Quality Assurance Program
Handbook
© Community Catalysts of California
Quality Assurance Program
Introduction
The Quality Assurance Program is designed to assure that we as an organization are providing a good quality service and are meeting the expectations of our consumers, the funding agencies, other stakeholders as well as our own agency Code of Ethics. The information gathered by the Quality Assurance Program provides data based measurement of how well we as an agency are meeting these expectations and goals. This information is used to show that we met our funding contract goals as well as assists in development, marketing and fundraising efforts.
There are four components within the Quality Assurance Program. They are:
1. Outcome Measurements
· Deliverables
· Program Outcome Measurement
2. Field Evaluation Surveys
3. Quarterly Site Checks
4. Special Incident Reporting
· Special Incident Reports (SIR)
· Special Incident Follow-Up
Each one of these components gathers information in a unique way from different perspectives and people. Each of these components will be discussed in more detail in the appropriate sections of the handbook.
The Quality Assurance Program is a very important and critical part of all of COMMUNITY CATALYSTS OF CALIFORNIA’S programs and services.
This handbook is to help you understand the different components within the Quality Assurance Program as well as to help you understand your role in the process.
Code Of Ethics
COMMUNITY CATALYSTS OF CALIFORNIA has evolved over the years from a small grass roots organization to a company that employees more than 225 staff and serves over 700 individuals with special needs. COMMUNITY CATALYSTS OF CALIFORNIA is committed to:
“Enhancing the quality of life for people with special needs in their quest for self-sufficiency”.
It is for this reason that it is important for all staff members of COMMUNITY CATALYSTS OF CALIFORNIA follow a Code of Ethics that will define expectations and guide actions.
Each Staff Member will:
1. Have knowledge of COMMUNITY CATALYSTS OF CALIFORNIA’S mission, vision, programs and policies and procedures.
2. Recognize that the chief function of COMMUNITY CATALYSTS OF CALIFORNIA at all times is to serve the best interest of our constituency.
3. Practice the values of compassion, empathy, respect, trust and resourcefulness in the interaction with those we serve and in the performance of all job duties.
4. Accord appropriate respect to the fundamental rights, dignity, and worth of all people. Being aware of cultural, individual and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status. Staff shall not knowingly participate in or condone unfair discriminatory practices.
5. Seek to contribute to the welfare of those we serve while promoting the concepts of personal growth, individuality of person and behavior and the dignity of risk-taking.
6. Understand that staff has a primary obligation and must take reasonable precautions to respect the confidentiality rights of those with whom they work and/or serve. Recognizing that sharing of confidential information is done only for appropriate professional purposes and only with persons clearly concerned with such matters and/or as mandated by law.
7. Assure a safe environment for self, other staff, and those we serve by reporting any injury, accident, and/or unsafe practice/condition immediately.
8. Prepare, update, and submit any and all reports, logs, case notes, files, and other appropriate data/information in a accurate, timely, objective, meaningful and concise manner.
9. Prepare, update and/or review individual’s Coordinated Service Plan at least annually to assess and review the individual’s goals and objectives. Progress towards programs goals and objectives are evaluated and are rewritten or renewed as needed during the year the CSP is in force.
10. To work cooperatively with co-workers, other agencies and organizations, employers, and other individuals in the community demonstrating integrity, honesty, and equality.
SECTION 1
Outcome Measurements
DeliverablesThe Deliverables forms are the forms that we use to measure a consumer’s satisfaction with COMMUNITY CATALYSTS OF CALIFORNIA services. This form is to be completed by the consumer with minimal assistance from staff if needed. This form is to be completed every 3 months.
STEPS:
1. Upon consumer intake the Deliverables sheet needs to be given to the consumer.
· Deliverables sheet should be read/explained to each consumer in the format that is useful to the consumer.
· Consumer should sign confirmation of receipt and understanding of Deliverables.
· Signed confirmation form should be placed in consumer’s file.
2. When the consumer has his/her quarterly plan review or every three months the COMMUNITY CATALYSTS OF CALIFORNIA Deliverables teleform needs to be completed by the consumer.
