, Respect, Privacy and Commitment to an excellent future.
Connections for Kids has always had a culture of improvement, our Mission statement is about our dedication to the field, in building relationships that foster healthy engagement and connections. We encourage creativity among our staff, we support people’s individual ideas, needs and skills. Our leadership bolsters a strong value of staff development and morale building.
PHILOSOPHY OF PQI
Connections for Kids (CFK), its leaders, and staff place top priority on a PQI plan which drives it to become a model of excellence in child and family mental health care. A well-defined, implemented, and continuously evaluated PQI plan enables CFK to develop a path of work that is clear, flexible, and responsive, and effective. CFK is committed to maintaining a high standard of values and personal accountability which is inclusive of all parts of the organization as well as its identified stakeholders. The PQI plan for CFK is the evaluation of services against standards to measure organizational innovation, performance, services, and effectiveness. Connections for Kids maintains a system for continuous quality improvement. This document summarizes the structure, process and activities of CFK’s PQI plan.
Connections for Kids has a list of key stakeholders and values their participation in our PQI process. Key stakeholders include our staff, clients, community service organizations, the Department of Health and Human Services, Office of Child and Family Services and Board of Directors.
- Clients (selected at random) participate in quarterly questionnaires which allow them to offer feedback and comments about the quality of service provided. Clients also receive a service follow-up questionnaire.
- Community partners participate in questionnaires on a quarterly basis which allows them to offer feedback and comments based on their interactions with our organization.
- The Board of Directors receives an agency PQI Report annually and is updated on PQI efforts and issues at full Board of Directors meetings. Board of Directors also receive monthly financial statements from our Director of Finance.
- CFK staff members participate in annual surveys regarding supervisors, working environment, employee engagement, communication, and evaluation of services. The surveys are designed to give each employee an opportunity to offer comments and suggestions for improvement. PQI and Risk Management reports are presented at least annually during staff meetings or e-mail communication and employees can offer comments and suggestions. Staff members are also given opportunities to serve on the PQI teams and safety committees.
The Management Team (Directors) review PQI and Risk Management reports as well as questionnaire results at quarterly meetings to identify trends based on Risk Evidence (Worker’s Compensation Reports, Vehicle Accident Reports, Incident Reports, etc.) Suggestions and recommendations are communicated to the PQI and Risk Management Committee as well as to the Management Team and Executive Director. Corrective action is based on stakeholder feedback and improvement suggestions from departmental PQI teams and the PQI and Risk Management Committee. Changes in policies, procedures, or staff training are implemented as necessary by the Management Team.
CFK’s PQI philosophy, PQI structure, stakeholder involvement, and a brief description of our outcome measures are provided to all new employees during a PQI presentation given at New Employee Orientation. All stakeholders may access PQI information on our agency website or annual e-mail notification. This information is maintained and updated as necessary by the PQI Coordinator. All feedback and input from stakeholders are utilized by our Management Team, Executive Director and our Board of Directors to formulate strategic planning and to identify short-term and long-term goals and objectives.
The PQI Plan and Connections for Kids Strategic Plan Alignment: Connections for Kids undertakes a strategic planning process every two years to ensure that the mission of the organization is responsive to the needs of the community. The strategic plan guides the administration and delivery of CFK services. CFK long-range strategic plan and short-term annual plan include goals, objectives and measurable outcomes that address organizational capacity. The PQI plan considers the strategic plan’s goals and takes a deep dive on specific standards, practices and outcomes that need focus.
PURPOSE OF PQI
Connections for Kids is committed to providing quality services to children and families. Performance and Quality Improvement (PQI) is a method of regular monitoring, evaluation, planning, remediation, and improvement that ensures that CFK accomplishes this goal of effectively delivering high quality service.
The PQI and Risk Management Committee is comprised of a few Directors, staff from HR and Administration as well as the PQI Coordinator and other program staff from two programs. This team meets quarterly to conduct analyses of PQI, and risk management related data gathered by individual PQI teams and Safety Committees within each department/program. The PQI data is documented on a Performance Quality Improvement Report completed by each department/program and aggregated in quarterly and annual PQI reports.
