COA - Council On Accreditation

	Performance and Quality Improvement

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Administration and Management Narrative (PQI):

UPDATE: TABLE OF EVIDENCE - 05/01/11

The Administration and Management Narrative provides an overview of key practices that contribute to the performance and productivity of your organization. This Narrative supports, but should not duplicate, evidence provided elsewhere in your self-study.

The Performance and Quality Improvement Administration and Management Narrative should provide the Peer Review Team with a clear concise description of how your organization’s PQI program contributes to good use of limited resources, and achievement of the organization’s strategic and program goals.

Purpose Standard: Performance and Quality Improvement (PQI)

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

Provide responses to the following questions that address your organization’s achievement of the PQI Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

1. Explain how your organization defines and represents a culture that values quality, including:

how strategic priorities influence the quality improvement process;
how the CEO/Executive Director and senior managers promote a culture of service delivery excellence, customer satisfaction and continual improvement; and
fiscal and staff resources devoted to PQI.

2. How would your organization describe its progress/status with implementing the PQI standards?

3. How do you know that your organization's quality improvement process is working? Cite 2-3 examples of improvements that have been made in response to data/information generated by your PQI program. Include at least one example of a service-delivery/client-related improvement and at least one example of an operations/management improvement.

4. Provide any additional details that would increase the Peer Team’s understanding of how your PQI program is increasing the organization’s viability and sustainability.

Attachments:

Completed List of Survey Recipients Form (See Stakeholder Survey Instructions).
Completed Survey Distribution Totals Form.
All COA-approved NA Requests.
A list of all NAs applicable to your organization provided within the standards.

Note:

Organizations being accredited for the first time: Please provide information for the last year.

Organizations being reaccredited: Please provide information for the period since the last accreditation review.


	Self-Study Documents	On-Site Documents	On-Site Activities
PQI 1 Leadership Endorsement of Quality and Performance Values*	Long-term or strategic plan (See GOV 6.03)	Governing Body minutes	Interview: Governance Chair Advisory/Governing Body members CEO Senior management
PQI 2 The Foundation for Broad Use of PQI*	PQI plan Short term/annual plan(s) Job description of primary personnel assigned to PQI coordinating responsibilities (PQI 2.05) A document or chart that describes PQI structure including committees, work groups, and member lists, as appropriate	For Networks: Contracts with network service providers	Interview: CEO Senior management PQI personnel Staff
PQI 3 Support for Performance and Outcomes Measurement*	Description of what is being measured; including outcomes, outputs, indicators, and tools and instruments. See PQI documentation provided with the Service Narratives For Networks: Network performance measures	PQI committee minutes or other documentation of stakeholder involvement in choice of outcomes, indicators, etc.	Interview: PQI personnel Relevant staff Other relevant stakeholders
PQI 4 Analyzing and Reporting Information*	Sample reports of aggregated data See PQI documentation provided with the Service Narratives Stakeholder satisfaction survey instrument For organizations seeking re-accreditation: Pre-Commission Review Report (PCR) Final Accreditation Report (FAR) Maintenance of Accreditation (MOA) Reports for the three most recent years	PQI committees/work group minutes for analyzing PQI information Regulatory/licensing or other external reviews/reports (PQI 4.04)	Interview: PQI personnel Relevant staff
PQI 5 Use and Communication of Quality Information to Make Improvements*	Annual performance score card, reports of gains made against goals, or other summary documents or reports provided to internal and external stakeholders See PQI documentation provided with Service Narratives	Evidence of improvements made from the analysis and use of PQI data, e.g., revised procedures, training conducted, or implementation of an improvement plan Board minutes	Interview: PQI personnel Personnel at all levels External stakeholder groups
PQI 6 Staff and Stakeholder Support*	PQI information provided to stakeholders New personnel orientation materials (PQI 6.02)	Documentation of PQI orientation received by personnel For Networks: For subcontracted provider organizations and independent practioners, provide manual or other document used to orient the staff members of provider organizations to network operations	Interview: PQI personnel Personnel at all levels For Networks: For network subcontracted providers, interviews with those participating in the network-level PQI activities

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights

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.


	GOVERNING BODY A person or persons with the legal authority and responsibility to set policy and oversee the operations of an organization. Generally, the governing body is a group, such as a board of directors or board of trustees. While the exact responsibilities of the governing body depend on the nature and character of the organization, the governing body has minimum fiduciary responsibilities to the organization set by statute, regulation, and case law, and typically assume responsibilities for long term planning, risk management, and evaluation and effectiveness of management.


	SENIOR MANAGEMENT Employees who assume administrative oversight for the organization's programs. Senior management positions may include vice presidents, chief operating officers, assistant commissioners, directors, or other positions that involve management of program administration. The term does not include supervisors of direct service workers.


	JOB DESCRIPTION Explicit obligations and specific tasks required of personnel as a condition of employment. Such descriptions are in writing and may include educational, experiential, and skill requirements associated with the job.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	CONTRACT A formal written agreement between two or more parties that specifies the services, space, or products to be provided in exchange for some form of compensation. Also known as "purchase of service arrangement."


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


	STAKEHOLDER Any person, group, or organization that has a vested interest in the services provided by the organization. Examples: clients, consumers, personnel, funding organizations, referral organizations, vendors, and governmental bodies.


	SAMPLE A portion or representative percentage of a greater whole.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	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.