· Case Manager and or his/her designee will go over COMMUNITY CATALYSTS OF CALIFORNIA Deliverable teleform with consumer.
· The completed original COMMUNITY CATALYSTS OF CALIFORNIA Deliverable teleform will be given to the Finance Support Staff for scanning and a copy placed in the consumer’s file.
· Case Manager or his/her designee should review each COMMUNITY CATALYSTS OF CALIFORNIA Deliverable teleform and complete follow-up as indicated below.
3. A Quality Assurance Follow-Up form needs to be complete if 79% or less of the Deliverables were met (3 or more questions answer by a “NO”).
· The Quality Assurance Follow-Up form should be completed within 90 days of completed COMMUNITY CATALYSTS OF CALIFORNIA Deliverable form.
· Original should be submitted to Regional Manager for signature and filed in consumer’s file.
· A copy of the signed follow-up form needs to be sent to Administrative Coordinator.
COMMUNITY CATALYSTS OF CALIFORNIA
DELIVERABLES
These are things that we promise we will do for you and with you.
1. We promise that we will honor your right to make decisions in your life.
2. We promise that we will ask your permission before talking to anybody about you.
3. We promise that you will be treated with respect and dignity.
4. We promise that we will offer services in a timely manner.
5. We promise that we will keep all appointments or give you enough notice when we have to cancel.
6. We promise that the services we offer to you will meet your needs.
7. We promise that you will create your own goals that are realistic.
8. We promise that we will review your goals with you and you can make changes that you feel are appropriate.
9. We promise to help you make decisions for yourself to become your own self-advocate.
10. We promise to help you improve your quality of life.
Promesas de COMMUNITY CATALYSTS OF CALIFORNIA
Esta son algunas de las cosas que nosotros le prometeremos
realizar para usted y con usted.
1. Nosotros prometemos que honraremos su derecho de tomar las decisiones en su vida.
2. Nosotros prometemos que obtendremos permiso de usted primero antes de hablar con alguien acerca de su caso.
3. Nosotros prometemos que usted sera tratado(a) con respeto y dignidad.
4. Nosotros prometemos que le ofreceremos servicios a tiempo con usted.
5. Nosotros prometemos que mantendremos toda cita con usted y notificarle con tiempo cuando tengamos que hacer una cancelacion.
6. Nosotros prometemos que los servicios que le ofrezcamos seran para llevar a cabo sus necesidades.
7. Nosotros prometemos que crearemos sus propias metas siempre y cuando sean realistas.
8. Nosotros prometemos que revisaremos sus metas con usted y que pueda realizar cambios que considere sean apropiadas.
9. Nosotros prometemos en ayudarle a tomar sus decisions para que usted sea mas autosuficiente.
10. Nosotros prometemos en ayudarle en mejorar su calidad de vida.
SAMPLE FORM
Original forms can be found in the Forms Section of the handbook.
Program Outcome MeasurementThese are the forms that we complete for each program to measure our effectiveness and efficiency in providing these services. This information is used to assist us as an agency to set goals and to monitor our progress in achieving these goals. These forms are to be completed by the Program Leader/Case Manager or his/her designee as scheduled but at a minimum of twice a year.
STEPS:
1. The Outcome Measurement forms will be completed by the Program Leader/Case Manager or his/her designee according to the following schedule:
MONTHLY
/ /Three Times a Year
· Day Program
/ /· Independent Living ◊
· External Situational Assessment / · Supported Living *· Generalist/Employment Prep
· Habilitation
· Mental Health Access Center
· Mental Health Vocational Services
· Supported Employment
· Triage Facility
· Trips
· Crisis Services (REST)
◊ / Independent Living forms will be completed three times a year as follows:
Consumers whose last names begin with the letters A through L will be completed in:
February / June / OctoberConsumers with last names beginning M through Z will be completed in
March / July / November* / Supported Living forms will be completed in:
January / July / December
2. The completed original outcome measurement form will be given to the Finance Support Staff for scanning and a copy placed in the consumer’s file.
