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Project Manager: Päivi Johnson, Director of Quality Management
6/30/2015
LECHRIS ANNUAL QA
OUTCOME MEASURES
REPORT For the Fiscal Year 2014-2015
LeChris is committed to Total Quality Management in which to improve our organization and the service delivery to the persons served. Our outcomes this year included indicators in the areas of Efficiency, Effect, Access and Satisfaction. The collected data will be used to facilitate organizational decision making and strategic planning through: 1) Identifying areas needing improvement; 2) Developing action plans to address the improvements needed to reach desired goals; and 3) Outlining actions taken or changes made to improve our performance in delivering best possible services.
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LeChris Annual QA Outcome Measures Report for the Fiscal Year 2014-2015
Project Team Members: Amy Thorne, and Melissa Eastwood - Executive Directors of Operations; Oneida Levine, Clinical Director; Directors (Beth Redmon - Wilson, Crystal Smith - Morehead City, Jennifer Reedy – New Bern, and Jack Zieg – Jacksonville), PSR Coordinators (Caimyn Anderson – Morehead City, Jeneita Green - Jacksonville, Jessica Hendrix - Greenville, Anna Stancil- Rocky Mount), Day Treatment Directors (Jason Wood – Elizabethtown, Brandon Matthews – Morehead City, and Antoine Pittman – New Hanover), Aleshia Loyd and Pregina Bailey – QA/QI Specialists and Päivi Johnson, QM/Training Director
Introduction: LeChris collected data on four outcome indicators for this annual year. This report will address all of the projects in separate sections.
The purpose (project basis) for our annual outcome report is to determine: • Service Access • Effectiveness of services (results of the services) • Efficiency of services (responsiveness, timeliness and cost effectiveness of services) • Satisfaction of our consumers with our services and achievement of their personal goals • Satisfaction of our employees and outside stakeholders
The Results of the Outcomes measured will be used to improve:
• Goal setting for quality services • Strategic planning • Staff development and subsequent morale • Public relations
In preparation of this report, data was collected from the following sources: • Consumer Satisfaction Surveys (conducted during the month of March, 2015) • Employee Satisfaction Surveys (conducted during the month of April, 2015) • Stakeholder Surveys (conducted during the month of June, 2015) • Alpha CM Electronic Medical Record & Authorization Letters • Referral Logs & Admission/Discharge Logs • BECK Youth Inventory and UCLA PTSD Scale • NC Topps & Aggregate data from the Division Webpage under the “NC TOPPS Report at a
Glance” • CST and PSR Outcome Management (OM) report cards • Medical Records
By measuring tangible outcomes and sharing them with our stakeholders, not only are we able to make more informed decisions about adapting specific services, we also hold ourselves accountable to the high standard of quality that we establish as our service goal when we developed our mission statement. A summary of our projects with overall results are below:
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Quality Improvement Outcomes for FY 2014-2015 (Jul 1, 2014 – Jun 30, 2015)
Indicator Goal Data Source
Who Applied
To Timing Obtained
By Outcome
Results
EFFECT
FOLL
OW
-UP
1. 85% of Intensive In-Home /Day Tx consumers (over the age of 6) will report a reduction in all significant components of the BECK Youth Scale, except Self Esteem which if low, will report an increase per self-report measure 2. 85% of Intensive In-Home consumers who are suspected of experiencing trauma in their past will report a change from significant range to Insignificant range in the UCLA PTSD scale. 3. Sample of charts for persons served receiving medication management only will be monitored for appropriateness & effectiveness of their medication(s) 4. 50% of CST and PSR clients will experience a reduction in symptoms as a result of utilizing the IMR Model as a best evidence based practice
BECK Youth
Inventory
UCLA PTSD Scale
Med Mgt Charts PSR/CST OM Report Cards
Consumers and /or parents/ guardians
Med Mgt Clients
PSR/CST Clients
Minimally at
Admission & at
discharge Jul 2015– Jun 2016
Minimally on an
annual basis for the FY 2014-2015
Weekly
IIH/Day Tx Therapists
Medical Director
Clinical Director
EFFICIENCY
EFF
ICIE
NC
Y
85% of the Authorized Hours approved by Authorizing Authority will be delivered to our Consumers
Authorizations/documentation of records
ALL services
Jul 1, 2014 – Jun 30,
2015
Program Coordinators, Facility Directors
ACCESS
AC
CE
SS
TO
SE
RV
ICE
S
90% of Consumers will begin Services within 10 days after referral to that service.
