The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-PQI 5 Practice standards. Comprehensive PQI data management procedures support the organization's ability to systematically collect, aggregate, analyze and maintain data.
Practices are basically sound but there is room for improvement as noted in the ratings for the CA-PQI 5 Practice standards.
Practice requires significant improvement as noted in the ratings for the CA-PQI 5 Practice standards.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PQI 5 Practice standards.
Procedures for collecting, reviewing, and aggregating PQI data
Data analysis/reports related to the elements in CA-PQI 5.02
Most recent summary documents or reports provided to internal and external stakeholder
Procedures for sharing and reviewing reports and findings with staff and stakeholders
PQI committee/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
Documentation of improvements made from the analysis and use of PQI data, including any related corrective action/improvement plans
Interviews may include:
Observe system for collecting, aggregating, analyzing, and maintaining data
Procedures for collecting, reviewing, and aggregating data include:
cleaning data to ensure data integrity, including accuracy, completeness, timeliness, uniqueness, and outliers;
quarterly aggregation of data; and
developing reports for analysis and interpretation.
Data should be collected, aggregated, and reviewed at least quarterly at all three levels of performance measurement as addressed in CA-PQI 3.03, CA-PQI 4, and the Client-Centered Logic Model Core Concept in each assigned Service Standard.
Examples: 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;
uniqueness - ensuring that data was recorded only once and not multiple times; and
outliers - look for data that is unexpected (Note: This could mean 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).
Examples: Discussions with board, staff, and stakeholders about PQI findings can include:
areas of strength and quality practice;
areas for improvement; and
how to prioritize targeted areas, identify interventions, and monitor the effectiveness of interventions over time.
In order to engage in meaningful discussions about the data being collected, organizations should 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 board, 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 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.
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.
Examples: Organizations can use PQI findings and feedback to:
eliminate or reduce identified problems;
replicate good practice;
recognize and motivate staff; and
improve organizational systems, processes, policies, and procedures.
Examples: Information generated by the PQI system can be used to:
monitor progress toward achieving its mission and strategic and annual goals;
meet funder requirements; and
promote the organization and its services throughout the community.
Examples: Corrective Action Plans or Improvement Plans can be implemented when issues have been identified that will involve ongoing effort and monitoring.
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.
Corrective Action Plans are implemented to correct problems or deficiencies, including those related to compliance with regulatory 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.
Organizations may also wish to create an annual summary report for oversight entities, stakeholders, and staff that includes:
key PQI activities that are ongoing, have been resolved, or that need further intervention;
issues that require continued monitoring within the PQI system; and