Performance Quality Improvement (PQI) Philosophy:
The Catholic Charities Diocese of Springfield in Illinois' Performance Quality Improvement Plan (PQI) is an integrated and ongoing system of monitoring and evaluating the agency’s programmatic and administrative functions. Through the PQI, the Agency's leadership sets forth quality expectations and broad goals that merit ongoing monitoring. Catholic Charities leadership promotes a culture that values service quality and ongoing efforts by the full organization, its partners, and contractors to achieve strong performance, program goals, and positive results for our clients.
Catholic Charities recognizes that in order for the PQI to be successful, the full endorsement of the Executive Director is integral in terms of:
- promoting a culture of excellence and quality improvement;
- implementation of an organization wide PQI framework;
- constructive use of data to promote a high-learning, high performing, results oriented agency;
- the involvement of a wide range of managers and staff in the PQI process;
- inclusion of external stakeholder and community members;
- Annual Agency Report regarding the gains made in terms of goals.
The PQI serves as the “vehicle” for maintaining the agency in a continuous quality improvement environment. The PQI seeks, through an inclusive and team-oriented approach, to achieve three major tasks:
- the systematic and continuous evaluation of service effectiveness and efficiency and the relationship to agency planning;
- the establishment of quality expectations and service outcomes;
- the identification and remediation of deficiencies indicated through various review processes and stakeholder feedback.
Another primary activity of the PQI Councils involves the process of peer review. Peer review is a function of the Utilization Review Council requiring cooperation with programmatic QI Councils and site personnel. The PQI requires the agency to allocate the necessary resources to conduct effective peer review on a continuous basis. In order to minimize duplication of effort, the incorporation of traditional record review information into peer review assessments is considered. Under the direction of the Utilization Review Council facilitator, who is the Director of Family Services and Quality Improvement, Catholic Charities adheres to COA guidelines regarding the number of case file reviews that need to be reviewed annually. Research indicates that the number of files reviewed in this chart will result in confidence level of 95%, with a 5% margin of error. Area Office's should conduct Peer Reviews quarterly, administration will randomly select the files to be reviewed.
Peer review teams will consist of at least three members designated by the Program Supervisor or Area Director in individual Area Offices. The other peer reviewers are either programmatic QI Council members or volunteer site personnel. Individual Peer Reviewers cannot review their own files, or if they are a supervisor, review the files of their staff. Area Directors from the agency’s decentralized sites support the peer review process by encouraging participation from staff members. The URC member participating in peer review is responsible for coordinating and conducting the assigned reviews according to PQI standards.
Finally, in instances where a peer review involves a DCFS foster child, Medicaid Rule 132 requires that the files be reviewed by a QMHP, and that the review involves an assessment of the appropriateness of services, the intensity/ level of services and the needed for continued services.
Catholic Charities recognizes the importance of involving stakeholders in our PQI plan. Through the survey process, Catholic Charities regularly solicits the opinions, criticisms and recommendations from stakeholders. Stakeholders include but are not limited to:
• clients (including families);
• advisory boards;
• consumer advocates;
• contractors and partners.
The information gleaned through the stakeholder survey process is reviewed and assessed through both the traditional management and PQI processes. Through this review and evaluation process, recommendations for changing the agencies policies and practices through the traditional management structure and QI Councils. Refer to Section IV for further detail of this process.
There is a great deal of discussion regarding the development of quantified performance outcomes in the social work field. A primary activity of the QI Councils is the establishment and modification of outcome measures. The agency’s PQI possesses a bias towards simplifying outcome development to target and concise indicators. This approach emphasizes an efficient approach to data collection in order to maximize the limited availability of resources. Programmatic indicators Table 4 are measurements of:
• Service efficiency
• Service effectiveness
• Service volume
• Program financial status
• Client grievance activity
• Program satisfaction
Indicators are presented through various sources related to these areas. Table 5 the Catholic Charities Performance Report provides an overview of these sources. The programmatic QI Councils establish quantified “benchmarks”, or statistical targets, which indicate the councils desired best practice standards. The Senior Management Team approves programmatic benchmarks.
