PQI Quarterly Report

KOOTENAY FAMILY PLACE

PERFORMANCE & QUALITY IMPROVEMENT

BI-ANNUALREPORT

APRIL – SEPTEMBER 2014

Kootenay Family Place, Society for Children & Youth is dedicated to serving the needs of children, youth and families in the West Kootenay Boundary Region. This is achieved through providing high quality, cost-effective services based onbest practices.Performance & Quality Improvement (PQI) is an organizational process in which staff and management identify potential improvements in service delivery, create corrective action plans, and implement them through an ongoing process.

Goals of PQI

  1. To contribute to organizational effectiveness by providing opportunities for all staff to be involved in leading and promoting positive change within the organization.
  2. To develop continuous improvement strategies in an effective feedback and reporting system that involves stakeholders, staff and participants as well as undertaking a comprehensive review of organizational functions.
  3. To contribute to organizational effectiveness by continually seeking ways toimprove upon our quality client-centered services.
  4. To demonstrate organizational accountability to all stakeholders through a welldesigned system of measurable outcomes.
  5. To implement Best Practices in all aspects of the organization.

Performance & Quality Improvement Team:

  • Jim Fisher, Executive Director
  • Lynnene Lewis, Director of Quality Assurance
  • Sally Bojechko, Director of Child Care Programs

Performance & Quality Improvement Team Achievements this Half:

Program Evaluations

OHS Committee Meetings

Essential Learning training curriculum

CARF transition & letter of intent

Strategic Planning Retreat

Strategic Plan Report Card

Management Retreat SWOT Analysis

CSSEA Job description review

Early Intervention Strategic Plan

Recommendations for Action for last Half:

  • Begin File Review process - done
  • Begin CARF standards - done
  • Plan Board Retreat - pending
  • Review and Update Strategic Plan - done
  • Policy Review - done

Recommendations for next Half:

  • Review Policy Manual
  • Review PQI Manual
  • Review OHS Manual
  • Review Employee Manual
  • Go through CARF time lines
  • Go through CARF “written documentation required” section
  • Complete on line application to CARF
  • Set accreditation meetings – add to EI agendas
  • Revamp PQI template
  • Complete program evaluations
  • Board Self-Evaluation
  • Audit Committee meets
  • ED Evaluation
  • Staff Evaluations updated
  • Family Handbook review

File Review(quarterly):

File Review is a process in which staff review the case records prepared by other staff members in order to ensure that the case records are complete and that the services that are provided are consistent with the agency’s principles and practice standards.

The Peer File Review Committee has started using the new procedures and conducting peer reviews. The policy has been reviewed and updated. Initially, it is expected that older files will not be in compliance with the CARF standards that required signatures. This will change over time and all files will eventually be in compliance. The new form will make it easier to find the information that the team needs to review.

18 files were reviewed. 6 files were flagged for follow-up. The issues were around signatures on consent forms, missing flow sheets and updated needed to flow sheets. The file review form is not perfect, still getting feedback on possible improvements.

Service Delivery – Program Reports – Barriers and Opportunities(bi-annually): Using the reporting tools, program managers will provide information each quarter on Staffing, Client & Stakeholder contact, Statistics, Service Barriers, Outcomes Measurement and Recommendations to PQI. These reports are collected and reviewed for trends or need for corrective action. See Program reports for details.

Program reports were reviewed by the PQI team.

  • Question: IDP report – the stats for the wait list are high. Is this for all programs or the IDP program. Please report.
  • Recommendations: Please go over your reports for correct grammar and spelling before submitting them.

Health, Safety& Risk Management(bi-annually):

The Society recognizes the importance of protecting the health and safety of its staff and clients. Program Managers must ensure that each worksite complies with all applicable health, safety and fire codes. The Health and Safety Committee is available to support this task and regularly reviews WCB health and safety regulations.

  • No incident reports during this half of the year.
  • 1 Fire drill conducted.
  • 3 OHS meetings (April, June, September)
  • 1 building inspection (April 16/14)

Human Resources Review(annually):

The purpose of the Human Resources Review is to determine whether the organization is sufficiently diverse in strengths and capabilities to meet the HR goals. The review will determine how human resources are deployed, trained and supervised. The goals of HR management are to effectively and efficiently meet the demand for services and to provide and coordinate those services that the Society offers.

Compared to the same sector, KFP’s turnover rate is 5.6%, while the entire B.C. sector is 16.4%.

The rate of replacing employees is:

Management – no turnover, compared to the sector average of 5.9 weeks

Paraprofessionals – no turnover, compared to the sector average of 6.3 weeks

Regular employees – 2 weeks, compared to the sector average of 4.4 weeks

Casuals, no turnover, compared to the sector average of 4.1 weeks.

The Age profile of departing employees is:

Under age 25KFP – 0%Sector Average – 15.2%

26-35KFP – 33.3%Sector Average – 36.4%

36-45KFP – 66.7%Sector Average – 21.5%

46.55KFP – 0%Sector Average – 16.9%

Over 56KFP – 0%Sector Average – 10%

Employees in the age group 36-45 who depart do so due to a move within the agency or relocation.

Summary of Internal/External Reviews:

The Society takes action based on the findings of its PQI processes. Action plans will:

  • Build on strengths.
  • Determine possible causes when data reveals issues of concern.
  • Identify and initiate solutions for identified problems.
  • Replicate best practice.
  • Monitor the effectiveness of corrective action.

This Quarter Evaluations were conducted on:

  • Speech Therapy Family Survey
  • Behaviour Support Program Family Survey
  • IDP Parent Support Group Survey
  • Infant Development Program – Families Receiving Service
  • Supported Child Development – Survey for Families
  • Supported Child Development – Survey for Early Childhood Educators
  • Occupational Therapy Family Survey
  • Physiotherapy Family Survey
  • Strategic Plan pre-survey

Excellent feedback, no concerns or recommendations at this time.

Summary:

This shift from COA to CARF has been gradual. Now that our accreditation with COA is ending, we have been focusing on getting familiar with the differences between CARF and COA. A big achievement this half of the year was the Strategic Planning Retreat. Closing programs in order to invite all staff to participate in the Strategic Plan is a testament to the agency’s commitment to a holistic approach moving forward. It takes a huge effort both financially and energetically to pull this off and everyone should be congratulated. One of the priorities for the next half of the year is to find ways that staff and board can access the PQI reports easily and keep updated on our Priority Action Plan.

1