Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.


Rochelle Haimes, ACSW

Volunteer Roles: Commissioner; Peer Reviewer; Standards Panel Member; Team Leader

Rochelle is a Consultant working with a variety of private organizations to become accredited. Her primary area of expertise is in facilitating the development of PQI systems and activities. Her previous experience with both small and large organizations is the cornerstone for her long-standing volunteer activities as a Peer reviewer and as a Team Leader.
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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 4: Measures and Indicators

The agency’s mission, mandates, and strategic priorities drive the identification and utilization of measures and indicators for evaluating the following within the agency and with any contracted providers within the service delivery system: 
  1. the impact of services on individuals and families; 
  2. the quality of service delivery; and
  3. management and operational performance.

Interpretation: Measures, indicators, and tools required by regulation can be utilized to go beyond measuring compliance by engaging staff and other stakeholders to: 
  1. review data that is important for their work or interest;
  2. use data to benchmark results with other agencies providing the same funded services; and
  3. compare data with additional or other data collected by the agency not covered by contractual requirements to improve services.

Research Note: The Child and Family Services Review (CFSR) encourages child and family services agencies to align CFSR activities with other monitoring and review activities, including the state-wide continuous quality improvement system.

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
    • See PQI plan (PA-PQI 2) for a description of what is being measured, including:
      1. outcome measures
      2. process and quality measures
      3. data sources 
      4. performance indicators
      5. performance targets (PA-PQI 4.02, PA-PQI 4.03, and PA-PQI 4.04)
    • Documentation of staff/stakeholder involvement in ongoing review of measures, indicators, data sources, and performance targets (PA-PQI 4.01)
    • See PQI outcomes/outputs documentation provided in the service narratives
    State Administered Agency (Regional Office)
    • See Regional PQI plan for region-specific measures or indicators, if appropriate (PA-PQI 4.02, PA-PQI 4.03, PA-PQI 4.04)
    • Regional documentation of staff/stakeholder involvement in ongoing review of measures, indicators, data-sources, and performance targets (PA-PQI 4.01)
    • See PQI outcomes/outputs documentation provided in the service narratives
    All Agencies
    • Regulatory/licensing or other external reviews/reports (PA-PQI 4.05)
    • For agencies 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
    All Agencies
    • Interview:
      1. PQI staff
      2. Relevant staff
      3. Other relevant stakeholders

  • PA-PQI 4.01

    Staff throughout the agency and stakeholders, including contracted providers, participate in the ongoing review of outcome and process and quality measures, as well as related:
    1. quantitative and qualitative indicators;
    2. data sources, including measurement tools and instruments for each identified measure; and
    3. performance targets.

    Interpretation: Agencies should assess variation in service population, service area, staffing and other factors in order to develop baselines, performance targets, and benchmarks that are tailored to the local area or program.
    Interpretation: Outcome Measures are the observable and measureable effects of a program’s activities on persons served.  See PA-PQI 4.02 for more information.
    Process and Quality Measures track management and operational performance and service delivery processes and the quality of service provision.  See PA-PQI 4.03 and PA-PQI 4.04 for more information.

  • PA-PQI 4.02

    To track the impact of services on individuals and families on an ongoing basis, each of the agency’s programs uses outcome measures related to the following areas, as applicable:
    1. change in clinical status;
    2. change in functional status;
    3. health, welfare, and safety;
    4. permanency of life situation; 
    5. quality of life; and 
    6. other outcomes as appropriate to the program or service population.

    Interpretation: Whenever available the agency should use standardized or recognized evaluation tools to gather and analyze the impact of its services on persons served. Functional assessments permit the analysis of an individual or family’s status over time and, in the aggregate, this case-level data can inform the analysis of trends and relationships to correlating service delivery components.

    Interpretation: For child and family services agencies, outcome measures must align with the safety, permanency, and well-being outcomes assessed by the Child and Family Services Reviews (CFSRs).

    Interpretation: In an EAP common outcomes include, for example, personal and/or workplace productivity and healthy workplace relationships.

    Research Note: Research recommends that child and family services agencies track placement and permanency outcomes by race and ethnicity in order to gain a better understanding of how racial and ethnic disparities and disproportionality are impacting children and families. 

  • PA-PQI 4.03

    To evaluate the quality of its service delivery practices, the agency identifies and uses process and quality measures and indicators related to the following:
    1. outreach, intake, assessment, and service planning and delivery processes;
    2. training, and supervision of program staff;
    3. review of immediate and ongoing risks related to service delivery; and
    4. consumer satisfaction.

    Interpretation: For child and family services agencies, implementation of PA-PQI 4.03 should include an examination of relevant systemic factors assessed by the Child and Family Services Reviews (CFSRs). 

    Note: Implementation of PA-PQI 4.03 requires that the program conduct periodic case reviews as outlined in PA-PQI 5 in order to assess the quality and effectiveness of service delivery practices.  

  • PA-PQI 4.04

    To evaluate management and operational performance, the agency identifies and uses process and quality measures and indicators across the agency and with contracted providers, when applicable, to:
    1. strengthen performance and build capacity;
    2. measure progress toward achieving its strategic goals and objectives;
    3. evaluate operational functions that influence service delivery; and
    4. identify and mitigate risk. 

    Interpretation: Examples of process and quality measure related to operations and management can include:
    1. efficiency in the allocation and utilization of its human and financial resources in furthering or impeding the achievement of agency objectives (PA-HR 2);
    2. effectiveness of risk prevention measures (See PA-RPM 2);
    3. staff retention/turnover and satisfaction (See PA-HR 4);
    4. the cost of delivering a unit of service as compared to similar programs (See PA-FIN 3.06)
    5. the relationship of service delivery costs to the benefits derived by persons served;
    6. achievement of budgetary objectives (PA-FIN 3);
    7. effectiveness of public education and outreach (See PA-AM 7.01); and
    8. staff fidelity to the process and quality standards set by the agency.
    Interpretation: For child and family services agencies, implementation of PA-PQI 4.04 includes an examination of relevant systemic factors assessed by the Child and Family Services Reviews (CFSRs).

    Interpretation: Agencies that use contracted providers may also measure important contract oversight and system integration processes, such as: 
    1. the proportion of services that are meeting defined outcomes for persons served;
    2. the proportion of services that are evidence-based or meet nationally recognized treatment guidelines developed by consensus groups; 
    3. the integration of performance and outcomes data across the system;
    4. the integration and coordination of service provision processes across the system including ease of access to services;
    5. the effectiveness of contractor training and technical assistance efforts; 
    6. the satisfaction of stakeholders, such as high volume referral agents (e.g., judges, court workers, schools, and law enforcement); and
    7. results of case reviews, including the percentage of charts in which a placement decision includes an appropriate application of clinical criteria.

  • PA-PQI 4.05

    The PQI system enables the agency to address the findings of external review and monitoring processes, including, as applicable:
    1. licensing and other reviews related to federal, state, and local requirements;
    2. litigated third party oversight, including consent decrees;
    3. government and other funder audits;
    4. accreditation reviews; and 
    5. other reviews, where appropriate.

    Interpretation: When agencies are involved in litigated third-party oversight, such as consent decrees, strategic plans and PQI plans (agency-wide plans or jurisdiction-specific plans) should indicate how the overall PQI system balances pursuit of compliance with the larger quality improvement agenda.

    Interpretation: For child and family services agencies, the PQI system must incorporate the findings of the Child and Family Services Review and support implementation of the strategies outlined in its Program Improvement Plan.

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