WHO IS ACCREDITED?

Private Organization Accreditation

Debt Education and Certification Foundation (DECAF), a private non-profit 501(c)(3) organization, provides high-quality financial education and counseling, with nationwide outreach throughout the U.S. DECAF is HUD-approved, and recognized as one of the 100 Best Companies to Work for in Texas.
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ORGANIZATION TESTIMONIAL

Brewer-Porch Children's Center

James W. Thompson, Executive Director

The COA standards as applied to the operations at Brewer-Porch Children’s Center at The University of Alabama has given the administration an opportunity to examine best practice and improve the quality of care provided to clients.
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Purpose

Through sound administration and effective management, the MFR program achieves its vision, mission and strategic goals; assures appropriate use of resources for the good of customers; and remains responsive to the needs of the military community.

MIL-AM 5: Performance and Quality Improvement

The MFR program develops and implements a system for promoting continuous quality improvement.

Interpretation: Performance and Quality Improvement is relevant to both how programs are run, and the outcomes programs promote for their customers. Accordingly, it may be relevant to measure desired goals and outcomes in both domains.

Interpretation: A variety of terms can be used to define this work including Quality Improvement, Continuous Quality Improvement, Performance Management, or similar language.

Note: The standards in MIL-AM 5 provide a framework for a MFR program-wide performance and quality improvement system that will support MFR program efforts to meet the evaluation component of DoDI 1342.22. As stated in the DoDI, MFR programs must use valid and reliable outcome, customer satisfaction, cost, and process measures and performance goals to measure the impact of family readiness services and then use that data to make informed decisions regarding sustainment, modification, or termination of family readiness services.

Note: Please see The Performance and Quality Improvement Tool Kit for additional assistance with this standard.

Rating Indicators
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the programs’ practices fully meet the standard and reflect a high level of capacity.  All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions; exceptions do not impact service quality or overall performance.  
2
Substantial Implementation, Good Performance 
A rating of (2) indicates that a programs’ infrastructure and practices are basically sound but there is room for improvement. The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.  Minor inconsistencies and practices that are not fully developed are noted; however, these do not significantly impact service quality or overall performance.
3
Partial Implementation, Concerning Performance
A rating of (3) indicates that significant aspects of the programs’ observed infrastructure and/or practices require significant improvement. The program has not implemented the basic framework of the standard but instead has in place only part(s) of this framework. Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  Service quality or program functioning may be compromised. Capacity is at a basic level.
4
Unsatisfactory Implementation and Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all. The programs’ observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.

Please see Rating Guidance for additional rating examples. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • PQI plan (MIL-AM 5.01)
    • Customer file review procedures (MIL-AM 5.03)
    • Sample form used for the customer file review (MIL-AM 5.03)
    • Description of sampling methodology for customer file review (MIL-AM 5.03)
    • Description of what is being measured, including: 
      1. Outcomes
      2. Outputs
      3. Data sources
      4. Indicators
      5. Performance targets (MIL-AM 5.06)
    • Data analysis/reports (MIL-AM 5.07)
    • Local level documentation tracking staff completion of  PQI training (MIL-AM 5.02)
    • PQI training curricula and materials (MIL-AM 5.02)
    • Aggregate data from customer file reviews for the previous two quarters, with any related corrective action plans (MIL-AM 5.03)
    • Methods for soliciting stakeholder feedback (MIL-AM 5.04)
    • Evidence of changes made based on stakeholder feedback (MIL-AM 5.04)
    • Results of external reviews/reports and relevant corrective action (MIL-AM 5.05)
    • For MFR programs seeking re-accreditation:
      1. Pre-Commission Review Report (PCR)
      2. Final Accreditation Report (FAR)
      3. Maintenance of Accreditation (MOA) Reports for the three most recent years (MIL-AM 5.05)
    • Documentation of stakeholder involvement in selection of outcomes and outputs (MIL-AM 5.06)
    • Documentation of stakeholder review and discussion of PQI results, including meeting minutes and agendas (MIL-AM 5.08)
    • Evidence of improvements made through the PQI system (MIL-AM 5.09, MIL-AM 5.10)
    • Interview:
      1. MFR program director
      2. Staff at all levels
      3. Other relevant stakeholders
    • Observe the MFR program’s system for collecting, aggregating, analyzing, and maintaining PQI data (MIL-AM 5.01, MIL-AM 5.06, MIL-AM 5.07)

  • MIL-AM 5.01

    A written PQI plan operationalizes the program’s PQI system, and:

    1. articulates the MFR program’s approach to quality improvement;
    2. describes the PQI system’s structure and activities;
    3. defines the MFR program’s internal and external stakeholders and describes how they will be involved in the PQI system;
    4. identifies what is being measured;
    5. defines data collection processes and applicable timeframes; 
    6. outlines processes for reporting findings; and
    7. outlines processes for monitoring results.

