REVISED DRAFT FOR REVIEW (v3)

Monitoring Procedures & Practice Guide[d1]

For use by Quality Service Staff monitoring program contracts, except for direct-funded Home Sharing agreements

What’s Inside

1.Introduction

2.Context

3.Practice Tips

4.Contract Monitoring: Service Levels

Reviewing Service Level Reports

Resolving Under-Delivered Service Levels

Resolving Over-Delivered Service Levels

Unresolved Variances in Contracted and Delivered Service Levels

5.Contract Monitoring: Management Information (Periodic)

Reviewing Periodic Management Information Reports

Following up on Non-Delivery of Management Information

6.Contract Monitoring: Management Information (Occurrence Based)

Reviewing Occurrence-Based Management Information Reports

7.Services Monitoring: Standards (Accredited)

Reviewing Standards Reports (Accredited)

On-Site Visits (Accredited)

8.Services Monitoring: Standards (Not Requiring Accreditation)

Reviewing Standards Reports (Not Requiring Accreditation)

On-Site Visits (Not Requiring Accreditation)

9.Services Monitoring: Outcomes

10.Agency Monitoring

11.Follow-up Measures

12.Forms, Templates and Checklists

1.Introduction

Monitoring is a key element of quality service. It is one of the most important aspects of a Quality Service analyst’s job. Monitoring has a direct impact on the lives of the people CLBC supports and forms a key part of the relationship with service providers.

This Guide provides detailed procedural and practice guidance for Quality Service staff responsible for monitoring the program services for which Community Living British Columbia (CLBC) contracts.

Make sure you are familiar with the Monitoring Policy before using this Guide– it has important definitions and general policy requirements that govern how you conduct monitoring activities. The content in this Guide is based on the policy and assumes that you are familiar with it.

CLBC’s monitoring framework is being implemented in phases. The Guide is organized to reflect those phases, and will be updated as each phase is implemented.

2.Context

Monitoring is a key component of the contract lifecycle. You can find guidance for the other parts of this lifecycle in the Contracting and Procurement Guide.

There are three types of monitoring for which Quality Service staff are responsible:

3.Practice Tips

Monitoring, like all of CLBC actions, is a values-based activity. Always go back to the CLBC values and to the Monitoring Policy. They should guide all your decisions and actions.

The information CLBC requires to determine that services are being delivered as described in the contract is gathered from a number of sources including onsite visits, receiving reports and maintaining communication with the service provider

Monitoring is a collaborative process – one that respects and nurtures a shared commitment to the quality of service being provided for individuals and families, and the effective and efficient use of funding for these services. In some situations, this may be a different approach from past practice. Access the support of managers and Corporate Services Division when needed.

Monitoring is as much about relationships as it is about results. Building good but independent relationships with service providers will provide you with the insight and connections you need to develop an accurate picture of what is going on in their services.

Always consider the risk associated with any situation that you encounter. You cannot be aware of all the details all the time. So focus on those in which the risk seems higher – maybe there have been complaints or other issues in the past – maybe another authority has raised concerns. Use your professional discretion and judgment to identify and focus on situations that may pose risk. Notice and respond to patterns.

Be sensitive to the concerns of individuals, families, and members of support networks and the community. Their informal monitoring is an important complement to the formal monitoring that you do.

Monitoring is not intended to be punitive. Look for opportunities to provide positive feedback and enhance successful practice by service providers.

Document everything.

Any more content here – given the negotiated principles?

4.Contract Monitoring: Service Levels

Contract monitoring of service levels is the first level of monitoring. It is about reviewing reports from service providers to make sure they aredelivering the service levels set out in their contracts, and discussing and resolving any over or under delivery of service levels.

Note: Insert detailed definitions of service levels (chart on pps 6-7 of draft v1.0 guide) if not put in policy.

AB suggests more narrative up front – need content for that.

