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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  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.		  
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  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.		  
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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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  AGENCY HEAD

See CHIEF EXECUTIVE OFFICER		  
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  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.		  
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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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  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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  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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  INDICATOR

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

A portion or representative percentage of a greater whole.		  
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  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.		  
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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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  TRAINING

Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.		  
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Performance and Quality Improvement
  
Private Org Public Agency  
Administration and Management Narrative (PA-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 agency. 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 agency’s PQI program contributes to good use of limited resources, and achievement of the agency’s strategic and program goals.

Purpose Standard: Performance and Quality Improvement (PA-PQI)

An agency-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 agency’s achievement of the PQI Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

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

  1. how strategic priorities influence the quality improvement process;
  2. how the agency head/senior managers promote a culture of service delivery excellence, customer satisfaction and continual improvement; and
  3. fiscal and staff resources devoted to PQI.

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

3. How do you know that your agency'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 agency’s viability and sustainability.

Attachments:

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

Note:

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

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

    Self-Study Documents On-Site Documents On-Site Activities
PA-PQI 1
Leadership Endorsement of Quality and Performance Values*
  • Long-term or strategic plan (See PA-AM 7.01)
 		  
  • Interview:
  1. Agency head
  2. Senior management
 		  
PA-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 (PA-PQI 2.05)
  • A document or chart that describes PQI structure including committees, work groups, and member lists, as appropriate
 

For Networks:

 
  • Interview:
  1. Agency head
  2. Senior management
  3. PQI personnel
  4. Staff
 		  
PA-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:
  1. PQI personnel
  2. Relevant staff
  3. Other relevant stakeholders
 		  
PA-PQI 4
Analyzing and Reporting Information*
  • Sample reports of aggregated data
  • See PQI documentation provided with the Service Narratives
  • Stakeholder satisfaction survey instrument

For agencies 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 (PA-PQI 4.04)
 
  • Interview:
  1. PQI personnel
  2. Relevant staff
 		  
PA-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 the 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:
  1. PQI personnel
  2. Personnel at all levels
  3. External stakeholder groups
 		  
PA-PQI 6
Staff and Stakeholder Support*
  • PQI information provided to stateholders
  • New personnel orientation materials (PA-PQI 6.02)
 
  • Documentation of PQI orientation received by personnel

For Networks:

  • For subcontracted provider agencies and independent practitioners, provide manual or other document used to orient the staff members of provider agencies to network operations
 
  • Interview:
  1. PQI personnel
  2. 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