	Performance and Quality Improvement

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PQI 4: Analyzing and Reporting Information*

The PQI plan describes how measurable data will be obtained and used on a regular basis to further monitor actual versus desired:

functioning of operations, that influence the organization’s capacity to deliver services;
quality of service delivery;
program results;
client satisfaction; and
client outcomes.

Note: Please see Worksheet: Initial PQI Review, Worksheet: PQI Operational Procedures_ and Model: Performance and Quality Improvement Plan in the Tools Index for additional assistance with this standard.

PQI 4.01

Collection of service delivery information focuses on key quality factors, including:

appropriateness;
effectiveness; and
any or all of the dimensions of quality.

Interpretation: Widely accepted dimensions of service quality include:

accessibility;
availability;
efficiency;
continuity;
safety;
timeliness; and
respectfulness.

Organizations may also choose to include mission-driven quality questions of special interest and importance, for example, cultural competence or workforce issues.

PQI 4.02

The organization aggregates and reviews several sources of information to identify patterns and trends, including:

quarterly case record review reports;
quarterly review of incidents, accidents, and grievances;
customer satisfaction data, usually annually;
customer outcomes data, usually annually; and
management and operations data and reports.

Interpretation: Element (a) is NA for network management entities. See NET 7.04.

Note: Please see Tip Sheet: EAP Stakeholder Surveys in the Tools Index for additional assistance with this standard.

PQI 4.03

Quarterly reviews of case records:

evaluate the presence, clarity, quality and continuity of required documents using a uniform tool to ensure consistency; and
include a random sample of both open and closed cases.

Interpretation: The organization develops a plan and method to review case records objectively, avoiding conflict of interest and including a case record review form that defines and tracks vital documents and elements. Documents included in the case record review may include:

assessments;
service plans;
appropriate consents;
progress or case notes or summaries;
evidence of quarterly case supervision;
relevant signatures;
service outcomes; or
discharge or aftercare plans.

COA recommends reviewing one or two quality issues that assess appropriateness, need for, and effectiveness of services. Criteria for assessing quality issues such as appropriateness, need for, and effectiveness of services can include:

services needed and provided or obtained;
length of service;
changes in status or level of service;
need for continued service;
compliance with mandated review indicators; and
timeframes.

Sampling: For the purpose of identifying trends and patterns COA suggests using the following guidelines based on an annual number of case records. Organizations may choose a different sampling method as long as a rationale is provided.

SAMPLING GUIDELINES TABLE for QUARTERLY CASE RECORD REVIEWS

Annual Case Record Numbers.......................Sample Size

5000 or >...................................................Seek COA Consultation

4,999 – 4,000..............................................20% annually

3,999 – 3,000..............................................30% annually

2,999 – 2,000..............................................30% annually

1,999 – 1,000..............................................35% annually

999 – 500...................................................40% annually

499 - 400...................................................45% annually

399 – 300...................................................45% annually

299 – 200...................................................47% annually

199 – 100...................................................48% annually

Less then 100............................................100% annually

Note: Please see Clarification: Case Record Review Sampling Standards in the Tools Index for additional assistance with this standard.

NA The organization is a network management entity.

PQI 4.04

The organization integrates the findings of external review processes, including licensing reviews, information related to compliance with federal, state, and department requirements, governmental audits, accreditation, and other reviews into its PQI process, where appropriate.

QUICK JUMP TO


	PURPOSE: An organization-wide Performance and Quality Improvement (PQI) program advances efficient, effective service delivery and the achievement of strategic and program goals.

RELATED FILES


	PERFORMANCE A measure of how well an organizational system provides services to consumers. Performance is often based on key indicators, such as rates of service, cost per consumer, degree of satisfaction with services, and extent of consumer access to services.


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	CULTURAL COMPETENCE The degree to which an organization modifies or tailors the system of service delivery to the ethnic, racial, cultural, religious, and national diversity in its service population. Such tailoring includes personnel selection, training and development; assessment; service planning and implementation; and program evaluation and consumer care monitoring. Sometimes referred to as "cultural sensitivity" or "cultural responsiveness." See also SERVICE POPULATION and DEFINED COMMUNITY.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.


	SAMPLE A portion or representative percentage of a greater whole.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	CONFLICT OF INTEREST A conflict between an individual self-interest and the public good. Example: an organization that operates a day treatment program awards a food services contract to a local restaurant that is owned by a governing body member. From a legal standpoint, "conflict of interest" is a term used in connection with fiduciaries and their relationship to matters of private interest or gain to them. When used to suggest disqualification of a fiduciary from performing his or her sworn duty, the term refers to a clash between public interest and private pecuniary interest of the concerned individual.


	CLIENT See service recipient.


	GRIEVANCE See COMPLAINT


	MANAGEMENT See ADMINISTRATION


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	SUPERVISION Assumption of responsibility for directly overseeing and evaluating the work or work products of personnel within an organization. Also includes inspecting the act or process of accomplishing a function or activity.


	SERVICE OUTCOMES The results achieved as a product of interventions measured against the treatment objectives specified in the service plan; the consequences of service that can be demonstrated in some objective manner.


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	CRITERIA Systematically developed, objective, and quantifiable statements used to assess the appropriateness of specific decisions, services, and outcomes.


	INDICATOR A described activity, event, outcome, or benchmark used for measurement in monitoring the quality and outcome(s) of service.


	SAMPLING The process of gathering data on only a portion, or percentage, of pertinent sources of information, such as case or service records, service plans, or other documents. Organizations use sampling methods when a study population or area of study is quite large.


	ACCREDITATION The formal evaluation of an organization against accepted criteria or standards. A professional society, non-governmental organization, or a governmental agency may conduct accreditation activities. A COA-accredited organization has undergone a period of rigorous self-study and is capable of providing programs and services that meet or exceed COA standards.