Administrative indicators are measurements of:
• Risk Management activity
• Personnel activity
• Agency financial performance
• Grievance activity
• Agency satisfaction
Indicators are presented through various sources related to these areas. The administrative QI Councils establish quantified benchmarks that indicate the councils’ desired best practice standards. The Executive Team approves administrative benchmarks.
Indicators of satisfaction for all QI Councils is generated from surveys distributed to clients, employees, volunteers, boards and other vested stakeholder groups. These surveys measure “sub” categories of satisfaction. Participation in surveying is the primary mechanism in providing an open opportunity to these groups for input into agency and program planning and direction. Section V provides further discussions regarding the agency’s survey processes. Again, it is important to note that the ability to strengthen and expand the use of indicators is dependent upon the technological and resource capacity of the agency.
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The agency’s PQI information process is characterized by eight distinct stages which constitute an organizational information dynamic that is perpetual and continuous process allows Catholic Charities senior management and board to:
• review results;
• identify areas of needed improvement;
• implement and evaluate improvements on a both on small and broad scale;
• modify implemented improvements as needed;
• keep staff informed and involved throughout the cycle.
This design is instituted for the sole purpose of improving the administrative and programmatic functions of the agency. Therefore the agency has implemented the following eight step process in terms of evaluating whether implemented charges have resulted in improvement:
Stage 1 — Continuous information is generated from clients, programs, stakeholders and employees relevant to the daily operations of the agency’s administration and programs. This information is both incidental and solicited. Additional information is generated through the surveying, which is a function of the agency’s evaluation process.
Stage 2 — Information from Stage 1 is reviewed by the agency’s traditional oversight participants and review processes as well as QI personnel.
Stage 3 — Information from Stage 2 is presented to the Executive Team for decision making and appropriate dissemination to QI Councils. Information designated for QI Councils is “screened” by the Executive Team and QI personnel to insure confidentiality and conflict of interest safeguards.
Stage 4 — QI Councils evaluate information from Stage 3 and make specific quality improvement recommendations for action to the Director of Quality Control.
Stage 5 — Director of Quality Control processes and formats Stage 4 information from QI Councils and reports to the agency’s senior management team. Director of Quality Control reports back to the QI Councils on action taken by the agency on specific recommendations.
Stage 6 — Agency’s Senior Management Team (SMT) reviews information from Stage 5 and determines the validity and viability of the QI Council recommendations. This process allows Senior Management to identify areas of needed improvement, set improvement activity priorities and manage their operations and programs. The SMT, with approval from the Executive Team, authorizes policy and procedure revision, program modifications and proposed QI Council special projects. The SMT reports back to the Director of Quality Control on specific actions taken regarding QI Council recommendations. Through this process, the Agency ensures that findings based on improvement efforts are disseminated to personnel and stakeholders and are used to improve programs and practices
Stage 7-The Agency's corporate board reviews the performance and outcome data to identify strengths and areas of positive practice and provide feedback about area of needed improvement.
Stage 8 — Based on the review and recommendations from Stage 6 and 7 needed improvements are incorporated into the agency’s oversight, evaluation or planning processes, thereby impacting the daily operations of the agency’s administration and programs. The Agency's leadership, stakeholders, board members and PQI staff communicate with staff and stakeholders the information regarding the Agency's achievements relative to desired outcomes, indicators and benchmarks. This stage significantly influences the information generated in Stage 1, thus completing the PQI information loop.
The scope of the PQI involves processes that ensure the agency is continually evaluating its services and performance in an effort to improve services to our clients. This objective is achieved through the establishment of several initiatives including:
1. Quality Improvement Councils
2 Peer Review
3. Established Programmatic & Administrative Outcomes
4 Systematic and Inclusive Agency Planning
5. Collection and Evaluation of Quantified Agency Data
6. Performance and Quality Improvement (PQI) Training
These components provide the foundation for the existence of agency wide continuous quality improvement within Catholic Charities. An in-depth discussion and outline for the establishment and monitoring of these components is provided in this document.