The PQI/ Risk Management Committee is comprised of at least one of the following individuals:
- Senior Management (Directors x 2)
- Administrative Staff
- HR staff
- Case Manager or Clinician or Program Coordinator
- BHP, Behavioral Health Professional
- BCBA or someone with knowledge
- PQI Coordinator
Corrective action plans developed by departmental/program teams are discussed at the PQI and Risk Management Council meeting and suggestions and recommendations are shared with our Management Team. Suggestions and recommendations developed by these teams are also shared at least quarterly at general staff meetings held by each area/program/department. All sharing of information and the creation of corrective action plans is documented in meeting minutes/reports.
PQI Structure Includes:
- Consumers (clients, employees, board surveys, staff relations, wellness, residential and school improvement)
- Programs Services (intake, strategic planning, and intake)
- Performance (records, Audits, employee evaluations, contract monitoring)
- Risk Management (incident reports, safety, reviews)
- Financial viability (Board Reporting, Auditing)
Initiative and Action Plans – annual review of the PQI Plan, PQI reports, and overall PQI activities is conducted by Executive Director and the Directors, the PQI Coordinator, and the Board of Trustees.
In each fiscal year, every area/program/department shares measurable PQI goals and objectives which are placed in the PQI reports, where quarterly and annual results are reported, analyzed, and tracked. Reports are provided to all staff regarding PQI efforts, including a semi-annual Performance and Quality Improvement Report that outlines improvements that have occurred because of PQI corrective action plans and plans that are currently being implemented. The sharing of information and data within every department/program leads to development or revision of short-term plans, policy, and protocol, and/or other improvement activities.
A Coordinator of Performance and Quality Improvement was implemented into the Finance Department to lead the PQI effort of Connections for Kids. The Coordinator of Performance and Quality Improvement is instrumental in the role of ensuring that quality improvement goals and objectives achieve desired results for Connections for Kids. The position works closely with the Director of Finance and Executive Director, as well as Program Directors, employees, and stakeholders to assure the proper structure, employee involvement, measurements and reports are in place according to guidelines outlined by the Council on Accreditation’s PQI standards.
MODEL OF CHANGE: Program Indicators:
When change is needed: Connections for Kids will be using the Plan, Do, Check and Act cycle as the framework for change. Improvement plans can be used for a variety of reasons, including:
When data shows that correction or points to an area of concern through the PQI program:
- For administrative functions that need increased efficiencies.
- To correct under-performing programs or sites.
- To provide guidance to staff members who demonstrate performance that is not meeting expectation.
- For successful programs that an organization would like to develop
- To increase the involvement of governing body.
Connections for Kids will look at the Plan, Do, Check and Act model.
Plan – During this phase preparations are made to effectively make the change. This may involve gathering additional data and information to support the need for change. A work plan will be developed to identify the specific objectives, responsibilities, and indicators of success.
Do – during the Do phase, the work plan or proposal is acted upon. There should be a plan for follow up and regular reporting on the status.
Check – This phase allows for the work to be assessed. Most importantly, it needs to be determined whether the change was successful or unsuccessful.
Act – Once Connections for Kids has determined if the change was an improvement, then the change is made part of the current practices.
LONG-TERM STRATEGIC GOALS AND OBJECTIVES
Connections for Kids is committed to a strategic planning process which incorporates quality improvement goals and objectives and defines plans and activities to complete these goals and objectives. The strategic planning process is led by our Executive Director, Board of Directors, Management Team, and staff give input; it is conducted on a two-year interval. The organization completed a comprehensive strategic plan in 2021. Our planning process includes our mission, values, measurable goals, timeframes, and strategies to meet identified goals. Our strategic plan’s goals and objectives drive the development of short-term and long-term plans across the organization.