Referral and
Admission Log
Consumers
Jul 1, 2014 – Jun 30,
2015
QPs, Coordinato
rs and Directors
SATISFACTION
Clie
nt
90% of sampled will report satisfaction with services received
Surveys Consumer
s/ Guardians
Mar 2015 Directors, QM Dept
Staf
f 90% Satisfaction with Employment with LeChris Surveys Staff Apr/May
2015 QM Dept
Stak
eho
lder
90% of sampled will report satisfaction with services received
Surveys Stakeholders Jun 2015 QM Dept
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EFFECTIVENESS As effectiveness measures address the quality of care through measuring change over time, our proposed outcomes were to measure these through:
1. BECKS Youth Inventory for the Intensive In-Home (IIH) and Day Treatment (Day Tx) Services; 2. UCLA PTSD scale (as applicable) for our consumers receiving Intensive In-Home Services and Day
Treatment Services. • Both BECKS and UCLA PTSD instruments are standardized to address validity and
reliability and both are widely used. 3. Med Management Audit tool – designed for Medical Director to conduct annual peer review of
sample client charts to assess appropriateness and effectiveness of medication prescribed. 4. Outcome Management (OM) Report Card - designed for our Community Support Team (CST)
and Psychosocial Rehabilitation (PSR) recipients to determine the effectiveness of the service in utilizing the IMR Model
Strategies:
1. In working with our Intensive In-Home programs and Day Treatment Programs, we have chosen the Beck Youth Inventories, Second Edition (BYI-II) as a way to measure outcomes for all children ages 6 to 18. The BYI-II is a widely-known and widely-used collection of 5 standardized, self-report scales that assesses a child’s experience of his or her self-concept, depression, anxiety, anger, and disruptive behavior. The child’s results are quantified, compared to national norms, and reported in relation to the national average for the child’s age range. The proposed goal was the following: 85% of Intensive In-Home/Day Treatment consumers (over the age of 6) will report a reduction in all significant components of the BECK Youth Inventory, except Self Esteem which when low, will report an increase per self-report measure. Evaluation of results is demonstrated for each of the programs separately.
2. For children with specific needs, we are using some additional measures. For example, for children with trauma issues, we are using the UCLA PTSD Index as a way to track the child’s and the parent’s perceptions of the presence and intensity of Post-Traumatic Stress Disorder (PTSD) symptoms in the child. The UCLA PTSD Index is based on the DSM-IV criteria for PTSD. It has two (2) sections: a self-report section that is completed by the child and a parent-report section that is completed by the primary caregiver. The proposed goal was the following: 85% of Intensive In-Home consumers who are suspected of experiencing trauma in their past will report a change from significant range to insignificant range in the UCLA PTSD scale.
3. Beginning in January 2014, we started asking our CST and PSR clients to report directly about behaviors that we are trying to address through our services by utilizing the Illness Management Recovery (IMR) Model (hospitalizations/ emergency department visits, arrests, involvement in job/school, homelessness, medication compliance, mental health symptomology and satisfaction to their living environment). The CST Leads and PSR Coordinators were trained on the tool and instructed to ask the persons served on a weekly basis the following questions:
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CST/PSR OM Report Card In the past week, 1. How many days were you in the ER/hospital or other Inpatient? 0 1 2 3 4 5 6 7 2. How many days were you in jail? 0 1 2 3 4 5 6 7 3. How many days were you at a job or in school? 0 1 2 3 4 5 6 7 4. How many days were you homeless? 0 1 2 3 4 5 6 7 5. How many days did you take your meds as prescribed? 0 1 2 3 4 5 6 7 6. Over the past week, how stressful were your symptoms (voices, Depression, anxiety)? 0 (Not at all) 1 2 3 4 5 6 7 (very stressful) 7. Over the past week, how satisfied were you with your living situation? 0 (not at all satisfied) 1 2 3 4 5 6 7 (totally satisfied)
4. For clients receiving medication management services through Le’Chris, a documented peer review by the Medical Director has been implemented to assess the appropriateness of each medication as determined by the needs and preferences of each person served as well as the effectiveness of the medication. The presence of side effects, unusual effects and contraindications are to be addressed and identified and determine if necessary tests were conducted. Too, the use of multiple simultaneous medications and medication interactions are to be identified.
