FAMILY SERVICE OPERATIONS
& SUBSIDIARIES
Family Service Association
Family Service Development
Family Service Enterprise

SECTION I

FAMILY SERVICE OPERATIONS

GOVERNANCE

PART N: CONTINUOUS QUALITY IMPROVEMENT

PART N

CONTINUOUS QUALITY IMPROVEMENT

TABLE OF CONTENTS

Policy Number

Continuous Quality Improvement Overview...... 1

Utilization Review & Quality Assurance Overview...... 2

Levels of Review in Utilization Review & Quality Assurance...... 3

Organization of Utilization Review & Quality Assurance Committees...... 4

Utilization Review & Quality Assurance Procedures...... 5

Quality Assurance Mechanisms...... 6

Quality Improvement Committee...... 7

Satisfaction Surveys...... 8

Measurement of Client Outcomes...... 9

Quality of Life Committee...... 10

Cultural Competence Committee...... 11

Consumer Mental Health Advisory Committees...... 12

Management Responsibilities...... 13

Unusual Incident Reporting...... 14

Infection Control Committee...... 15

PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 1

CONTINUOUS QUALITY IMPROVEMENT OVERVIEW

The Agency shall maintain a process of Continuous Quality Improvement, which has been sanctioned by the President/CEO and the Board of Directors. This process will continually change and adapt to the needs of the Agency, which includes services to clients and staffing issues. The Agency will strive to:

1.Prioritize its most important services (i.e. systems, processes, or activities);

2.Identify its most important customers (stakeholders);

3.Identify the unmet needs and expectation of these customers.

Consequently, the degree to which customers (staff and consumers, i.e. stakeholders) find the important services effective, timely, efficient, (or otherwise) shall be clearly documented and current.

Of those identified areas, highest priority shall be given to those processes or systems, which significantly affect one or more of the following:

1.The mission, vision, and strategic plans of the Agency;

2.The rights of consumers and their families;

3.Consumer outcomes;

4.Consumer (family, staff, referring Agency) satisfaction;

5.Unmet needs of clients and staff (i.e. stakeholders);

6.Issues of high risk to consumers or staff (i.e. feedback mechanisms);

7.Short and longterm planning.

The above tasks are accomplished through a variety of mechanisms that include the

Utilization Review/Quality Assurance Committee, Quality Improvement Committee,

Quality of Life Committee, Client Satisfaction Surveys, Staff Surveys, Board Surveys,

Surveys of Community Organizations, Quality Improvement Suggestions, and direct interviews with clients and staff.

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 2 of 2

CONTINUOUS QUALITY IMPROVEMENT OVERVIEW

The President/CEO of the Agency has appointed the Vice President to serve as the CQI Coordinator. The Vice President will serve as the Chairperson for the Utilization Review, Quality Assurance, and Quality Improvement Committees, and will be the link for information, concerns, and initiatives to the Agency's Middle Management and Senior Management teams. All client, staff, Board and community organization surveys, Quality Improvement Suggestions, Incident Reports, and other relevant information will be received and reviewed by the Vice President, who will forward the material to the appropriate committee or management team as appropriate.

The Continuous Quality Improvement process will involve staff from all levels of service within the organization, volunteers, and clients, when appropriate and will be reviewed annually.

Effective Date: 3/99

Revised Date:9/99

Revised Date:3/03

Revised Date: 9/09

Revised Date:07/13
PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 2

UTILIZATION REVIEW AND QUALITY ASSURANCE OVERVIEW

The Agency will conduct procedures necessary to maintain the highest possible quality and efficiency of service to clients.

Procedure:

1.The Utilization Review & Quality Assurance Plan and Policy was developed in accordance with the rules and regulations of Section 10:37-6-12 of the Rules and Regulations Governing Community Mental Health Services and State Aide under the Community Mental Health Services Act (NJSA 30:9A) and Professional Standards Review Organization 92-603 Section 294 (f).

2.The Utilization Review & Quality Assurance Plan is applicable to all cases that are registered with the Agency's clinical programs. All new programs developed by the Agency shall be reviewed to determine if their clinical components should be reviewed by Utilization Review & Quality Assurance Committee.