- The Board of Directors reviews the plan and the work of their committees to analyze existing programs and recommend needed changes, additions, or deletions.
- CFK staff at all levels will submit input and recommendations to achieve the outcomes. Action steps will be outlined by Program Directors and measured in the established Performance and Quality Improvement (PQI) Plan.
- Long Term Goals from Strategic Priorities #1:
Workforce Development: Improve retention
- Long term Goal from Strategic Priorities #2
Advance Our Mission
- Long term Goal from Strategic Priorities #3
Work on Performance and Quality Improvement Plans
- Long term Goal from Strategic Priorities #4
Improve Financial Stability of Connections for Kids
The Management Team represents the agency’s supervision and responsibilities for finance, Employees, programs and services, communications, and overall safety, risk and facility management. For PQI purposes, the following areas are monitored and analyzed for performance and operational excellence.
- Workforce Stability
Data Review & Analysis: The Director of Human Resources, in cooperation with members, works on stabilizing workforce development and improving retention. HR conducts a workforce analysis annually in preparation for the budget process. The information reviewed is a combination of internal workforce trends and projections for growth/decrease in service needs in accordance with CFK’s long-term goals and short-term annual objectives.
Additionally, HR analyzes workforce needs and patterns for reports annually. Employee surveys, exit interview information, payroll reports, and overtime, employee turnover data, hiring data, benefits data, DOL statements, Workers’ Compensation data are generated and reviewed.
An Affirmative Action Plan is in place, and it is monitored by HR. It includes data collection, reporting and training.
Communication Results & Action Plan: Identify trends, concerns, and opportunities which are reported to the Executive Directors and Board of Directors. The data is uses as part of the strategic planning process.
- Employee Satisfaction Surveys – Advance our Mission
Data Review and Analysis: Annually, an Employee Survey is distributed to all staff to identify areas of satisfaction and areas of needed improvement. The COA survey tool and survey groups (Employees/ Interns, managers/ supervisors and consultants and board) are utilized to collect data and assess improvements and trends. The responses are reviewed by the PQI Committee and Management Team for the purpose of creating improvement goals and objectives related to over-arching themes from employee feedback.
Communication Results & Action Plan: The results are shared with all staff, interns, consultants, and Board of Directors. Directors address areas of needed improvement in the written PQI action Plans.
- Work on Performance and Quality Improvement
The GOAL of Performance and Quality Improvement Planning is to achieve and maintain a level of service quality through present resources in each service area and administrative departments.
The OBJECTIVES that support the goal and give direction to the Performance and Quality Improvement Planning activities are to ensure that:
- All CFK departments and service delivery facilities conduct regular Performance and Quality Improvement reviews that monitor, evaluate and adjust/refine service elements and treatment modalities.
- Maximum utilization and effective management of facilities, finance, and human resources are being measured and evaluated.
- Policies and procedures are effectively designed to evaluate staff performance and identify necessary training programs.
- Mechanisms exist that monitor, evaluate and adjust/refine service delivery based on consumer and/or other stakeholder satisfaction feedback.
- There are efficient means to identify and resolve, in a timely fashion, problems that affect the quality of service to clients.
- A strategic planning process is in place to align short and long-term goals and objectives with the values and mission of the organization.
- The Board of Trustees, Executive Director, Program Directors, employees, consumers, collaborative agencies and other stake-holder groups have appropriate information necessary to understand the status of service delivery and to make changes to improve the quality of services.
- Financial Stability
Data Review & Analysis: The Executive Director, Director of Finance and Management Team have a working relationship with the Board of Directors’ members. Financial reports and other data are reviewed and analyzed monthly by the Management Team and Financial statements are provided to the Board of Directors for their review monthly. The Board of Directors participates in the budget process and approves the final proposed budget in June of each year. Connections for Kids financial audit is reviewed with the Board of Directors in the fall. CFK adheres to financial policies and procedures which render transparent and sound financial reporting to Board members, leadership staff, and service contractors.
