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Continuing Quality Improvement

Quarterly report

The quarterly report format is as follows:

Program Narrative / includes pertinent program activities, personnel changes, review of environmental risks, and external programmatic reviews and audits for the quarter
Statistical Review / examines caseload numbers, consumers served, continuing education, and program specific data
Budget Analysis / notes current status of budget, including areas of concern, funding sources, and availability of funds
QA Indicators / annually, the program directors choose three programmatic areas for improvement or monitoring, and set goals in the form of quality assurance indicators, tracked monthly and reported quarterly
Peer Review / program directors include the peer review committee's report, and respond to any comments
Outcome Measures / annually, Program Directors determine outcome measures to track consumer progress, and report progress quarterly
Incident Reports / Any incident where a person is a risk to self or others, those involving staff and/or consumer injury, any issue regarding medications, those where police are called out, incidents of restraint (seclusion is not utilized), runaway activity, or any other accidents involving persons served requires staff involved to complete an incident report form, which is immediately submitted to the Program Director, and forwarded to the Director of Social Services and the Executive Director. All incidents will be reviewed with staff for recommendations and to complete the Follow Up Incident Report Forms. Reports are also made to funding agents who require this information, and COA when required. All incident report forms and Follow Up Incident Report Forms are attached to the quarterly report. Incident Reports and Follow Up Incident Reports are again reviewed annually.
Consumer Satisfaction--a summary of all consumer satisfaction forms is included.
Consumer Profile Form / identifies demographics and numbers of consumers served.
Response to Previous Report / Every quarter, the CQI committee evaluates each program and responds to CQI data and activities in writing. Catholic Charities uses its CQI process to revise policies, operational procedures, personnel assignments, personnel training, contracts, and programs. Corrective action is then documented in the next quarterly report, or sooner if requested.

Updated: April 2007

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QUALITY ASSURANCE INDICATORS

Program: ______Year: ______

DEFINITION AND MEHHOD OF

QUALITY INDICATOR ACCEPTABLE QUALITYCOLLECTING & REPORTING

______Program/Service

Quality Assurance Indicator Report for ______20 _____

[month]

J / A / S / O / N / D / J / F / M / A / M / J

Updated: April 2007

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CATHOLIC CHARITIES, INC.

CONSUMER PROFILE

______TO ______, 200____

PROGRAM: ______

INDIVIDUAL SERVED:______

CASES SERVED: ______

CRISIS CALLS: ______

WORKSHOP PARTICIPANTS:______

Family Income:

Under $7,500______

$ 7,501 - $15,000______

$15,001 - $20,000______

$21,001 - $25,000______

$25,001 - $30,000______

$30,001 - $35,000______

$35,001 - $40,000______

$40,001 - $50,000______

$50,001 and over______

NA______

Sex:

Female: ______Male: ______Total______

Age:

Under 5______

5 – 17 years______

18 – 24 years______

25 – 64 years______

64 and over______

Total______

PROGRAM: ______

Racial/Ethnic Composition:

Asian______

Black______

Caucasian______

Hispanic______

Native American______

Other______

Total______

Major Language Groups:

English______

Spanish______

Vietnamese______

Sudanese______

Other______

Total______

Major Religious Groups

Catholic______

Jewish______

Islamic______

Protestant______

Buddhist______

Other______

Total______

Disabled

Physically disabled:______

Hearing impaired______

Total______

UTILIZATION REVIEW OF RECORDS

Record Number: ______

Program: ______

Date of Review: ______

Reviewed by: ______

Review each record focusing on [1] the appropriateness and effectiveness of service, [2] the necessity and cost-effectiveness of continued service. Use a {Y] or [N] to indicate your assessment of compliance on each point. Include comments on any point you feel needs explanation or development.

  1. ______Is the service offered appropriate for this consumer?

Comments: ______

______

  1. ______Is the service provided effective?

Comments: ______

______

  1. ______Is the service provided necessary?

Comments: ______

______

4.______Is the service provided cost-effective?

Comments: ______

______

Updated: April 2007