WHO IS ACCREDITED?

Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.
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ORGANIZATION TESTIMONIAL

Domestic Violence Intervention Services, Inc.

Donna Mathews, Associate Director

Becoming accredited and maintaining our accreditation through COA has helped us increase our professionalism and thereby provide better services to domestic violence, sexual assault, stalking, and dating violence survivors.
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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 6: Analyzing and Reporting Information

The organization systematically collects, aggregates, analyzes, and maintains data.

Interpretation: PQI data management procedures should be part of the organizations overall data management procedures/guidelines as required in RPM 5. Additionally, the need for, and use of, technology related to maintenance of PQI data should be addressed in the organization’s written technology and information management plan as described in RPM 5.01.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the PQI 6 Practice standards.

Comprehensive PQI data management procedures support the organization's ability to systematically collect, aggregate, analyze and maintain data.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 6 Practice standards.
3
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 6 Practice standards.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Procedures for collecting, reviewing and aggregating PQI data, including procedures for cleaning data (PQI 6.01)
    • Data analyses/reports related to the elements in PQI 6.02
    • Summary documents or reports provided to internal and external stakeholders, e.g.,
      1. performance dashboards,
      2. annual reports
      3. reports of gains made against goals
      4. annual scorecards, etc. (PQI 6.03)
    • Procedures for sharing and reviewing reports and findings with staff and stakeholders (PQI 6.04)
    • PQI committees/work group minutes for analyzing PQI information 
    • Documentation of stakeholder review and discussion of PQI results, including meeting minutes and agendas
    • Governing body meeting minutes regarding review of PQI data
    • Interview:
      1. PQI personnel 
      2. Relevant staff
    • Review of management information system regarding collecting, aggregating, analyzing, and maintaining data

  • PQI 6.01

    Procedures for collecting, reviewing and aggregating data include: 
    1. cleaning data to ensure data integrity;
    2. quarterly aggregation of data; and
    3. developing reports for analysis and interpretation.

    Interpretation: Data should be aggregated at least quarterly at all three levels of performance measurement as addressed in, PQI 4.02, PQI 4.03, PQI 4.04, and PQI 5.

    Cleaning data, also known as data cleansing, means checking for errors and inconsistencies in order to improve the quality of your data prior to aggregating and analyzing it. Common things to check for include:
    • Accuracy - making sure the data was recorded correctly including misspellings, correct numbers, addresses, etc.
    • Completeness - making sure all the data was recorded and none is missing
    • Timeliness - ensuring that the data is current and/or relevant to the current time frame, e.g., the last quarter that is the time period being aggregated, or that the data is not too old to be useful
    • Uniqueness - ensuring that data was recorded only once and not multiple times
    • Outliers - look for data that is unexpected. Sometimes that means you have a PQI issue that warrants attention. But sometimes a single extreme result, even if it is legitimate, can tip the results so they are not truly representative

    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.,
    • Procedures for ensuring data integrity and reliability are sufficient for sustaining the PQI system but need some improvement, e.g., formats for reports are not consistently useful for analysis; or 
    • In a few instances data was not aggregated and reviewed quarterly.
    3
    Practice needs significant improvement; e.g., 
    • Procedures are insufficient to sustain consistent data review; or do not address one of standard's elements;  or 
    • Only some of the collected data is reviewed and/or aggregated for review; or 
    • Data is rarely aggregated into a form that permits analysis.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 6.02

    The organization analyzes PQI data to:
    1. track and monitor identified measures;
    2. identify patterns and trends;
    3. compare performance over time;
    4. compare data against the results of internal benchmarks; and
    5. compare data against the results of external benchmarks, if available.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.

    The organization analyzes PQI data per the requirements of the standard and includes review against internal and external benchmarks.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Data from across the organization is analyzed, but data is not analyzed for one of the organization’s programs; or 
    • Data analysis does not include two of the elements of the standard. 
    3
    Practice needs significant improvement; e.g., 
    • Most of the organization's PQI data has not been analyzed; or 
    • Data analysis is not performed for most of the organization's programs or services; or 
    • Data related to management and operational performance are not analyzed.  
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.  

  • PQI 6.03

    Reports of PQI findings: 
    1. are distributed in timeframes and formats that facilitate review, analysis, interpretation, and timely corrective action; 
    2. facilitate compliance with regulatory reporting requirements.
    3. consider concerns related to the confidentiality of service recipients.

    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.,
    • Summary reports are created and distributed, but practice could be improved, e.g., 
    • Stakeholders have complained about reports that are hard to read or understand; or 
    • Summary reports are not always distributed in a useful timeframe. 
    3
    Practice requires significant improvement, e.g., 
    • There are many examples of relevant PQI data not being provided to stakeholders for review; or 
    • Data is not formatted into reports; or
    • The format of reports is unclear and confusing; or 
    • Confidentiality concerns have been raised or noted.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 6.04

    The organization has procedures for sharing and reviewing reports and findings with staff and stakeholders including discussion of:
    1. areas of strength and quality practice;
    2. areas for improvement; and
    3. how to prioritize targeted areas, identify interventions, and monitor the effectiveness of interventions over time.

    Interpretation: In order to engage in meaningful discussions about the data being collected, organizations need to decide how results will be communicated to staff and stakeholders. Organizations can start by determining who needs what data, with what frequency, and how best to share the information.

    Methods for sharing findings include: 
    • performance dashboards, report cards, or other types of summary reports;
    • discussion at staff and departmental meetings; 
    • using monthly reports of key service delivery outputs and outcomes in staff supervision activities; 
    • conducting focus groups and presentations at community meetings; 
    • soliciting feedback via interviews or surveys;
    • providing quarterly reports to the oversight entities, stakeholder advisory groups, and leaders on important data related to key operations and management functions; and
    • quality review activities that engage community providers.

    Research Note: Graphic presentation of data is very useful in communicating results of PQI activities. Data visualization techniques can facilitate understanding of complex information and reveal underlying patterns and relationships within the data that may otherwise go unnoticed.

    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.,
    • Stakeholder involvement is limited to staff, but the organization is in the process of establishing methods for involving clients.
    3
    Practice requires significant improvement; e.g., 
    • Data review is limited to PQI staff and/or management with little or no involvement of other staff or clients. 
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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