Connections for Kids is committed to the continuous monitoring of revenue and expenses and keeping the Board of Directors and the program directors well informed. The following are reports generated weekly: productivity reports, overtime expenditures, payroll analysis, billing procedures and collections are analyzed as are payables/ receivables reports.
Communication Results & Action Plan: Every other month the financial summary reports are presented to the full board, the other months, the Executive Committee reviews them. Data is also used in Strategic Planning, planning budgets, financial information is reported to all directors. Financial information is also a key element of risk reporting, which is included in the annual formal Board Risk Report.
Risk Prevention: Safety and Risk Management
Data Review & Analysis: The Executive Director writes a Risk Prevention and Safety Report, this report is done quarterly and presented to the Board of Directors for review.
The Executive Board reviews these reports before they are reviewed by the larger Board of Directors.
The Executive Board aggregates data related to legal and licensing requirements, insurance and liability including Workers Compensation, serious incident reports, vehicle accidents, medication errors, grievances, client rights, confidentiality issues, technology risk, financial risk, conflict of interest and other risk elements as outlined in COA’s Risk Prevention Standards. The data is analyzed to identify safety and risk trends and methods for improvement and prevention. Revisions in policies and procedures as well as corrective action steps involving training and supervision may be developed and distributed to the Management Team for implementation throughout the agency.
Communication Results & Action Plan: The results are shared with Board of Directors. Directors address areas of needed improvement in the written PQI action Plans.
- Client Grievance Review
Data Collection, Review & Analysis: The Executive Director and Program Directors are the ad hoc committee that meets as a grievance is brought forth in any program. If it is an employee then it will require HR to be on the committee. When a grievance reaches the Executive Director, per policy, a meeting is scheduled to review the grievance, documents are obtained, actions taken and a recommendation is made for change as indicated. The Committee puts recommendations in writing and responds to the person filling the complaint.
Communication Results & Action Plan: The Executive Director includes grievances filled in the Risk Management and Prevention Report to Board of Directors. Directors address areas of needed improvement in the written PQI action Plan and the PQI Coordinator for tracking data.
- Critical Incident review
Data Collection, Review & Analysis: Residential, Community and School incidents reports involving allegations of abuse, neglect, physical restraint or escort, self-injury, physical altercations, community incident or medication error are formally examined no less than weekly by the safety Committee. The Safety Committee includes HR, Safety Trainers, Residential and School supervisors, Training Coordinator, and clinician. A summary is given to the PQI committee for review and the Executive Director includes this in the Risk Management and Prevention Report to the Board.
Communication Results & Action Plan: The results are shared with Board of Directors and PQI committee after Safety reviews to address areas of needed improvement in the written PQI action Plans.
PROGRAM RESULTS/SERVICE DELIVERY QUALITY
Connections for Kids will measure the following dimensions of service quality on a quarterly and/or semi-annual basis. Following data collection and analysis by area/departmental staff, aggregated data is reviewed by departmental PQI teams and by the PQI and Safety Risk management to identify patterns and trends on the following activities:
- Accuracy of case records – Case records are reviewed randomly by supervisor and by peer supervisors to measure errors and compliance. A case record review document is used to aggregate data and identify trends.
- Medication administration – Every supervisor reviews medication logs for accuracy and checks medication cabinets for appropriate security and for expired meds. Results are aggregated and reviewed by departmental PQI teams and by PQI and Safety Risk Management Committee to identify patterns and trends.
- Assessment of services’ use of family conferences, family visitation, and parent involvement – Program staff and supervisors review on a case-by-case basis; aggregated data is reviewed by departmental PQI teams and by PQI and Safety Risk Management to identify patterns and trends.
- Client feedback – Surveys are utilized to collect feedback from consumers regarding their experiences with organizational programs and to solicit their ideas about areas needing improvement, it looks at rights and treatment plans. Responses are aggregated and reviewed by departmental PQI teams and by PQI and Safety Risk Management Committee.