3.Goals:

  1. To provide and maintain professional quality client service, continuity of care and increase the effectiveness of the utilization of the Agency's services.
  1. To foster and encourage the maintenance of professional quality service.
  1. To insure the effective utilization of the Agency's staff, programs, and resources in the delivery of services.
  1. To review client charts in order to assess that Agency's direct services are provided with the level-of-care appropriate to client's personal needs and functional abilities.
  1. To assure quick response to client's needs.
  1. To assure appropriateness of service within the Agency or make referral elsewhere.
  1. To assure accuracy of diagnosis, assessments and adequacy of treatment.

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 2 of 2

UTILIZATION REVIEW AND QUALITY ASSURANCE OVERVIEW

  1. To assure that client understands treatment goals and plans.
  1. To reassess periodically individual service plans to determine that continued services are justified.
  1. To assure appropriateness of the length of service.
  1. To review on an on-going basis adequacy of services and to determine that client receives as many services as needed for problem solution.
  2. To review and reassess treatment plans.
  1. To evaluate progress toward goal achievement.
  1. To review medication.
  1. To review appropriateness of client termination.
  1. To review and evaluate utilization of Agency's delivery of direct service.
  1. To review standards of service developed for each program element.
  1. To review and adopt length of stay guidelines for each program element.
  1. To document strengths and weaknesses in delivery of service.
  1. To recommend, if appropriate, a course of action to correct chart deficiencies.

Effective Date1/91

Revised Date: 1/95

Revised Date: 3/99

Revised Date:3/03

PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 3

LEVELS OF REVIEW IN UTILIZATION REVIEW AND QUALITY ASSURANCE

The Agency will monitor utilization of services and quality assurance procedures at various levels.

Procedures:

1.Peers Review - Each program element has its own method of peer review in the form of Unit staffing or Unit teams. These reviews are based on Unit needs and reflect the program element's commitment to better service. These staffing and teams are noted in the chart.

2.Supervisory Review - Each supervisor holds individual sessions with their workers concerning worker's clients. In addition, every 90 days supervisors are required to review charts and make written notation in record attesting to the occurrence of the review. After one-year, reviews are required every six months. Upon review, any updates that are required are assigned to staff, by the supervisor. A new admission will be reviewed by supervisor within three contacts in Outpatient-type programs, or three weeks in-group programs (exception being 10 days in adolescent partial care). All inappropriate admissions are reviewed by the supervisor. Statistical reports of reviews are to be sent to the Utilization Review Committee. Supervisory Reviews will also include all cases exceeding the Program's Length of Stay criteria by 25%.

3.Medical Director's Review - Reviews conducted by the Utilization Review and Quality Assurance Committee. These reviews are conducted on a monthly basis to include an average of 10% of the Agency's caseload. A sampling may include:

  1. a recent intake;
  2. an active case;
  3. recently terminated cases; or
  4. Any case exceeding length of stay criteria by 50%.

Reviewed cases are selected randomly and proportionate to program size based upon number of cases seen in the previous fiscal year.

4.Clerical Review of Charts - Clerical section shall review charts upon opening and closing to determine if record keeping procedures (i.e., forms and reviews) are complete. No charts shall have been deemed "complete" unless all elements are included.

Effective Date: 1/91

Revised Date: 1/95

Revised Date: 3/99

Revised Date:3/03

PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 4

ORGANIZATION OF UTILIZATION REVIEW ANDQUALITY ASSURANCE

COMMITTEES

The Utilization Review and Quality Assurance Committees will be established by the following requirements.

Procedure:

1.Authority

  1. The Utilization Review and Quality Assurance Committees have the authority to make recommendations to therapists, supervisors, Senior Staff and the President/CEO.
  1. The Utilization Review and Quality Assurance Committees are empowered by the President/CEO of the Agency via the Board of Directors and are directly responsible to him/her.

2.Composition

  1. The Utilization Review & Quality Assurance Committee shall be appointed by the Vice President.
  1. The Committees shall consist of representatives of all clinical programs, the Medical Director and Vice President.
  1. The membership shall include at least one each of the following:
  1. Psychiatrist (Medical Director)
  2. Social Worker in direct service, and
  3. Program Manager Supervisor
  1. The Vice Presidentand the Medical Director are permanent appointees.
  1. All other members shall be appointed to yearly terms.
  1. The Vice Presidentshall act as Chairperson.