Reviewing Service Level Reports

Task / Responsibility / Tools
Identify Reports Due
  • Run Reports Due Reportand identify all service level reports due on last day of the previous month.[a2]
/ Contract Clerk
(1st working day of month) / Reports Due Tracking
Spreadsheet
Document Receipt of Reports
  • Identify reports that have been received and mark ‘received’ in spreadsheet.
  • Record the date received in the CLBC received date field in the office use section of the service level template.
/ Contract Clerk / Reports Due Tracking
Spreadsheet
Follow up on Late Reports
  • For each expected report that has not been received, send a reminder to the service provider by mail or e-mail.
  • Advise the analyst if there is no response to your reminder within a week.
/ Contract Clerk
(3 days after due date) / Service Level Report Reminder Letter Template
Preliminary Review of Service Level Reports
  • Put together all reports from each service provider.
  • Review all reports to see if required areas have been completed.
  • Where a report is incomplete, contact the service provider and request that they re-file the report. Give the service provider a due date. Update the Reports Due Tracking Spreadsheet to indicate ‘not received’.
  • Make a note to follow-up and advise the analyst if there is no complete report received within a week.
  • Distribute packages of complete reports to the appropriate Analysts.
/ Contract Clerk / Service Level Report Incomplete Letter Template
Reports Due Tracking
Spreadsheet
Detailed Review of Service Level Reports
  • Record the date you start the report review in the CLBC review date field in the office use section of the service level template.
  • Compare the contracted service levels against the delivered service levels.
  • If contracted and delivered service levels are equal (NKS to add content), document any comments in the area ‘Analyst’s Comments’; and record the date you complete the report review in the completion date field in the office use section of the service level template.
  • Retain the report in the Resource file/Contract file.
  • If the contracted and delivered service levels differ, follow up per next section.
/ Analyst
Documentation
  • Send results of the review to the service providerby e-mail.
  • Enter in Contract Monitoring Summary.
/ Analyst / Contract Monitoring Summary

Resolving Under-Delivered Service Levels

Tasks for Analyst:[d3]
Determine Cause of Under-delivery
  • Review the comments on the variance provided by the service provider.
  • Check to see if the under delivery was discussed and an agreement reached, during the reporting period, between CLBC and the service provider which resolved the under delivery.
  • If you need further clarification, contact the service provider and discuss the situation, with a view to developing a shared understanding for the cause(s) of the situation, and whether is a one-time occurrence or likely to persist. If it is a significant or potentially difficult situation, brief the SCC and/QSM before contacting the service provider, and decide how to proceed together.
  • If helpful, review prior service level reports for the contract to understand the history and look for factors or patterns, such as:
  • Planned changes in service volume, and thus service levels, where these changes are expected to be short term and reasonable.
  • Consistent variations between the contracted and delivered service levels which may or may not offset one another over the reporting periods.
  • Insufficient referrals from CLBC.
  • Previous flagging by service provider that a funded service level may not be fully utilized.
  • If there was no prior agreement about the undelivered service, request repayment by the service Asprovider. a result of this analysis and discussion, you may decide that no further action is required with respect to the variance.If this is a onetime variance and the service levels are Finishrequired in the future the contract does not need to be amended. Finish your review by completing the area for CLBC completion in the office use section of the service level template. Document any comments in the area ‘Analyst’s Comments’.
Determining repayment and whether the contract needs to be amended e Actionin Response to Under-delivered Service Levels
Determine whether or not CLBC attempted to fill the available capacity in the service.
oIf not, determine what portion of the under-delivered service level can be attributed to insufficient referrals by CLBC.
oIf so, determine why this was not sufficient to utilize the service level. This may require a review of other contracts with the service provider to determine whether funded service levels on this contract are being applied to subsidize other contracts (which should result in over-delivery of service levels on those other contracts).
  • Determinewhich of the following conclusions and possible actions is appropriate for the situation:
Pattern of Under-delivered Contract(s) Subsidizing Other Contract(s)
  • Consider modifying all the contracts to re-align the contracted service levels to the appropriate amounts.
Business Reasons
  • Determine if there is a short or long term factor affecting the service provider, such as a shortage of qualified staff, and investigate with the service provider to better understand the situation.
  • Request the service provider return the unused portion of the funding per the Terms and Conditions section on Undelivered Service.
  • If the situation cannot be resolved and ongoing undelivered service is likely, consider negotiating a variable portion to the contract or reducing the contract value.
Insufficient Referrals from CLBC
  • Request funding for undelivered service be paid back by the service provider.
  • For the next contract term, if demand is insufficient, consider renegotiating the contract to reduce the service level to what is actually required.
  • If there are people on the request for service list who want this service, arrange for referral of additional individuals/families for this particular service.
  • Consider a needs-based increase in the service to existing individuals/families, so as to use the full contracted service level for the remainder of the reporting period.
  • Where contracted service levels have not been fully delivered at the end of a reporting period, arrange for adjustments to payments on the following basis:
  • The wages, benefits and backfill attributable to the undelivered services; and
  • Any specific fixed costs that are funded but substantially not incurred.
  • Specifically, use the following rules to calculate any such adjustment:
  • Program staffing costs (i.e. wages, benefits and backfill) – 100% of the funding attributable to the undelivered service level.
  • Direct program costs – 100% of specific funded costs for which corresponding financial commitments were not entered into by the service provider.
  • Facility costs – 100% of specific funded costs for which corresponding financial commitments were not entered into by the service provider
  • Administration costs – no adjustment
Sign off and Document
  • Sign off on the review by completing the area for CLBC completion in the office use section of the service level template. Document any comments in the area ‘Analyst’s Comments’.
  • Retain all documentation supporting the analysis, discussions with the service provider and resulting actions in the Resource file/Contract file.
  • Confirm the results of the review and actions taken in writing to the service provider.

