Standards for Canadian organizations

2020 Edition

Performance and Quality Improvement (CA-PQI) 4: Case Record Review

The organization conducts case record reviews at least quarterly for each of its services to:
  1. minimize the risks associated with poorly maintained case records;
  2. document the quality of the services being delivered; and
  3. identify barriers and opportunities for improving services.

Interpretation

COA is not prescriptive about who can conduct case record reviews. While a peer review model is recommended, it is acceptable for PQI staff, a consultant, or another person or combination of persons to conduct the reviews. Please note that, regarding CA-PQI 4.03, persons with clinical or service delivery experience may be needed to obtain the relevant qualitative data from the case records.
NA The organization provides only Early Childhood Education (CA-ECE) and/or Out-of-School Time Services (CA-OST).
 

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.
2020 Edition

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Purpose

An organization-wide performance and quality improvement system uses data to promote efficient, effective service delivery and achievement of the organization’s mission and strategic goals.
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-PQI 4 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the CA-PQI 4 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the CA-PQI 4 Practice standards; e.g.,
  • Case records may pose a risk to the organization and corrective action has not been implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PQI 4 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case record review procedures, including sampling methodology
  • Sample of case record review data collection tool(s)
  • Most recent quarterly report from the case record review process
  • Results of external case record audits, if applicable
  • Interviews may include:
    1. PQI personnel
    2. Relevant personnel

CA-PQI 4.01

The quarterly case record review process:
  1. includes a random sample of both open and recently closed cases;
  2. uses uniform data collection tools to ensure consistency and permit comparison of data across similar programs and services; and
  3. maintains objectivity by ensuring that reviewers do not review cases in which they have been directly involved as a service provider or supervisor.

Interpretation

Sampling: See recommended sampling guidelines. Organizations may choose a different sampling method as long as a rationale is provided.
 
Closed Cases: COA does not define the percentage of closed cases that must be included in the sample. The majority of cases the organization reviews should be open, but the organization must include a sample of closed cases to evaluate documentation related to discharge planning, case closing, aftercare, and the condition of the case record including whether or not records have been expunged as required by CA-PRG 1.06.
Examples: Organizations can get more from the case record review process by stratifying the random sample of open cases to account for length of service. For example, a program that serves clients for up to six months could divide the sample proportionally between cases that have been open less than one month, one to three months, three to six months, and more than six months.

For generating random numbers, the Research Randomizer is an easy to use tool. The tool is made available for free by the Social Psychology Network and includes short tutorials.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the standard's elements is not sufficiently developed, e.g., cases are not selected randomly for more than half of the organization's programs or services but includes both open and closed cases.
3
Practice needs significant improvement; e.g.,
  • At least two of the standard's elements are not sufficiently developed, e.g., sample size is insufficient to enable the organization to draw conclusions from the data; or
  • The organization only reviews open cases; or
  • Little effort is being made to ensure objectivity, e.g., supervisors frequently were the sole reviewers of supervisee cases.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

CA-PQI 4.02

Quarterly reviews of case records evaluate the presence, clarity, quality, continuity, and completeness of required documents.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One or two important documents are not included in the review; or
  • Procedures need strengthening.
3
Practice needs significant improvement; e.g.,
  • A number of important documents are not included in the review; or
  • Reviews are conducted no more than three times per year; or
  • Reviews are not conducted for one of the organization's services; or
  • The review process is poorly designed or haphazardly conducted; or
  • Case records may pose a risk to the organization and corrective action has not been implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

CA-PQI 4.03

The organization identifies indicators and measures the quality of services for each of its programs or services in its quarterly case record review process.
Examples: Quality of services is a very broad category and varies according to the program, service population, service mandates, and any number of other factors and can include criteria for evaluating the appropriateness and/or effectiveness of the services provided to persons served.

Examples of common qualitative measures include:
  1. timeliness and comprehensiveness of individualized assessments;
  2. length of service;
  3. need for continued service;
  4. family involvement; and
  5. achievement of service goals, etc.
Some organizations take a utilization management approach to case record review and, rather than review case records quarterly, conduct more frequent or ongoing reviews. A utilization management approach looks at the key decisions and process milestones including, for example:
  1. appropriateness of admissions and authorization decisions;
  2. intake and referral processes;
  3. service planning and service delivery milestones;
  4. need for continued service; and
  5. discharge decisions.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Indicators for one program need strengthening; or
  • Data is aggregated and used to monitor service quality for 75% of the organization’s programs/services including all high risk programs.
3
Practice needs significant improvement; e.g.,
  • Data is not consistently collected, or is collected and aggregated but not used to monitor service quality; or
  • Service quality data is collected for less than 75% of the organization's programs; or
  • Service quality data is not being collected for at least one high-risk program.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.