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 2 of 2

ORGANIZATION OF UTILIZATION REVIEW AND QUALITY ASSURANCE

COMMITTEES

  1. All voting members of the Committees are required to have at least a Bachelors' Degree in their field with expertise in assessment and treatment as noted by Program Manager Nomination.
  1. Some Quality Assurance functions may be performed by the Quality Improvement Committee with proper documentation of issues discussed.

3.Meetings

  1. The Committees shall generally meet a minimum of once a month to conduct business.
  1. A simple majority constitutes a quorum to conduct business.
  1. Minutes of the meetings will be maintained separately from charts and should not include any client's name.
  1. Minutes should include statistical information as well as findings of review.

Effective Date:1/91

Revised Date: 1/95

Revised Date: 3/99

Revised Date:3/03

Revised Date:07/13

PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 5

UTILIZATION REVIEW AND QUALITY ASSURANCE PROCEDURES

The Committee will function in accord with the following procedures.

Procedure:

1.The Vice Presidentor designee shall randomly select charts as described and prepare them for the Committee.

2.Committee members shall review the file and complete the attached Utilization Review & Quality Assurance worksheet and make necessary comments.

3.Results of initial review are presented to the full Committee and discussed.

4.Any incomplete charts are forwarded for remediation.

5.The clerical staff collects all charts and the member score sheets.

6.The clerical staff will give the completed notification of chart reviews to the chairman for his/her signature.

7.After the chairman returns all signed reviews, the clerical staff makes two copies and distributes one to the therapist and one to his/her supervisor. The original copy is kept in the UR cabinet.

Effective Date:1/91

Revised Date: 1/95

Revised Date: 3/99

Revised Date:3/03

Revised Date:8/09

Revised Date:07/13
PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 6

QUALITY ASSURANCE MECHANISMS

The function of quality assurance will be carried out by the administrative staff or the Utilization Review/Quality Assurance Committee as appropriate.

Procedure:

1.Authority

  1. The Utilization Review and Quality Assurance Committee have the authority to make recommendations to therapists, supervisors, Vice President and the President/CEO of the Agency.
  1. The Utilization Review and Quality Assurance Committee are empowered by the President/CEO of the Agency via the Board of Directors and are directly responsible to him/her.

2.Problem Identification:

  1. Establishment of priorities and problem resolution
  1. Using existing monitoring mechanisms of clinical performance, committee, department and unit activities, exceptions to pre-established clinically valid criteria, objectives and standards will be reported to the Quality Improvement Committee, or administrative staff, as appropriate. The President will determine the appropriate body in consultation with the Vice President.
  1. Problems, which have been identified and solved, should be reported as well as unresolved identified problems. Establishment of priorities for problem resolution shall be related to the degree of impact on client care that can be expected should the problem remain unresolved.
  1. Data sources to identify problems or matters meriting study may include, but are not limited to:
  1. client's record; to ensure appropriateness of treatment
  2. monitoring activities of the professional and support staff;
  3. appointments not kept and cancellations;
  4. service terminations;
  5. peer review;
  6. incident reports relating to both individual safety and clinical care;
  7. patient/client's evaluation of service;
  8. review of high risk/difficult cases

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 2 of 3

QUALITY ASSURANCE MECHANISMS

  1. review of medication regime;
  2. specific process oriented/outcome oriented studies;
  3. review of Agencyprotocols, which can affect client care;
  4. data obtained from staff interviews and observations of unit activities;
  5. financial data;
  6. diagnostic clinical reports of services rendered;
  7. New Jersey State Department of Health & Human Services Statistics;
  8. Routine and special data and reports.
  9. statistical MIS computer reports

3.Once an actual or potential unresolved problem is identified, the Committee will assess related information. Whatever time frames for review and whatever quality assessment activities are used, representative care or adequate sampling provided by all clinical departments, disciplines, and individual clinicians shall be evaluated using objective criteria.

A.Specific, objective, and measurable criteria that related to essential or critical aspects of client care, which are approved by the staff, both professional and medical, shall be used to assess problems, and measure the compliance with achievable goals.

