CONSUMER

The individual, family, group, or community that seeks or receives services.		  
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  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.		  
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  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		  
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  PRACTICE

Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.		  
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  POLICY

A written statement of principles, values, or intent that provides a basis for consistent decision making and guides the actions of staff, management, and board of trustees. A policy is intentionally broad in its language and application. The following is an example of an anti-discrimination policy:

"[Organization Name] shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers, selection of vendors, and provision of services."

In contrast, a procedure is a detailed, step-by-step description of a process. It tells the reader how to do something. Generally, policies are implemented through procedures. For example, the above anti-discrimination policy would require a detailed grievance procedure in order to operationalize it within an organization.

The governing body has the fiduciary responsibility for setting organizational policy. Therefore, policies must be approved and periodically reviewed by the organization's governing body. However, the governing body typically delegates (via policy) the responsibility for policy development to management. In owner-operated for-profit companies, the owner can act as the company's governing body, depending on the company's corporate structure.

In a public agency the responsibility for setting and reviewing policies may belong to the agency's management team, elected officials, another governmental agency, or as is often the case, a combination of the above.

  
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  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.		  
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  PROCEDURES

Written instructions that outline the steps for performing a task(s) or operationalizing an administrative or service delivery process. A procedure can be written as a step-by-step set of instructions or as a narrative description of a process. A procedure tells someone how to do something not just what to do.

Unlike policies, procedures do not need to be approved or reviewed by the governing body, and need not be associated with a specific policy. For example, whereas a broad anti-discrimination policy requires grievance or other procedures in order to be operationalized within an organization, assessment procedures do not require a governing body approved assessment policy.

Note: Procedures are sometimes referred to as administrative policies.

  
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  BACKGROUND CHECK

The review of an individual's personal information typically performed by or at the request of an employer, which may include verification of educational credentials or employment experience, as well as an examination of the individual's criminal records, driving records, licensing records, and civil abuse or neglect history.		  
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  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.		  
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  SAMPLE

A portion or representative percentage of a greater whole.		  
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  VOLUNTEER

An individual who performs services for an organization for civic, charitable, or humanitarian reasons, without promise, expectation, or receipt of compensation for services rendered. Such service must be offered freely and without pressure or coercion, direct or implied, from an employer. If the individual is otherwise employed by the same employer for which s/he volunteers, the individual cannot volunteer to perform the same type of services that s/he is paid to perform as an employee.		  
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  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.		  
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  CLINICAL

The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.		  
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  GRIEVANCE

See COMPLAINT 		 
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  PROTOCOLS

Instruments and procedures used to accomplish a particular goal, activity, or purpose.		  
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  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.		  
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  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.		  
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  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."		  
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  INDEPENDENT CONTRACTOR

An independently employed individual who contracts with an organization to do a piece of work according to his/her own methods and is subject to an employer's control only as to end product or final result of the work, not as to the means whereby it is to be accomplished.		  
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Human Resources Management
  
Private Org Public Agency  
Administration and Management Narrative (HR):
  

UPDATE: TABLE OF EVIDENCE - 12/15/11

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

The Human Resources Administration and Management Narrative should provide the Peer Review Team with a clear, concise description of how your organization's human resources practices advance and sustain your organization’s mission and strategic goals.

Purpose Standard: Human Resources (HR)

A stable, qualified workforce contributes effectively and efficiently to consumer satisfaction and positive service delivery results.

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

1. Describe how your organization manages its human resources: Does your organization have a separate HR department? If not is there a dedicated HR position, or is human resource management the responsibility of an individual with additional non-HR responsibilities? Does your organization outsource some of its human resources functions? If so which ones?

2. Describe any challenges that your organization may have faced with regard to recruiting qualified staff. Has your organization implemented any solutions that have proven effective?

(e.g, there is a shortage of MSW's in your area, or funding cuts have made it difficult to pay for direct service staff with advanced degrees for your foster care program…)

3. Provide 2-3 examples of how your organization has recruited staff that are culturally and ethnically representative of the service population.

4. Describe any challenges that your organization may have faced and any solutions that have proven effective with regard to staff retention.

