PERFORMANCE AND QUALITY IMPROVEMENT
Quarterly Report
April 2017
INTRODUCTION
Welcome to MHCO’s PQI Quarterly Report! This report is for all stakeholders including residents, personnel, community members, board members, donors, and any individual interested in the great work that we do. PQI – Performance and Quality Improvement – is an integral part of MHCO. We are open and willing for new opportunities to grow. We hope this report demonstrates our commitment to the residents we serve, our transparency for when things don’t go as well as planned, and desire to receive feedback from others. If you have ideas on how this document can be improved, please let us know!
We seek to learn from our experiences and grow. As you read through this report, when you see progress that is not up to our expectations, there will always be a plan for how to address the challenge. Being able to take ownership of our shortcomings and work to improve them is an underlying philosophy of our organization.
Our outputs are simple numeric measurements of productivity. The outputs do not necessarily mean that the residents are achieving desired outcomes, but do mean that personnel provided a certain number of services to a certain number of people. You will notice that we use a simple icon system for our outputs:
A yellow sticky note means that still have work to do to meet reach the target.
A green arrow hitting the bullseye means we are at target or above.
Resident outcomes show sustainable change that demonstrates the interventions provided by MHCO work. Outcomes are measured over time. We are currently developing methods of tracking outcomes to identify any trends and determine ways to improve.Over the course of residency, it is our intention to increase life skills appropriate to each resident’s development.
Additionally, resident records are reviewed quarterly to ensure that the records contain all required information to provide service. The record review is an opportunity to assess the quality of service delivery and ensure that confidential information remains confidential. The target for MHCO is 80% compliance for Direct Care and the Independent Living Program. Resident satisfaction is another very important to MHCO mission achievement and methods are being developed to determine satisfaction outcomes.
OUTPUTS
------
------
------
------
------
DIRECT CARE
Direct Care / Jan / Feb / Mar / Q1 2017 / Q1 2016Admissions (total residents) / 5.0 / 3.0 / 0.0 / 8.0 / 5.0
Discharges (total residents) / 1.0 / 5.0 / 5.0 / 11.0 / 2.0
Referrals (total residents) / 2.0 / 2.0 / 1.0 / 5.0 / 8.0
Length of stay (avg. days) / 951.8 / 969.0 / 994.3 / 971.7 / 933.3
Deferrals (total residents) / 0.0 / 0.0 / 1 (HLC) / 1.0 / 0.0
Ethnicity and Gender / Jan / Feb / Mar / Q1 2017 / Q1 2016 / Deferred / Discharged
African-American (total residents) / 15.0 / 15.0 / 12.0 / 14.0 (avg) / 22.0 (avg) / 0.0 / 4.0
Caucasian (total residents) / 20.0 / 19.0 / 19.0 / 19.3 (avg) / 20.0 (avg) / 1.0 / 2.0
Hispanic (total residents) / 0.0 / 0.0 / 0.0 / 0.0 / 0.0 / 0.0 / 0.0
Multi-Racial (total residents) / 14.0 / 12.0 / 13.0 / 13.0 (avg) / 5.0 (avg) / 0.0 / 5.0
Male (total residents) / 27.0 / 27.0 / 26.0 / 27.0 (avg) / 28.0 (avg) / 1.0 / 8.0
Female (total residents) / 20.0 / 20.0 / 19.0 / 20.0 (avg) / 20.0 (avg) / 0.0 / 3.0
Custody / Jan / Feb / Mar / Q1 2017 / Q1 2016
Parents (total residents) / 41.0 / 39.0 / 34.0 / 38.0 (avg) / 37.3 (avg)
Self (total residents) / 6.0 / 5.0 / 5.0 / 5.3 (avg) / 2.0 (avg)
DSS (total residents) / 2.0 / 2.0 / 2.0 / 2.0 (avg) / 5.7 (avg)
------
------
Direct Care / Jan / Feb / Mar / Q1 2017In School (total residents) / 41.0 / 40.0 / 40.0 / 40.3 (avg)
Tutoring (% of residents) / 85.0% / 90% / 90% / 88.3% (avg)
Absences (total absences) / 19.0 / 30.0 / 57.0 / 35.3 (avg)
Residents with IEP (total residents) / 10.0 / 9.0 / 9.0 / 9.0
Report Cards / 2nd 9 weeks
Honor Roll (total) / 9
Honorable Mention (total) / 8
GPA Increase 5+ Points (total) / 4
Maintained 90+ GPA (total) / 3
Campus GPA (avg) / 79
Passing all Subjects (total) / 24
Failing 1 Subject (total) / 10
Failing 2 Subjects (total) / 1
Failing 3 Subjects (total) / 1
Failing all Subjects (total) / 1
------
------
Direct Care / Jan / Feb / Mar / Q1 2017 / Q1 2016Medical Illnesses (total illnesses) / 18.0 / 15.0 / 15.0 / 16.0 (avg) / 23.3 (avg)
Medical Appointments (total appointments) / 21.0 / 20.0 / 45.0 / 28.6 (avg) / 19.0 (avg)