3. The Finance Support Staff will scan form and send scanned information to the Administrative Coordinator.
4. The Administrative Coordinator will compile all the data for all areas and programs and will print out a report quarterly.
5. The report will be given to the Director of Operations/COO and to each Regional Manager for review.
SAMPLE FORM
Original forms can be found in the Forms Section of the handbook.
SECTION 2
Field Evaluation Surveys
These forms are sent out to our consumers and stakeholders to assess the quality of services we are providing. This information is used to help assure we are providing a good quality of service. These forms are to be completed by consumers, employers, the funding agency and other stakeholders as appropriate.
STEPS:
1. All Field Surveys are sent out according to this schedule and in the month assigned by program and office:
· Supported Living Program – Once per year in the assigned month.
· Independent Living Skills - Once per year in the assigned month.
· Vocational Program – Once per year in the assigned month.
· Licensed Residential Facility – Upon consumer exiting program
· Mental Health Vocational Program – Once per year in the assigned month.
· Transportation Program – Twice a year: for all consumers served in the previous 6 months.
· Crisis Program – Twice a year: for all consumers served in the previous 6 months.
JAN / FEB / MAR / APRIL / MAY / JUNE / JULY / AUG / SEPT / OCT / NOV / DECSan Diego / Modesto / Merced / Fresno / Santa Clara / Visalia / San Diego / El
Centro / Monterey / Ukiah
REST / ILS / SL / SL / SL / SL / SL / SL / SL / SL / SL
Stockton / El Centro / Monterey / Santa
Clara / Merced / Coalinga / Fresno / Visalia
TRIPS / SL / ILS/DAY / ILS / ILS / ILS / ILS / ILS / ILS
Stockton
ILS / ALL Vocational / REST
TRIPS
2. The designee of the Regional Manager will distribute the Field Evaluation Surveys to the appropriate persons with a cover letter explaining the purpose and intent of the survey. A stamped envelope shall be included with a return address to the Home Office Attn: Administrative Coordinator.
3. The Administrative Coordinator in the Home Office will do the following:
a) Log and tabulate the incoming Field Surveys to allow data to be utilized for strategic planning, marketing and for compilations in an annual report.
b) Photocopy the completed survey and file for future reference.
c) Send the original to the Regional Manager for review and for appropriate action as needed.
d) Complete a monthly report to be available for review as needed.
4. The Regional Manager shall review the evaluations, share them with the appropriate persons on a need to know basis, preserving anonymity when possible.
5. The Regional Manager or his/her designee will submit written follow-up on the Quality Assurance Follow-Up form to the Administrative Coordinator as necessary.
6. The original completed survey will be placed in the consumer’s case files.
SAMPLE FORMS
To Whom It May Concern:
Your feedback is important to us at COMMUNITY CATALYSTS OF CALIFORNIA. We want to be sure we are providing the best service possible.
In advance, we thank you for taking time from your busy schedule to complete our survey.
Enclosed is a stamped, self-addressed envelope to our Home Office where this information is compiled for distribution to our staff in order to assure we are offering the best quality of services possible to our consumers.
We appreciate your candid and complete evaluation.
Cordially,
Regional Manager
Original forms can be found in the Forms Section of the handbook.
SAMPLE FORMS
PROFESSIONAL SURVEY
CASE RESPONSIBLE PERSON
COMMUNITY CATALYSTS OF CALIFORNIA Area: ______
COMMUNITY CATALYSTS OF CALIFORNIA Office: ______
ID #: ______
Dear Fellow Professional:
Thank you for taking the time to complete this field survey regarding our services for your consumer, ______, program code ______. Your candid and complete evaluation will help us to provide appropriate feedback to our staff regarding the services we provide. Enclosed is a self-addressed stamped envelope for your convenience.
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HOW WOULD YOU RATE:
The needs of the consumer -- assessed
and served? [ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] N/A
The services provided to the consumer in a
timely manner? [ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] N/A
Our employee(s) kept you updated and informed
regarding the consumer’s progress? [ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] N/A