	Performance and Quality Improvement

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PQI 2: The Foundation for Broad Use of PQI*

The infrastructure that supports performance and quality improvement is sufficient to identify organization-wide issues, implement solutions that improve overall efficiency, and promote accessible, effective services in all regions and sites.

Note: Please see Model: Performance and Quality Improvement Plan and Chart: Sample_PQI Committee Structure in the Tools Index for additional assistance with this standard.

PQI 2.01

The PQI program takes into account all of the organization’s regions and sites, and all individuals and families served.

Interpretation: Every organization, regardless of size, should implement PQI in a manner that is consistent with its service philosophy to increase support for and reduce barriers to implementation of the PQI program. This guidance could be of particular value for an organization making broad, deep change in service delivery, changing rapidly, or operating in a widely dispersed service delivery system.

PQI 2.02

A PQI plan which operationalizes the organization's PQI program:

assigns responsibility for implementation and coordination of PQI activities and technical assistance;
sets forth the purpose and scope of PQI activities;
establishes a periodic review of essential management and service delivery processes consistent with quality priorities;
outlines methods and timeframes for monitoring and reporting results; and
includes provision for an assessment of the PQI program’s utility, including any barriers to and supports for implementation.

Interpretation: It is recommended that organizations establish a separate, independent PQI committee structure; however, it is acceptable to integrate PQI responsibilities into an organization's existing decision-making and support structure, e.g., management teams, standing committees, or task forces.

Interpretation: The PQI plan provides an overview of the organization's PQI program, as well as procedures for operationalizing specific aspects of the program, e.g., case record reviews and data collection procedures. Organizations may choose to maintain PQI operational procedures separately in a PQI Procedures Manual.

Note: Please see Worksheet: PQI Operational Procedures in the Tools Index for additional assistance with this standard.

PQI 2.03

The organization in its PQI plan defines its stakeholders and specifies how different stakeholder groups will be involved in the PQI process.

Interpretation: Stakeholder involvement is fundamental to a well-designed, useful PQI process. Examples of potential stakeholders include:

service recipients, including families;
employees;
volunteers;
consultants;
citizen review and advisory groups;
consumer advocates;
funders; and
contractors and partners.

For networks, contracts with service provider organizations and independent providers include the requirement that they participate in the network's performance and quality improvement activities, including utilization management processes.

PQI 2.04

The organization describes the steps in an improvement cycle, including determining if an implemented change is an improvement.

Note: Please see Chart: Improvement Cycle in the Tools Index for additional assistance with this standard.

PQI 2.05

Staff responsible for PQI are qualified by education and experience to:

engage people throughout the organization;
systematically collect information and analyze data; and
communicate results and recommendations to various key audiences.

Interpretation: Organizations that assign primary PQI responsibility to a staff member without quality improvement, performance measurement, or program evaluation training and experience should anticipate supporting this individual through professional development, training, and networking opportunities.

Responsibility for PQI may be shared among different staff members or committees.

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.


	SERVICE PHILOSOPHY The theoretical framework that describes and explains an organization's approach to service.


	MONITORING An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance.


	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.


	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.


	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.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	MANAGEMENT See ADMINISTRATION


	EMPLOYEE Paid member of an organization. Foster parents are not considered employees and are specifically referenced in relevant standards.


	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.


	CONSULTANT A person who provides specialized or technical advice or services to an organization for specific purposes on a contractual or fee basis, or who provides such services as a volunteer with an agreement to provide services on a pro bono basis.


	ADVISORY GROUP A group of individuals selected by an organization's governing body or management who possess unique skills and/or knowledge and whose role is to make recommendations, provide information, and/or share input from stakeholders. Advisory groups do not have formal governance authority or responsibilities. Advisory groups can be ongoing or ad hoc.


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


	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."


	EVALUATION The review and assessment of organizational operations, programs and services.


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