WHO IS ACCREDITED?

Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.
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ORGANIZATION TESTIMONIAL

Orange County Government, Youth & Family Services Division

Rodney J. Hrobar Sr., LMHC, CPP, Quality Assurance Manager

As the lead agency in Orange County, providing the safety net for children and families, it is reassuring that our clients can be confident that their needs will be addressed in accordance with the most stringent standards of public, as well as private, accountability as monitored and reviewed by the Council on Accreditation. 
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Purpose

An organization-wide Performance and Quality Improvement system advances efficient, effective service delivery, effective management practices, and the achievement of strategic and program goals.

FOC
PQI 2: Infrastructure

A PQI system has the capacity to:
  1. evaluate services and administration at all regions and sites;     
  2. identify organization-wide and program-specific issues; and
  3. implement solutions that improve overall efficiency.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the PQI 2 Practice standards.
  • The PQI system has sufficient structure, defined procedures, and resources to ensure its long-term sustainability.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 2 Practice standards, however the plan and procedures are sufficient to implement and sustain a PQI system.
3
Practice requires significant improvement as noted in the ratings for the PQI 2 Practice standards.
  • A PQI plan and procedures have been developed but several areas outlined in the PQI Practice standards are not adequately addressed or a few are not addressed at all. 
  • The PQI system, as reflected in the plan and procedures, does not appear to be sustainable.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 2 Practice standards.
  • A PQI system has not been developed, or it is wholly inadequate.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • PQI plan / PQI operational procedures
    • Document or chart that describes the organization's PQI structure including committees, work groups, and member lists, as appropriate
    • PQI meeting/activity schedule for the next twelve months
    Networks Only
    • Network contracts with network service providers

    • Interview:
      1. CEO Senior management 
      2. PQI personnel 
      3. Staff at all levels

  • PQI 2.01

    A written PQI plan and procedures cover each region or site, division, and department, and each program or service area, and: 
    1. articulates the organization’s approach to quality improvement and methods;
    2. describes the PQI system’s structure, functions, and activities;
    3. defines staff roles and assigns responsibility for implementing and coordinating the PQI program (PQI 3);
    4. identifies what is being measured and why; (PQI 4, PQI 5) and
    5. describes an improvement cycle including procedures for reporting findings and monitoring results (PQI 6 and PQI 7). 

    Interpretation: The PQI plan describes how the system is structured and functions,  includes an overview of the organization’s approach to quality improvement, and may include specific models and/or methodologies it may employ (e.g., Six-Sigma, CQI, Plan/Do/Check/Act, and TQM).

    PQI Structure: There are many ways to structure how information and data flow through an organization, mechanisms for review, and decision-making, etc.  Many organizations integrate PQI responsibilities into their existing decision-making and support structure, e.g., management teams, committees, or task forces. Others establish a separate, independent PQI committee to oversee and guide their PQI system.  

    Some small organizations may not have the resources to have a separate PQI structure or committee so they are diligent about including PQI as part of the agenda of regular staff meetings (see PQI 7.04).  In effect, the entire staff serves as the PQI committee.   Please note that it is especially important to thoroughly document PQI discussions in this scenario.

    PQI Procedures:  Due to the amount of detail associated with operationalizing the different components of their PQI system, many organizations maintain a separate PQI Procedures Manual.

    Interpretation PQI 2.01(e): Procedures for reporting findings and monitoring results should include:
    1. obtaining feedback about findings from stakeholders; 
    2. taking action in response to PQI findings and feedback; 
    3. monitoring improvement plans and corrective action plans; and    
    4. determining if an implemented change is an improvement.

    Rating Indicators
    1
    The written PQI plan provides the organization with a framework for operationalizing and implementing a comprehensive PQI system, and includes all of the elements of the standard.

    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • The PQI plan and procedures do not cover one or two of the organization's programs or one of its service delivery sites, or divisions or departments, but the organization is actively working to integrate these into their plan and procedures; 
    • One of the elements is not fully addressed.
    3
    Practice needs significant improvement, e.g., 
    • More than 50% of the organizations programs and service delivery sites or one region or division is not integrated into the organization-wide plan and procedures; or
    • Two of the elements are not fully addressed; or
    • One element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 2.02

    The PQI plan:
    1. defines the organization’s stakeholders; and
    2. specifies how important internal and external stakeholder groups will be involved in the PQI process.

    Interpretation: An organization’s "stakeholders" are the people who have an interest or "stake" in the organization’s success at achieving its mission or purpose.

    Stakeholder involvement is fundamental to a well-designed, useful PQI system. Ideally, a broad range of internal and external stakeholders, including staff from all levels of the organization, the organization’s governing body, persons served, and other external stakeholders have a role in the organization’s PQI system. Examples of stakeholders include:
    • staff;
    • governing body members;
    • persons served, including families as appropriate;
    • volunteers;
    • licensing authorities;
    • consumer advocates;
    • funders; and
    • contractors and partners.
    COA’s Stakeholder Involvement Tip Sheet provides examples of different stakeholder groups often identified by organizations and describes different ways stakeholders can be involved in an organization’s PQI system.

    Interpretation for Networks: Contracts with service provider organizations and independent providers, including fee-for-service-providers, include the requirement that they participate in the network’s performance and quality improvement activities, including utilization management processes.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Most of the important internal and external stakeholders have been identified; and/or 
    • Procedures for involving stakeholders lack specificity regarding how some stakeholder groups will be meaningfully involved.
    3
    Practice needs significant improvement; e.g., 
    • Written documentation does not address involving clients or other external stakeholders; and/or 
    • Provides only minimal guidance about how stakeholders will be involved.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 2.03

    The PQI plan outlines the flow of information between those responsible for implementing and coordinating the organization’s PQI process and the governing body, management, and staff, to ensure:
    1. staff at all levels receive relevant information on PQI findings;
    2. 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 to the organization’s leadership. 

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Plan/procedures lack specificity regarding the flow of information.
    3
    Practice needs significant improvement; e.g., 
    • Plan/procedures provide only minimal guidance.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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