Resolving Over-Delivered Service Levels

Tasks for Analyst:
Determine Cause of Over-Delivery
  • Review the comments on the variance from the service provider.
  • Review the Resource file/Contract file to determine whether the service provider has previously flagged an over delivery of service levels. If so, review any resulting actions by CLBC, including the rationale if no action was taken.
  • If you need further clarification, contact the service provider and discuss the situation, with a view to developing a shared understanding for the cause(s) of the situation, and whether is a one-time occurrence or likely to persist. If it is a significant or potentially difficult situation, brief the SCC and/QSM before contacting the service provider, and decide how to proceed together.
  • If helpful, review prior service level reports for the contract to understand the history and look for any factors or patterns, such as:
  • Planned changes in service volume, and thus service levels, where these changes are expected to be short term and reasonable.
oConsistent variations between the contracted and delivered service levels which may or may not offset one another over the reporting periods.
  • If helpful, review other contracts with the service provider to determine whether funded service levels from other contracts are being applied to subsidize this contract (which should result in under-delivery of service levels on those other contracts).
  • As a result of this analysis, you may decide that the service provider is accountable for the decision to over deliver service and no further action is required with respect to the variance. Finish your review by completing the area for CLBC completion in the office use section of the service level template. Document any comments in the area ‘Analyst’s Comments’.
  • Determine Action in Response to Over-delivered Service Levels
Consider providing one time funding to cover the over delivery if this is the commitment made by CLBC when the issue was first reported by the service provider.Or agree on reduced service levels for the remainder of the reporting period. (Does this belong under one of the scenarios below?)
  • Determinewhich of the following conclusions and possible actions is appropriate for the situation:
Needs of Individuals/Families Higher than Originally Identified
  • Consider re-negotiating the contracted service level to better match the needs of the people being served. (Note: It is the service provider’s responsibility to have reported such circumstances to CLBC as soon as they realized the situation was likely to continue.)
Pattern of Over-delivered Contract(s) being Subsidized by Other Contract(s)
  • Consider modifying all the contracts to re-align the contracted service levels to the appropriate amounts and ensure that contracted service levels are not exceeded in the future.
o(For reporting period covered by the report, or for going forward?)
Business Reasons
  • Determine if there is a short or long term factor affecting the service provider, such as inefficient staff allocations, and investigate with the service provider to better understand the situation.
  • Decide whether or not to accept this explanation/situation.If not, ensure that the service provider understands that they have to cover the costs associated with the over-delivery of service levels.
oIf the situation cannot be resolved and ongoing over-delivered service is likely, consider terminating the contract. negotiating a variable portion to the contract or increasing the contract value.
Sign off and Document
  • Sign off on the review by completing the area for CLBC completion in the service level report as applicable.Document any comments in the area ‘Analyst’s Comments’.
  • Retain all documentation supporting the analysis, discussions with the service provider and resulting actions in the Resource file/Contract file.
  • Confirm the results of the review and actions taken in writing to the service provider.

Unresolved Variances in Contracted and Delivered Service Levels

The Monitoring Policy states that where CLBC and service providers are unable to jointly resolve over or under delivery of contracted service levels, CLBC funds the actual service levels that are delivered subject to the maximum specified in the contract.

This is a section of policy and I hesitate to repeat it here – not sure how it links to procedures below?

