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1
SQA
STANDARDS AND QUALITY ASSURANCE
Comprehensive Program ReviewMay 29, 2015
2
SQA STAFFBill Coughlin,
Vice-President and COO
Susan Jenness Phillips, Director of SQA and PREA Coordinator
Heriberto Crespo, Senior Quality
Assurance Manager
Jessica Tooley, Quality Assurance
Manager
Penny White, Quality Assurance
Coordinator
Chelsey Frazier, Assistant Quality
Assurance Coordinator
Andrea White, Administrative Assistant
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VISION STATEMENT • The Standards and Quality Assurance Department (SQA) is
dedicated to working with all of CRJ’s programs and departments to continuously improve them, and strives to achieve the highest levels of compliance with applicable regulations, requirements and funding agency contracts.
• Through our use of data, being transparent in our actions, broadcasting our successes and development of CQI (Continuous Quality Improvement) systems, the SQA Department assists CRJ staff and clients (and the programs serving our most challenged clients) become the best they can be and positively impact their return to their communities.
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SQA Prouds:• Growth of department from 2000-2015; increase in quality
and quantity • CQI Pilot Project – Centralized training database – SJS training identified • SOPs – approximately 25 completed• Walk-Throughs completed (4x/year – SJS; 2x/year – CSMA &
CSCT)– 80% for SJS and 100% for CSMA and CSCT
• Reaching more programs with SQA services concurrently (present) as opposed to consecutively (in past)
• Balancing multiple accreditation audits (ACA, QUEST, PREA)
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SQA Challenges:• Responding to changing needs of programs • Audits reflecting limited standardization in procedures• Geography • Limited access to all databases• Programs are not consistent in utilizing audit findings to
improve services (often due to understaffing, conflicting priorities, multiple priorities)
• Promoting a better understanding and creating more awareness of SQA as a resource for programs
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STAFF TURNOVER RATES
SQA CRJ - Overall
40.0%
29.8%
16.7%
27.7%
3/31/2014 3/31/2015
Data obtained from HR Staff Turnover and Retention Report
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RETENTION RATES
SQA CRJ - Overall
71.4% 67.1%
83.3%
69.6%
3/31/2014 3/31/2015
Current SQA Staff:
• Susan: 8/85 (30 years)
• Heriberto: 6/12 (3 years)
• Penny: 11/13 (1 ½ years)
• Jessica: 2/14 (1+ year)
• Chelsey: 9/14 (9 months - new
position)
• Andrea – 11/14 (7 months -
Newest Member)SQA Quiz:
The combined total of human service experience of current SQA staff =
A. 54 years B. 61 years C. 74 years D. 89 years
Data obtained from HR Staff Turnover and Retention Report
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STAFF TRAINING HOURS
SQA
61.75
27.5
4/1/14-3/31/15 10/1/14-3/31/15
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DATA PROVIDED VIA SURVEYS & EVALUATIONS
Surveys:• SJS Satisfaction Surveys – quarterly basis• CS MA Satisfaction Survey – annual basis New:• CS CT Satisfaction Survey - annual basis
Evaluations:• CS-CJI Clinical Data and PBS Evaluations• WA Training evaluations• CPR Evaluations • Caretracker/Benchmarking
Benefits:• Provides a snapshot of satisfaction of client;
affords clients to voice their concerns/opinions and/or compliments about the program
• Provides data to make improvements into programming/services
• Assesses increased knowledge of staff and value of training
Evaluation data from WA
This an example of a WA evaluation
Measuring increase in staff knowledge
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WALK-THROUGHS• SJS Programs: Quarterly Basis • Watson Academy and CSMA & CSCT Programs:
Semi-annual basis• CS-SL: annual basis
Walk-Through Initial Report Benefits
SQA conducts walk-through with designated staff person from program/site
Initial findings submitted to Program/Facilities Dept./Dept. Director
Clean/safe program adds to morale of staff and clients
De-brief with program about initial findings
Ensure that Program enters any Facilities Tech Request
Assist in documenting ‘need areas’
Identifies items for Capital Expense Budget in upcoming year
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AUDITS (MONITORING)• CSMA/CSCT Monthly Audits – Penny & Chelsey– Confidential Files, financials, program and walk-throughs,
(CSNH is starting up) • SJS Audits – Jessica and Heriberto – Case files, medication audits on a monthly basis – Quality Control Plans on a quarterly basis (for FBOP
programs only) – Walk-throughs (quarterly basis)
• CS SL Monthly Audits – Confidential files (monthly) and fiscal (quarterly)– Home Provider Reports reviews – monthly
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DATA COLLECTED & DATABASES UTILIZED• MMRs: monthly and quarterly reviews (CRJ)• CareTracker (CS)• Benchmarking (CS)• CSMA database• CS-CJI Collaborative: Clinical & PBS Data• Facilities /Maintenance database (CRJ)• WA Evaluations (SJS)• SecurManage (SJS)• PREA (SJS)• CPRs (CRJ)
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MEASURING SUCCESS: IMPROVEMENTS • Facilities Walk-Throughs – increase number of timely
submission of Work Orders requests by program– Issues identified in walk-through corrected
• Audits – increase in scores over time• Beginning to standardize forms – new Medical
screening form (SJS); audits forms (CSMA/CSCT)• Annual review of SOPs (Standard Operation
Procedures)• More SQA involvement in initiatives: CS-CJI
Collaborative; PBS; CareTracker; Benchmarking• PREA Template Developed • PREA information now on CRJ web page
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OTHER SQA ACTIVITIES o Accreditation/Certifications & Licensing:
ACA Accreditation: SJS DDS Quality Enhancement (aka QUEST): CS DCF/DMH: Caring Together – Sargent House State of New Hampshire: CS NH State of Connecticut: CS CT
o Quality Council (CQI Projects: Centralize training database; Email Etiquette; On-Site Orientation Plan (OSOP); Facility Maintenance Binders)
o CS-CJI Collaborative o WA Annual Training Reporto Development of SOPso Development of CS CT auditing forms, scoring sheets and satisfaction surveyo Drafting of CS NH auditing forms, scoring sheets and satisfaction surveyo PREAo Other: (coming soon)
Utilization Rates compiled by SQA SQA Department Satisfaction Survey More newsletter articles including Quality Corner
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CPR ACTION PLAN (Next 6 months)Proposed Objective Proposed Timeline
Increase staff training hours December 1, 20151. Assess training opportunities and
include in IDPs2. Existing resources i.e. PBS training
CQI of SQA July 1, 20151. Compile data from SQA Satisfaction
Survey by July 302. Submit report to key stakeholders 3. Conduct survey annually thereafter
Smooth Transition to CJI July – December 20151. Hold meetings to share information
about SQA with CJI2. Fuse strengths and talents in projects,
as feasible3. Share resources
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