B.Structure, process and outcome criteria, standards of practice of professional organizations, or criteria developed within the Agency may be utilized as appropriate in determining the cause and scope of the problem.

4.Proposals for problem resolution

  1. Corrective Action - Appropriate action shall be taken to eliminate or minimize the identified problem. Such action may include:
  1. education and training;
  2. implementation of new or revised policies and procedures;
  3. staffing changes;
  4. equipment and facility changes;
  5. Recommendation will be made to the Board by the President as appropriate.

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 3 of 3

QUALITY ASSURANCE MECHANISMS

  1. Follow-up - Periodic monitoring of results of proposals for corrective actions shall be determined by the Utilization Review and Quality Assurance Committee or administrative staff to insure that identified problems have been eliminated or satisfactorily minimized.

Effective Date:1/91

Revised Date: 1/95

Revised Date: 3/99

Revised Date:3/03

Revised Date:07/13

PART N: CONTINUOUS QUALITY IMPROVEMENTPolicy No. 7

QUALITY IMPROVEMENT COMMITTEE

At a UR/QA meeting on 6/18/98, and under the direction of the President/CEO, it was determined that the Agency shall maintain a Quality Improvement Committee separate and apart from the Utilization Review and Quality Assurance Committee.

Procedure:

1.Statement of Purpose

  1. As part of Family Service Association's commitment for quality services to consumers and staff in the Agency, the formation of an Agency Quality Improvement Committee which has been charged with the responsibility for planning, designing, measuring, assessing, improving and maintaining a program in which optimal standards of client care and staff performance are continuously sought.
  1. Family Service Association believes in an organizational culture where all levels of staff in all programs and disciplines are constantly motivated to improve identifiable elements of the services provided in the Agency. All staff shall be actively and continuously engaged in the pursuits of excellence and quality. The Quality Improvement Committee's focus is on:
  1. emphasizing quality improvement on Agency systems, rather than on individual staff members;
  2. educating staff that the delivery of quality care to consumers of Agency services cannot take place without also delivering quality services to one another (emphasizing internal and well as external customers);
  3. Enabling supervisors to mentor, coach and facilitate staff.
  1. The Family Service Association Quality Improvement Committee has integrated the principles of Continuous Quality Improvement, which are intended to provide a comprehensive mechanism for improving all of the Agency's services. Its purpose is to:
  1. focus continuously upon improving the effectiveness and appropriateness of Family Service Association's major systems, processes, and outcomes;
  1. seek constantly to upgrade staff performance;

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 2 of 8

QUALITY IMPROVEMENT COMMITTEE

  1. Work diligently to improve the delivery of management and support services throughout the entire organization.
  1. The Quality Improvement Committee shall function as the driving force for the Agency's Continuous Quality Improvement program.
  1. The Quality Improvement Committee in collaboration with Agency staff will develop standards, solve problems, monitor/interview reports of consumer satisfaction, and seek corrective actions when necessary.

2.Committee Membership

  1. The Quality Improvement Committee will be chaired by the Vice President. The Chair or his/her designee, shall be responsible for monitoring all activities and serve as the custodian of all Quality Improvement Committee documents. He/she shall advise Program Managers at monthly Management Team Meetings, and senior management, including the President/CEO and Vice President at bi-weekly Senior Management Team Meetings of committee functions and issues, as relevant.
  1. Membership of the Committee will include the following:

Vice President--Chair

Program Manager, School Based Services or his/her designee

Program Manager, FamilyLifeCenter or his/her designee

Program Manager, Older Adult Services or his/her designee

Program Manager, Development Office

Program Staff, PleasantvilleFamilyCenter

Program Staff, EggHarborTownshipCommunity Center

Program Staff, Outpatient Department

Program Staff, Managed Care

Program Staff, Adolescent Services

Program Staff, Family Preservation Services

Clerical Staff

Director, Human Resources

Volunteers

Clients (when appropriate).

PART N: CONTINUOUS QUALITY IMPROVEMENTPage 3 of 8

QUALITY IMPROVEMENT COMMITTEE

  1. Quality Improvement Committee meetings are conducted monthly or more often as needed. All members are provided with minutes of the meetings and all members are encouraged to take an active part in contributing in the process.

3.Performance Improvement Initiatives