Private Organization Accreditation

Children's Home Society of Florida delivers a unique spectrum of social services designed to protect children at risk of abuse, neglect or abandonment; to strengthen and stabilize families; to help young people break the cycle of abuse and neglect; and to find safe, loving homes for children.


Audrey Coleman, RN-MSN

Volunteer Roles: Military Reviewer; Peer Reviewer; Team Leader

My first experience with COA was in 1999 with what was a NC Area Program. I started as a peer reviewer in 2005, doing two to four site visits a year. I am also a team leader and have recently been approved to be a military reviewer.
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An agency-wide Performance and Quality Improvement system effectively engages staff, persons served, and other stakeholders in advancing the agency’s mission and achieving strategic goals through continuous, integrated, data-driven efforts to improve service delivery and administrative practice.

PA-PQI 2: PQI Infrastructure

The PQI system has an infrastructure that gives the agency capacity to:
  1. ensure the integrity of measurement practices, including data collection and analysis; 
  2. identify agency-wide, as well as region- and program-specific areas of strength and areas for improvement; and
  3. identify, implement, and monitor improvement strategies.

Note: See Model PQI Plan - Private, Public, Canadian, Network for assistance with implementing PA-PQI 2.

Rating Indicators
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's 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 agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's 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 not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
  • A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part 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 agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
  • A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s 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
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • PQI operational procedures (procedures related to program or office specific PQI processes, not otherwise submitted in PA-PQI)
    • PQI Plan
    • Document or chart detailing the agency's PQI structure including committees and work groups with member lists, as appropriate 
    State Administered Agency (Regional Office)
    • Regional PQI operational procedures 
    • Regional PQI plan 
    • Document or chart detailing the region’s PQI structure including committees and work groups with member lists, as appropriate
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Networks only:
      1. Network contracts with network service providers
    State Administered Agency (Regional Office)
    • No On-site Evidence
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Interview:
      1. Agency head
      2. Agency leadership
      3. Program field personnel
      4. Community stakeholders
      5. PQI Director
      6. IM/data analysis manager
      7. Contracted providers
      8. Persons served
    State Administered Agency (Regional Office)
    • Interview:
      1. Regional Director
      2. Agency leadership
      3. Program field personnel
      4. Administrative personnel (HR, Training, PQI, IM)
      5. Community stakeholders
      6. Contracted providers
      7. Persons served

  • PA-PQI 2.01

    Each region or site within the agency’s jurisdiction, and each program or service area, are part of the agency’s PQI system and addressed in the PQI plan. 

    Interpretation: For child and family services agencies, the PQI system must include all the jurisdictions in which the services included in the Child and Family Services Plan are provided. 

  • PA-PQI 2.02

    A PQI plan and accompanying procedures operationalize the agency’s PQI system, and: 
    1. articulate the agency’s approach to quality improvement including specific models and methodologies it employs;
    2. describe the PQI system’s structure and outline all major PQI activities;
    3. define staff roles and assigns responsibility for implementing and coordinating the PQI process (PA-PQI 3)
    4. identify the core areas of performance being measured and the purpose or goals for measuring these areas; (PA-PQI 4, PA-PQI 5)
    5. define measurement practices including data collection and analysis methods, process, and applicable timeframes (PA-PQI 6); and
    6. reflect how the PQI system is evaluated.

    Interpretation: For state-administered agencies, regional PQI plans should directly correlate with the agency-wide plan while also being responsive to the region’s specific needs. The regional plan and accompanying procedures explain the structure for carrying out PQI activities in the region, including any region-specific committees, processes, and performance measures. Additionally, if the region contains any unique programs, the regional PQI plan should address the PQI activities and measures for those programs.

    Interpretation:  Among other things, evaluation of the PQI system should include assessing how well PQI activities align with best practices in measurement including (1) is the agency asking the right performance questions, (2) how well do chosen metrics answer the performance questions being asked, and (3) is the agency accurately measuring change over time. 

    Interpretation: The agency’s PQI plan, as the guiding document for implementing and refining the PQI system, is distinct from time-sensitive actionable plans that the agency develops to target improvement activities such as the Child and Family Services Review Program Improvement Plans.  

    Note: See PQI Operational Procedures Worksheet - Private, Public, Canadian for assistance with this standard. 

  • PA-PQI 2.03

    The PQI plan:
    1. defines a broad range of internal and external stakeholder groups; and
    2. specifies how these stakeholder groups will be involved in the PQI process.

    Interpretation: An agency’s "stakeholders" are any institutions or individuals who will be impacted by the agency’s decisions, i.e. they have an interest or "stake" in the agency’s success at achieving its mission or purpose. Stakeholder involvement is fundamental to any well-designed PQI system and is crucial to a public agency’s ability to achieve its mission and elicit public trust. Stakeholders are often thought of in terms of categories or groups of people—sometimes referred to as communities of interest. 
    Common stakeholder categories include: 
    1. persons served, including children and youth when applicable;
    2. community-based organizations and neighborhood associations; 
    3. service providers, particularly contracted providers;
    4. community-based business entities;
    5. public agency partners, including other social service agencies and the court system; 
    6. statewide or national advocacy organizations; and 
    7. academic, learning and research institutions. 
    Stakeholders should participate in a broad range of activities including involvement in PQI planning activities; activities that gather qualitative data on the experience of receiving services or providing services as a contracted provider; reviewing and interpreting summary data information; and identifying, implementing, and monitoring solutions.
    Interpretation: While staff are a common stakeholder category, throughout the PA-PQI standards, staff are intentionally differentiated from other stakeholders in order to highlight their unique involvement in the PQI process.

    Note: COA’s Stakeholder Involvement Tip Sheet provides examples of different stakeholder groups often identified by agencies and describes different ways stakeholders can be involved in an agency’s PQI system.

    Research Note: Participatory design is an approach that involves stakeholders in the development and structuring of systems to promote system responsiveness to stakeholder needs. By encouraging stakeholders who are involved and/or invested in the day-to-day-work of the agency to participate in the development of the PQI process, agencies can better ensure that the end-product of their efforts have a positive and sustainable impact on persons served.

    An effective way to improve stakeholder involvement and foster participatory design is to do an assessment of the agency’s current relationships with its partners and collaborators. Eco –mapping is an effective method of evaluating agency relationships with stakeholders, setting the groundwork for improved participatory design. See PA-AM 5 and PA-AM 6 for more information on effectively engaging stakeholders in the development and structuring of systems.

  • PA-PQI 2.04

    The PQI plan outlines the flow of information between frontline workers and those responsible for implementing and coordinating the agency’s PQI process to ensure:
    1. staff at all levels of the agency receive information on PQI evidence and findings;
    2. frontline staff and their supervisors have timely access to the information they need to clarify expectations and implement practice improvements; and
    3. timely, effective delivery of data and feedback back to PQI system administrators.  

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