Standards for private organizations

2020 Edition

Performance and Quality Improvement (PQI) 1: Infrastructure

The organization’s PQI system has the capacity to:
  1. evaluate services at all regions and sites;
  2. identify organization-wide and program-specific issues; and
  3. implement solutions that improve overall effectiveness.
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 PQI 1 Practice standards. The PQI system has sufficient structure, defined procedures, and resources to ensure its long-term sustainability.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 1 Practice standards; e.g.,
  • The plan and procedures are sufficient to implement and sustain a PQI system.
3
Practice requires significant improvement as noted in the ratings for the PQI 1 Practice standards; e.g.,
  • A PQI plan and procedures have been developed but several areas outlined in the PQI Practice standards are not adequately addressed or a few are not addressed at all; or
  • The PQI system, as reflected in the plan and procedures, does not appear to be sustainable.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 1 Practice standards; e.g.,
  • A PQI system has not been developed, or it is wholly inadequate.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • PQI plan
  • PQI operational procedures
  • Document or chart that describes the organization's PQI structure including committees, work groups, and member lists, as appropriate
  • PQI meeting/activity schedule for the next 12 months
No On-Site Evidence
  • Interviews may include:
    1. CEO 
    2. Senior management 
    3. PQI personnel 
    4. Relevant personnel

 

PQI 1.01

A written PQI plan and procedures cover each program or service area and, if necessary, outline any variances between regions or sites, and:
  1. articulate the organization's approach to quality improvement and methods used;
  2. describe the PQI system's structure, functions, and activities;
  3. define staff roles and assign responsibility for implementing and coordinating the PQI program (PQI 2);
  4. identify what is being measured and why (PQI 3, PQI 4, Service Standards); and
  5.  include procedures for reporting findings and monitoring results (PQI 5).
Examples: The PQI plan describes how the system is structured and functions, includes an overview of the organization’s approach to quality improvement, and may include specific models and/or methodologies it may employ (e.g., Six-Sigma, CQI, Plan/Do/Check/Act, and TQM).

PQI Structure: There are many ways to structure how information and data flow through an organization, mechanisms for review, and decision-making. Many organizations integrate PQI responsibilities into their existing decision-making and support structure, e.g., management teams, committees, or task forces. Others establish a separate, independent PQI committee to oversee and guide their PQI system.

Some small organizations may not have the resources to have a separate PQI structure or committee so they are diligent about including PQI as part of the agenda of regular staff meetings (see PQI 1.04). In effect, the entire staff serves as the PQI committee. Please note that it is especially important to thoroughly document PQI discussions in this scenario.

In regards to element (e), procedures for reporting findings and monitoring results can include:
  1. obtaining feedback about findings from stakeholders;
  2. taking action in response to PQI findings and feedback;
  3. monitoring improvement plans and corrective action plans; and
  4. determining if an implemented change is an improvement.
Note: In regards to element (d), please see the Client-Centered Logic Model Core Concept in each assigned Service Standard for additional information on program outputs and client outcomes to be included in the PQI plan.
1
The written PQI plan provides the organization with a framework for operationalizing and implementing a comprehensive PQI system and includes all of the elements of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The PQI plan and procedures do not cover one or two of the organization's programs or one of its service delivery sites, divisions, or departments, but the organization is actively working to integrate these into their plan and procedures; or
  • One of the elements is not fully addressed.
3
Practice needs significant improvement, e.g.,
  • More than two of the organization's programs or service delivery sites, regions, or divisions are not integrated into the organization-wide plan and procedures; or
  • Two of the elements are not fully addressed; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

PQI 1.02

The PQI plan:
  1. defines the organization's stakeholders; and
  2. specifies how important internal and external stakeholder groups will be involved in the PQI process.

Interpretation

 Stakeholder involvement is fundamental to a well-designed, useful PQI system. Ideally, a broad range of internal and external stakeholders including staff from all levels of the organization, the organization's governing body, persons served, and other external stakeholders have a role in the organization's PQI system.
Examples: Examples of stakeholders include:
  1. staff;
  2. governing body members;
  3. persons served, including families, as appropriate;
  4. volunteers;
  5. licensing authorities;
  6. consumer advocates;
  7. funders; and
  8. contractors and partners.
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 of the important internal and external stakeholders have been identified; or
  • Procedures for involving stakeholders lack specificity regarding how some stakeholder groups will be meaningfully involved.
3
Practice needs significant improvement; e.g.,
  • Written documentation does not address involving clients or other external stakeholders; or
  • Written documentation provides only minimal guidance about how stakeholders will be involved.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

PQI 1.03

The PQI plan describes how:
  1. staff and their supervisors have timely access to the information they need to clarify expectations and implement practice improvements; and
  2. staff at all levels receive relevant information on PQI findings.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Plan/procedures lack specificity regarding the flow of information.
3
Practice needs significant improvement; e.g.,
  • Plan/procedures provide only minimal guidance.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

PQI 1.04

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.
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, senior managers, 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, senior managers, etc. do not consistently put in 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.