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 3: Roles and Responsibilities

The organization has sufficient qualified staff to conduct and sustain its PQI system.

Interpretation: COA does not expect all staff to be involved in PQI but expects a cross-section of staff from different departments and levels of the organization to be involved.
 

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the PQI 3 Practice Standards.

Staff have the knowledge and experience to implement and coordinate the PQI system, including the ability to implement evaluation methods, as per the requirements of the standard. 
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 3 Practice standards.
  • Identified staffing and training deficiencies do not significantly compromise the organization's ability to implement its PQI system or sustain it over time.
  • Job descriptions reflect the required competences, and the organization seeks to hire and/or assign or train people with the requisite skills.
3
Practice requires significant improvement as noted in the ratings for the PQI 3 Practice standards.
  • Implementation of the PQI 3 Practice Standards is limited, and the organization's inability to hire or train staff is presenting a serious challenge to its ability to implement and sustain a PQI system. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 3 Practice standards.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Job description of staff members responsible for oversight and coordination of the PQI system
    • Job descriptions of staff with ongoing PQI responsibilities
    • Tables of content of training curricula
    • See response to Narrative Question #2
    • Documentation of staff PQI training 
    • Training curricula and materials
    • Interview:
      1. PQI personnel 
      2. Managers and program directors 
      3. Personnel at all levels 
    • For Networks
      1. Subcontracted providers
      2. Staff participating in the network-level PQI activities

  • PQI 3.01

    Staff responsible for implementing and coordinating the organization’s PQI system are competent to:
    1. identify indicators of quality practice;
    2. implement internal and external evaluation methods, such as benchmarking, as appropriate to the programs being evaluated;
    3. ensure proper data entry and data integrity; and
    4. collect, analyze, and interpret data from a range of sources.

    Interpretation: PQI may be a shared responsibility as opposed to being under the leadership of a single staff position. 

    The staff who share responsibility for implementing and coordinating PQI understand the organization and its services and can provide a common perspective more easily.
     
    Staff will have the education and experience in quality improvement, performance measurement, and/or program evaluation, or the organization provides support, e.g., training, professional development, access to consultation, mentoring, and/or opportunities for networking.

     
    Organizations that have limited resources or are new to measuring performance can partner with colleges or universities or other organizations to gain access to knowledge and expertise related to setting up and sustaining their PQI system, collecting and analyzing data, etc.

    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.,
    • PQI staff have the competency and/or support needed to implement and coordinate the PQI system, but one of the elements is not fully addressed.
    3
    Practice needs significant improvement; e.g.,
    • PQI staff are not sufficiently competent and/or supported to implement and coordinate the PQI system (e.g., one element is not addressed at all, or two of the elements are not fully addressed).
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 3.02

    Staff responsible for implementing and coordinating the organization’s PQI process are competent to:

    1. effectively engage people throughout the organization; 
    2. assess staff training and resource needs; and
    3. communicate evidence and findings to staff in a manner that facilitates their active engagement.

    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.,
    • PQI staff have the competency and/or support needed to implement and coordinate the PQI system, but one of the elements is not fully addressed. 
    3
    Practice needs significant improvement; e.g.,
    • PQI staff are not sufficiently competent and/or supported to implement and coordinate the PQI system (e.g., one element is not addressed at all, or two of the elements are not fully addressed).
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 3.03

    Staff receive support, as appropriate to their responsibilities, on: 

    1. inputting data into the data management system;
    2. using data collection tools and forms; 
    3. reading and interpreting reports; and  
    4. using data to improve performance.

    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 staff receive the support they need.
    3
    Practice needs significant improvement, e.g. 
    • Staff support is insufficient for at least two of the standards elements; or 
    • Support is not being provided for either element (a) or (b); or
    • The integrity of the data may be compromised due to insufficient staff support.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.
    • Staff are not supported and cannot demonstrate competence, and further support is not being provided.

  • PQI 3.04

    Supervisors of direct service personnel and program directors:  
    1. help the organization meet its quality improvement, evaluation, and reporting requirements; 
    2. contribute to developing outcomes and indicators and setting targets;
    3. participate in the collection of data;
    4. interpret data;
    5. apply data to improve practices and outcomes; and
    6. use program and client outcomes data to improve service delivery.

    Interpretation: Providing an opportunity for supervisors and program directors to increase their competencies may come from “bartering” an exchange of time with another organization that has a more developed PQI program. Some small agencies may obtain some training hours from a colleague organization’s PQI Coordinator at a nominal cost or as a collegial gesture.

    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 supervisors of direct service personnel and program directors have the knowledge/skills, and actively participate in the PQI system as per the requirements of the standard; or 
    • Only a few have knowledge/skills related to elements (d) and (e).  
    3
    Practice needs significant improvement; e.g., 
    • Most supervisors of direct service personnel and program directors do not have the knowledge or skills; or
    • Most supervisors do not participate as required by the standard; or
    • There is little or no support available to supervisors and program directors who do not have the relevant knowledge/skills.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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