COA - Council On Accreditation

	Performance and Quality Improvement Program

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Introduction

COA's Performance and Quality Improvement (PQI) standards encourage organizations to use data to identify areas of needed improvement and implement improvement plans in support of achieving performance targets, program goals, client satisfaction, and positive client outcomes.

A hallmark of COA’s comprehensive approach to PQI is the promotion of a broad-based, organization-wide process inclusive of staff and stakeholders, as a vital, necessary management tool. The PQI standards reflect what experts from national and state reform efforts with multiple accountability systems know about what it takes to start, and maintain, a useful quality improvement program. Taken together, the standards include practices that counter the tendency of organizations to place responsibility for quality improvement and results in one or a few individuals. As such, the standards recognize the “top to bottom” infrastructure that supports a successful program.

COA's PQI standards provide significant new guidance directed at the role of leadership, support for measurement, use and communication of improvement results, and staff training and support practices that reach the full organization. The standards promote wide support and full participation in the improvement process.

Update: Added Note - 04/01/09

Added Note

Interpretation: Organizations use a variety of terms for this work including Quality Improvement, Continuous Quality Improvement, and combinations of this and similar language. While the language chosen by COA intentionally highlights both performance and quality, certain terminology may be more comfortable for and familiar to the organization. The standards are intended to accommodate the organization’s preferred language and not to prescribe particular techniques; for example, a root cause analysis, as is sometimes associated with Performance Improvement (PI), may or may not be a tool the organization chooses.

Interpretation: Network management entities conduct quality improvement activities related to network performance and systems level services.

Note: This section of standards (PQI-OLD) should not be used by organizations whose accreditation agreements have been received by COA on or following April 1, 2009. Those organizations should refer to COA's newly revised Performance and Quality Improvement standards (PQI). Organizations that have begun their process using this section of standards may continue to do so, or can contact their COA Accreditation Coordinator if they are interested in using the new PQI standards.


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


	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.


	ACCOUNTABILITY The extent to which an organization is answerable for its processes and outcomes to a variety of relevant stakeholders including: consumers, community representatives, governing bodies, and governmental regulators.


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


	LEADERSHIP A nonprofit organization's leadership consists of its governing body, chief executive officer, and may also include its senior management. In a public agency the term refers to the agency head and administration team. The term "leadership" is not generally applied to for-profit organizations. With respect to COA standards, in for-profit organizations the term leadership applies to the owner and board of directors if one exists.


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


	PRESCRIBE To issue lawful order from a practitioner for the preparation and administration of a drug or device for a specific client that is communicated directly to a pharmacist in a licensed pharmacy.


	CLIENT See service recipient.


	MANAGEMENT See ADMINISTRATION


	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.