- Stakeholder feedback — Surveys are utilized to collect feedback from stakeholders regarding their experiences with organizational programs and to solicit their ideas about areas needing improvement. Responses are aggregated and reviewed by departmental PQI teams and by PQI.
CLIENT AND PROGRAM OUTCOMES
Case Record Reviews Procedures Connections for Kids conducts case record reviews at least quarterly for each of its services:
The goal for conducting case record reviews is to minimize the risk associated with poorly maintained case records,
- Document the quality of the services being delivered and
- Identify barriers and opportunities for improving service.
- Quarterly reviews of case records evaluate the presence, clarity, continuity and completeness of required documents.
The Review Process:
- Includes a random sample of both open and recently closed cases.
- Uses uniform data collection tools to ensure consistency and permit compassion of data across similar pragmas and services; and
- Maintains objectivity by ensuring that reviewers do not review cases in which they have been directly involved as a service provider or supervisor.
Data Collection, Review & Analysis: Case Record Review is conducted quarterly in Community and School Based Services and Residential programs to analyze and evaluate clarity, content and continuity of open/closed records; to determine if a client’s need and strengths are being assessed appropriately for interventions and compliance for regulations.
Sample Size and Methodology:
Case record reviews are conducted quarterly by supervisors and Directors. CFK will determine the total population of cases and a sample size will be determined by using COA’s recommended sampling guidelines (http://coanet.org/standard/pqi/5/), which account for confidence intervals (precision of results and confidence level (certainty that sample is reflective of overall case records). The higher your confidence level and the narrower your confidence interval, the more confident you may be that the sample will sufficiently identify trends reflective of all case records. The guidelines suggest case reviews for both closed and open cases.
The sample population would be determined using the stratified random sampling methodology. Stratified sampling is a method of sampling from a population which can be partitioned into subpopulations, so you take from each subpopulation or group. The Stratified sampling method would include reviewing files from all programs.
A percentage (based on the annual number of case records in each service) of open and closed cases are selected at random to be reviewed. A case record review document is used for each record that incorporates specific expectations as deemed appropriate to that program. Case review items include but are not limited to:
- Intake paperwork
- Comprehensive Assessment
- Treatment Plan
- Appropriate consents
- Progress Notes, Case notes
- Discharge Summary
The data collected from this process is aggregated to identify trends and implement necessary improvement plans for each program. Summarized results and corrective action plans are documented on the quarterly departmental/program Performance Quality Improvement Report.
Connections for Kids conducts a comprehensive review annually and case reviews quarterly of client charts and case notes every 6 months. The purpose of the review is to evaluate CFK’s programs so each program can receive objective feedback from peers to narrow the practice gap and to improve the quality of services.
Client Outcomes Data
Client Outcomes Data is collected and reported on a quarterly basis by departmental/program PQI teams. This data is used to evaluate the health, safety and welfare of our clients, behavioral changes and changes in functional status. Client Outcomes are measured using the following:
- Number of discharges during review period along with completed records.
- Number of serious incident reports during review period
- Number of residents determined to be dangerous to self or others during review period (including, but not limited to, all incidents of physical aggression, accidents that require professional medical treatment, suicide threat(s) or attempt(s) or other such as self-mutilation or the use of drugs, and/or behavior that results in a referral for a psychiatric assessment and/or hospitalization, serious damage of property, criminal activity, suspected or confirmed sexual activity, and runaways)
- Assessments of use of family visitation and family involvement.
- Evaluation of treatment plan goals
Summarized results and corresponding corrective action plans are documented on the quarterly departmental/program Performance Quality Improvement Report.
ASSESSMENT OF THE EFFECTIVENESS OF THE PQI PROCESS
Recommendations for improvement to the PQI process are made from the PQI and Risk Management Council to the PQI Coordinator, Management Team, and Regional/Area Directors based on the annual agency PQI scorecard and quarterly PQI reports. Changes made to the existing Performance and Quality Improvement Plan are based on these recommendations.