5. Provide any additional information that would increase the Peer Team’s understanding of how your organization’s human resource practices contribute effectively and efficiently to consumer satisfaction and positive service delivery results.

Attachments:

  1. A list of administrative and management personnel that includes: a) name; b) title; c) degree held and/or other credentials; d) FTE; e) length of service at the organization; and f) time in current position. Please organize the list by department.
  2. An organization chart that includes all the organization’s departments or divisions and programs.
  3. All COA-approved NA Requests.
  4. 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
HR 1
Work Environment*
  • Copies of attorney, administrative agency or court opinions that indicate the organization's personnel practices comply with applicable laws and regulations
  • Discrimination prohibition policy
  • Harassment policy
 
  • Personnel Manual
  • Relevant meeting minutes
  • See nepotism policy
 
  • Interview:
  1. CEO
  2. HR manager
  3. Supervisory personnel
  4. Direct service personnel
  5. Persons served
 		  
HR 2
Human Resources Planning*		  
  • Assessment of workforce needs
  • Analysis of workforce composition
  • EEO plan (as necessary)
  • Documentation of actions taken

For Networks:

  • Annual network-wide analysis report
 
  • Interview:
  1. CEO
  2. HR manager
  3. Supervisory personnel
 		  
HR 3
Recruitment, Selection, and Deployment*
  • Recruitment and selection procedures
  • Enabling legislation/regulations pertaining to background checks
  • Policy and procedures regarding background checks

For Networks:

  • Credentialing and verification procedures
 
  • Job descriptions (CEO, CFO or equivalent, senior managers, and sample of direct service personnel)
  • Personnel records
  • Personnel Manual
  • Legal permissibility regarding the consideration of protected characteristics in personnel recruitment and selection
  • Policy and procedures describing the use of volunteers

For Networks:

  • Individual provider and contractor files, re: required information and verifications of current licenses or credentials (HR 3.06/07)
  • Records of actions to approve practitioners (HR 3.06/07)
 
  • Interview:
  1. CEO
  2. HR manager
  3. Senior managers
  4. Supervisory personnel
  5. Direct service personnel
  6. Students as applicable
  7. Volunteers
  8. Personnel responsible for recruitment and supervision of volunteers

For Networks:

  • Interview:
  1. Committee chair or person in charge of the credentialing process
  2. Managing entity staff members responsible for verifications
  3. Clinical supervisors of selected non-accredited contracted providers to verify provision of supervision
 		  
HR 4
Satisfaction and Retention*
  • Personnel grievance policy and procedures
  • Aggregated personnel satisfaction and retention information
 
  • Meeting minutes and/or schedules
  • Personnel Manual
  • Methods/protocols employed by the organization to obtain personnel participation/input and for providing feedback to personnel about their recommendations/ suggestions
  • Grievance reports
  • Relevant minutes related to retention rates and improvement action, if necessary
 
  • Interview:
  1. CEO
  2. Governing Body
  3. HR manager
  4. Personnel at all levels
 		  
HR 5
Human Resource Practices*
  • Table of Contents for Personnel Manual
 
  • Personnel Manual
  • Personnel records
  • Review and analysis reports (regarding compensation/benefits and compliance with legal requirements)
 
  • Interview:
  1. CEO
  2. Governing Body regarding CEO
  3. HR manager
  4. Supervisory personnel
  5. Personnel at all levels
 		  
HR 6
Performance Review
  • Performance review forms/templates or description of ongoing review process
 
  • Personnel Manual
  • Personnel records
  • Contract policy and procedures
  • Contracts
 
  • Interview:
  1. HR manager
  2. Supervisory personnel
  3. Direct service personnel
  4. Personnel at various levels
  5. Independent contractors
 		  
HR 7
Personnel Records
  • Sample of five job descriptions (of different jobs throughout the organization)
 
  • Personnel records
  • Procedures regarding access to personnel records

For Networks:

  • Review the managing entity's records for independent practitioners
 
  • Interview:
  1. HR manager
  2. Supervisory personnel
  3. Personnel at all levels
 		  
   
 
Fundamental Practice Standards:
  Essential Life and Safety Health and Welfare Client Rights
HR 3.03  HR 1.02