Medication Administration Record Controlled (% signed off daily) / 100.0 / 100.0 / 100.0 / 100.0 (avg) / 100.0 (avg)
Medication Administration Record Non-Controlled (% signed off daily) / 100.0 / 90.0 / 100.0 / 96.7 (avg) / 100.0 (avg)
------
Other Activities / Jan / Feb / Mar / Q1 2017 / Q1 2016CFT Meetings (total meetings) / 0.0 / 1.0 / 4.0 / 5.0 / nd
Cottage Moves (total residents) / 0.0 / 3.0 / 2.0 / 5.0 / 4.0
Wellness Participation (total residents) / 315.0 / 324.0 / 211.0 / 283.3 (avg) / nd
Animal Assisted Therapy (total residents) / 31.0 / 25.0 / 12.0 / 16.7 (avg) / nd
Church Service Attendance (total residents) / 103.0 / 145.0 / 129.0 / 125.7 (avg) / 108.7 (avg)
Eligible for Employment (total residents) / 11.0 / 13.0 / 11.0 / 11.7 (avg) / 9 (avg)
Employed (total residents) / 9.0 / 6.0 / 5.0 / 6.7 (avg) / 4.3 (avg)
------
INDEPENDENT LIVING PROGRAM
Admissions (total residents) / 2.0 / 0.0 / 0.0 / 2.0 / 0.0
Discharges (total residents) / 2.0 / 0.0 / 2.0 / 4.0 / 4.0
Referrals (total residents) / 2.0 / 0.0 / 7.0 / 9.0 / 0.0
Length of stay (avg. days) / 1461.1 / 1292.6 / 1358.4 / 1370.7 / 1593.7
Deferrals (total residents) / 1 (HLC) / 0.0 / 1 (HLC) / 2.0 / 0.0
Ethnicity & Gender / Jan / Feb / Mar / Q1 2017 / Q1 2016 / Deferred / Discharged
African-American (total residents) / 8.0 / 8.0 / 8.0 / 8.0 (avg) / 6.0 / 1.0 / 1.0
Caucasian (total residents) / 7.0 / 6.0 / 5.0 / 6.0 (avg) / 6.0 / 1.0 / 3.0
Hispanic (total residents) / 0.0 / 0.0 / 0.0 / 0.0 (avg) / 0.0 / 0.0 / 0.0
Multi-Racial (total residents) / 2.0 / 2.0 / 1.0 / 1.7 (avg) / 3.0 / 0.0 / 1.0
Male (total residents) / 8.0 / 8.0 / 8.0 / 8.0 / 9.0 / 1.0 / 1.0
Female (total residents) / 10.0 / 9.0 / 8.0 / 10.0 / 6.0 / 1.0 / 4.0
------
Independent Living Program / Jan / Feb / Mar / Q1 2017 / Q1 2016College (total residents) / 9.0 / 10.0 / 10.0 / 9.7 (avg) / nd
GED (total residents) / 1.0 / 1.0 / 1.0 / 1.0 (avg) / nd
Eligible for Employment (total residents) / 17.0 / 16.0 / 16.0 / 16.3 (avg) / 12.0 (avg)
Employed (total residents) / 11.0 / 11.0 / 12.0 / 11.3 (avg) / 11.3 (avg)
------
Other Activities / Jan / Feb / Mar / Q1 2017 / Q1 2016Workshops (total workshops) / 1.0 / 0.0 / 1.0 / 2.0 / 3.0
Workshops attendance (% residents) / 58.8 / n/a / 56.3 / 57.5 / 61.2
Transports given (total transports) / 180.0 / 127.0 / 125.0 / 144.0 (avg) / nd
Residents with own car (total residents) / 7.0 / 8.0 / 9.0 / 8.0 (avg) / nd
Wheels4Hope applications (total applications) / 1.0 / 1.0 / 1.0 / 1.0 (avg) / nd
------
IMPROVEMENT PLANS
Over the past quarter, a new improvement plan was implementedto address inconsistent methods of reporting incidents. To assist with this, we instituted a new PQI report form and review process by the PQI Subcommittee to process incidents. The PQI Subcommittee has developed recommendations for improving the process of incident review and prevention of incidents. More information will be provided as appropriate. The improvement plan is on target.
------
FUTURE PLANS
We hope you found the information contained in this report helpful. For our next report, we would like to be able to report on the following items:
- The status of resident outcome development
- Information on improving incident reporting
- Quarterly file review results
- More inclusive output data from MHCO operations
- Resident satisfaction data and new improvement plans.
------
MISCELLANEOUS INFORMATION
MHCO is undergoing the self-study process for reaccreditation with the Council on Accreditation. We completed submission of evidence and gathering surveys from stakeholder groups. Our site visit is scheduled for July 16-18.
Additionally, the strategic planning process is underway. We hosted 44 MHCO stakeholders at a Strategic Planning Retreat to gather ideas goals, and plans for the future. There is still a lot of work to do before beginning to implement the ideas. The Board of Directors and MHCO management will discuss the feasibility, value, appropriateness, cost benefit, acceptability, and timing of the goals, objectives, and initiatives of the plan. Action plans on how to achieve the objectives will then be developed annually to include measures, desired levels of performance, timeline targets, and how to monitor progress for departments, stakeholder groups, and personnel.
------
CONTACT US!
If you have any feedback, questions, or comments about this report, please contact the PQI Director via email or phone:
Samantha M. Coleman, PhD, MAC, LPCA, LCAS, CCS
(919) 603-3941