    Interpretation: Stakeholders are the people who have an interest or "stake" in the MFR program’s success at achieving its mission or purpose. Examples of internal and external stakeholders include staff, oversight entities, and customers.


  • MIL-AM 5.02

    Staff receive PQI training that is appropriate to their identified role in the PQI system.


  • MIL-AM 5.03

    Quarterly reviews of customer files:

    1. evaluate the presence, clarity, quality, continuity, and completeness of required documents using a uniform tool to ensure consistency;
    2. include one or two indicators of quality for each of the MFR program’s services;
    3. include a random sample of both open and closed or inactive cases that reflect each of the MFR program’s services and, for the Reserve component, all of its program sites; and
    4. are conducted by reviewers that do not have direct involvement in the cases as a service provider or supervisor, whenever possible. 

    Interpretation: MFR Programs should choose a sampling method that satisfies any applicable regulatory requirements and is appropriate to their size and structure.

    Interpretation: Examples of indicators of quality (b) can include:

    1. services needed and provided or obtained;
    2. length of service;
    3. changes in status or level of service;
    4. need for continued service; and
    5. timeframes. 

    Note: The quarterly review process addressed in MIL-AM 5.03 produces aggregate data from across each service area that can be used to evaluate the MFR program’s record keeping practices. These reviews are distinct from the case-level, supervisory review that is conducted for individual cases on a quarterly or more frequent basis to assess services plan implementation and the customer’s progress towards meeting his or her service goals and desired outcomes.


  • MIL-AM 5.04

    The MFR program establishes formal mechanisms to solicit input and feedback from its stakeholders and has a clear process for using this information to:

    1. implement MFR program improvements;
    2. better serve its customers and the military community; and
    3. identify and address staff satisfaction concerns within their MFR program.

    Interpretation: Examples of ways to demostrate standard implementation include, but are not limited to:

    1. establishing a stakeholder advisory group;
    2. distributing customer satisfaction surveys;
    3. conducting town hall meetings; and
    4. maintaining a suggestion box.


  • MIL-AM 5.05

    The program integrates the findings of external review processes, including accreditation and monitoring reviews, into its PQI process.


  • MIL-AM 5.06

    The MFR program works with relevant stakeholders to identify outputs and outcomes, and related: 

    1. indicators;
    2. data sources; and
    3. performance targets.

    Interpretation: Outputs are what the MFR program delivers, such as the number of referrals made or the total number of customers served over a specific period of time. 

    Outcomes are the observable and measurable effects of a MFR program’s activities on its customers such as debt reduction or improved functioning as measured by a standardized assessment tool whenever possible. 

    Indicators are the specific, measurable, objective events, occurrences, or facets of service delivery that the MFR program will track in order to assess its achievement of targeted performance goals, such as percentage of MFR customers that report being satisfied or very satisfied with the services they received at the MFR program.

    Data sources are the tools or instruments that will be used to collect information on each indicator, such as customer satisfaction surveys.

    Performance targets are the goal that the MFR program is working towards, such as 85% of customers will report being either satisfied or very satisfied.


    Interpretation: Examples of outputs and outcomes include items related to any or all of the following:

    1. customer outcomes such as achievement of individual service goals, quality of life, safety, etc.;
    2. management and operational performance such as efficiency, effectiveness, staff satisfaction, etc.;
    3. the quality of MFR programming and services provided;
    4. MFR program results; or
    5. customer satisfaction.


  • MIL-AM 5.07

    Staff has access to performance data relevant to identified outputs and outcomes that:

    1. is collected, aggregated, analyzed, and maintained in a clear, user-friendly format;
    2. allows for longitudinal reporting and comparison of performance over time; and
    3. informs decision-making and PQI recommendations. 

  • MIL-AM 5.08

    The MFR program communicates PQI findings and recommendations to key audiences and stakeholders.

    Note: The MFR program should be mindful of confidentiality issues when preparing reports.


  • MIL-AM 5.09

    The MFR program takes action based on PQI findings and recommendations to:

    1. replicate good practice;
    2. recognize and motivate staff; 
    3. make MFR program improvements; or
    4. eliminate or reduce identified problems.


  • MIL-AM 5.10

    The program monitors the effectiveness of actions taken and modifies its activities, as needed.

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