WHO IS ACCREDITED?

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.
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VOLUNTEER TESTIMONIAL

Barry Gourley

Volunteer Roles: Endorser; Peer Reviewer

It is an honor to be a COA volunteer. I’ve had a great opportunity to work with fabulous COA volunteers, I’ve grown professionally in the COA accreditation process and I’ve met some wonderful people across this nation who are working hard to help and support children and families.
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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 7: Using Data

The organization acts on findings to build capacity, improve programs, and have a positive impact on persons served. 

Interpretation: Information generated by the PQI system is used to:
  • monitor progress toward achievement of strategic goals and long-term direction;
  • manage programs and operations efficiently and effectively;
  • support direct service staff to meet program goals and have a positive impact on persons served; 
  • meet funder requirements; and
  • promote the organization and its services throughout the community.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the PQI 7 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 7 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the PQI 7 Practice standards.
  • PQI data is not routinely used and there are serious concerns about the PQI system's sustainability due to lack of attention on the part of leaders and senior managers.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 7 Practice standards.Data is not being used to improve performance and the PQI system is unsustainable due to inattention by leaders and senior managers.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Annual PQI Report or other mechanism for reporting results (PQI 7.03)
    • See response to Narrative Question #3
    • Evidence of improvements made from the analysis and use of PQI data, including data related to the standards in PQI 4, PQI 5, and PQI 6, and any related corrective action/improvement plans.
    • PQI meeting minutes, agendas, attendance lists
    • Governing body meeting minutes reflecting review of PQI data / annual PQI report
    • Interview:
      1. PQI personnel 
      2. Personnel at all levels 
      3. External stakeholder groups

  • PQI 7.01

    The organization reviews findings and feedback and takes action, when indicated to:
    1. eliminate or reduce identified problems;
    2. replicate good practice;
    3. recognize and motivate staff;
    4. improve organizational systems, processes, polices, and procedures; and
    5. improve services.
       

    Interpretation: Corrective Action Plans or Improvement Plans should be implemented when issues have been identified that will involve ongoing effort and monitoring.
     
    Corrective Action Plans are implemented to correct problems or deficiencies, including those related to compliance with regulatory requirements (e.g., Medicaid documentation requirements). The need for a Corrective Action Plan suggests that the issue has moved beyond program improvement to the level of oversight by the organization’s leadership. 
     
    Improvement Plans formally lay out the actions that will be taken to address areas in need of improvement that are identified by staff and stakeholders as crucial to meeting the organization’s goals and delivering quality services.  Improvement plans should be implemented when it is necessary to monitor and address the issue over time.

    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.,
    • The organization uses PQI data to improve programs, etc., however some available findings and recommendations are not being used.
    3
    Practice requires significant improvement; e.g., 
    • Except for a few examples, the organization does not generate enough useable data to take meaningful action; or
    • Does not routinely use data in any of the ways listed in the standard.   
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 7.02

    The organization monitors the effectiveness of actions taken and modifies implemented improvements, as needed.

    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.,
    • Actions made in response to findings and feedback are being monitored, and modifications are made when needed, but practice could be improved, e.g.,
      • Monitoring does not appear to be a priority and as a result, the process for monitoring or modifying some of implemented improvements has not been established, or 
      • The data is not being reviewed in a timely manner.
    3
    Practice requires significant improvement; e.g., 
    • While there is some evidence that the standard is being met, monitoring is not routinely done; or
    • Important modifications are not often made despite evidence that they are needed. 
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 7.03

    The organization creates a summary report, at least annually, for oversight entities, stakeholders, and staff, that includes:
    1. key PQI activities that are ongoing, have been resolved, or that need further intervention;
    2. issues that require continued monitoring within the PQI system; and  
    3. PQI priorities and goals for the coming year.

    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.,
    • The annual summary report serves as a useful planning tool, but practice related to one of the standard's elements could be better developed.
    3
    Practice requires significant improvement; e.g., 
    • The annual summary report does not adequately address two of the standard's elements; or 
    • One of the elements is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 7.04

    Organization leaders, senior managers, program directors, and supervisors:
    1. keep PQI on the agenda of board, management, and staff meetings;
    2. regularly evaluate the need for and uses of data; and
    3. evaluate the PQI system, infrastructure, processes and procedures.

    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.,
    • Leaders, etc. are committed to maintaining a sustainable PQI system, but practice related to one of the standard's elements needs improvement.
    3
    Practice requires significant improvement; e.g., 
    • Leaders, etc. do not consistently put the effort and attention needed to sustain the organization's PQI system, as indicated by limited implementation of two of the standard's elements. 
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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