Tasks for Analyst:
Where contracted service levels have not been fully delivered at the end of a reporting period, arrange for adjustments to payments on the following basis:
oThe funded variable costs attributable to the undelivered services; and
oAny specific fixed costs that are funded but substantially not incurred.
Specifically, use the following rules to calculate any such adjustment:
oProgram staffing costs (i.e. wages, benefits and backfill) – 100% of the funding attributable to the undelivered service level.
oDirect program costs – 100% of specific funded costs for which corresponding financial commitments were not entered into by the service provider.
oFacility costs – 100% of specific funded costs for which corresponding financial commitments were not entered into by the service provider
oAdministration costs – no adjustment

5.Contract Monitoring: Management Information (Periodic)

Monitoring of management information is the next part of contract monitoring. It is about reviewing periodic management information reports from service providers to make sure they are complying with their obligations periodic management information reporting requirements set out in their contracts.
Link to definition in policy?
The frequency of management information reporting is determined by the type of service being provided. The reporting schedule is clearly identified in Schedule D of the Terms and Conditions. Services in which there is limited flow-through (e.g. residential) typically require annual reporting. Services in which individuals / families are expected to access the service for a definite period (e.g. employment, skill development) typically require more frequent reporting.

Reviewing Periodic Management Information Reports

Task / Responsibility / Tools
Identify Reports Due
  • Run Reports Due Reportand identify all management information reports due on last day of the previous month.
/ Contract Clerk
(1st working day of month) / Reports Due Tracking
Spreadsheet
Document Receipt of Reports
  • Identify reports that have been received and mark ‘received’ in spreadsheet.
  • Record the date received in the CLBC received date field in the office use section of the management information template.
/ Contract Clerk / Reports Due Tracking
Spreadsheet
Follow up on Late Reports
  • For each expected report that has not been received, send a reminder to the service provider by mail or e-mail.
  • Advise the analyst the report has not been received if no response to your letter within a week.
/ Contract Clerk
(3 days after due date) / Management Information Report Reminder Letter Template
Preliminary Review of Management Information Reports
  • Put together all reports from each service provider.
  • Review all reports to see if required areas have been completed.
  • Where a report is incomplete, contact the service provider and request that they re-file the report. Give the service provider a due date. Update the Reports Due Tracking Spreadsheet to indicate ‘not received’.
  • Follow-up and advise the analyst if there is no complete report received within a week.
  • Send packages of complete reports to the appropriate analysts.
/ Contract Clerk / Management Information Report Incomplete Letter Template
Reports Due Tracking
Spreadsheet
Detailed Review of Management Information Reports
  • Record the date you start the report review in the CLBC review date field in the office use section of the management information template.Reports must be reviewed in a timely fashion.
  • Compare the contracted management information requirements against the reported delivery.
  • If contracted management information requirements have been delivered, document any comments in the area ‘Analyst’s Comments’; and record the date you complete the report review in the completion date field in the office use section of the management information template..
  • Retain the report in the Resource file/Contract file.
  • Enter in Contract Monitoring Summary.
  • If the contracted management requirements have not been delivered, follow up per next section.
/ Analyst / Contract Monitoring Summary

Following up on Non-Delivery of Management InformationService

Tasks for Analyst:
Investigate Further
  • Contact the service provider to discuss and Rreview their written comments provided by the service provider.
  • If the explanation appears valid and in-line with what you know about this contract, finish your review by completing the area for CLBC completion in the office use section of the management information template.Document any comments in the area ‘Analyst’s Comments’.
  • Follow up on the issue during your next visit to the location of service
  • If it requires further investigation, review prior reports for the contract and all pertinent communication that occurred during the reporting period to understand the situation.
  • As a result of this analysis, you may decide that no further action is required. Finish your review by completing the area for CLBC completion in the office use section of the management information template.Document any comments in the area ‘Analyst’s Comments’.
  • If it is not satisfactorily resolved or there are outstanding issues, arrange to meet with the service provider to identify the issue and determine a course of action. Brief the SCC and/or QSM if the situation is significant or potentially difficult, and decide how to proceed together.
  • Determine Action
  • Depending on the issue, there are a number of possible responses. Two of the most common are:
  • Provideadditional referrals to ensure that capacity is fully utilized
  • Request the service provider develop a plan to ensure the anticipated flow through of people receiving service occurs
  • Modify the contract.
Sign off and Document
  • Sign off on the review by completing the area for CLBC completion in the office use section of the management information template. Document any comments in the area ‘Analyst’s Comments’.
  • Retain all documentation supporting the analysis, discussions with the service provider and resulting actions in the Resource file/Contract file.
  • Document the agreed-upon actions in writing to the service provider.

6.Contract Monitoring: Management Information (Occurrence Based)

Monitoring of occurrence-based management information reporting is the thirdlast part of contract monitoring. It is about reviewing occurrence-based management information reports from service providers, as they are received, to make sure they are complying with the occurrence-based management information reporting requirements set out in their contracts.