Actions Taken:
For BYI-II and UCLA PTSD Index: Clinicians for each of the programs administered the BYI-II test upon admission to services and then upon discharge. The results of the tests were then forwarded to our Clinical Director Oneida Levine, PhD who interpreted the results and analyzed the data.
For CST and PSR project, the completed Outcome Management (OM) Report Cards were gathered by the CST Leads and PSR Coordinators and then forwarded to our Clinical Director for analysis of the data. The results of the data interpretation are covered under “Evaluation of results”.
For Peer review of medication management charts: During our survey with CARF (10.2011), it was recommended that Le’Chris conduct peer reviews on a representative sample of records of persons for whom prescriptions are provided. In 2012, the Medical Director Dr. O’Daniel developed audit tool questions using an excel spreadsheet to record the findings. The following information was to be recorded during the peer review: 1) Client record #; 2) Dates of notes that were reviewed; 3) Name of the Prescriber, 4) Diagnosis of Client, 5) List of medications prescribed; 6) Is use of evidence based practice evident; 7) Was AIMS test completed; 8) BMI/BP/Vitals checked; 9) Client Status; 10) Timing of follow-up appropriate; and 11) Comments. Le’Chris has had two changes in Medical Directors since Dr. O’Daniel. The intent and the tool was introduced to both Dr. Junius Rose (Medical Director from Nov 2013 to April 2014), followed by Dr. Robert Turton who took on the role of the Medical Director for Le’Chris in May, 2014 until May 2015.
Evaluations of Results:
For the BYI-II: Day Treatment:
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This is our third data compilation and we now have data on 128 children (32 girls, 96 boys), covering October 2010 through March 2015. Most of our comparisons are made on cross-sectional data, but as we continue to gather data, we will have more longitudinal data. We currently have longitudinal data (from beginning of treatment to end of treatment for the same child) for 37 children (7 girls, 30 boys).
Whether looking at the cross-sectional or longitudinal data, the data suggest that at the beginning of treatment, most children reported scores in the Average range for Self-Concept, Anxiety, Depression, Anger and Disruptive Behavior. Comparing girls to boys, girls reported lower scores for Self-Concept and more elevated scores for Depression, Anxiety, Anger, and Disruptive Behavior. By the end of treatment, for all children, all measures have changed in the desired direction: Self-Concept increased, while Anxiety, Depression, Anger, and Disruptive Behavior went down. The largest change is seen in Self-Concept. This pattern held when data were separated by sex.
BYI-II Initial compared to Final Data (cross-sectional results) - For both sexes and all ages, all measures changed in the desired direction from the initial average/mean scores to the final average/mean scores: Self-Concept increased, while Anxiety, Depression, Anger, and Disruptive Behavior went down. The largest change is seen in Self-Concept. Please refer to table and graph below to further illustrate this:
Beginning to End of Treatment (Cross-Sectional) for children of all ages and both sexes
# Age Self- Concept Anxiety Depression Anger Disruptive Behavior
Initial 128 11.9 47.8 51.9 51.4 53.3 54.6
Final 53 12.3 52.2 50.2 48.1 51 51.5
Difference 4.4 -1.7 -3.3 -2.3 -3.1 *Self-Concept is scored in the opposite direction as the other variables. For Self-Concept, higher scores indicate better self-concept, while for the other variables, higher scores indicate more problematic feelings or behaviors
Looking at the BYI-II longitudinal data (the data we have from the same child from beginning to end of treatment) for the 37 day treatment children of both sexes and all ages, all measures changed in the desired direction from the initial average/mean scores to the final average/mean scores: Reports of Self-concept increased, while reports of Anxiety, Depression, Anger, and Disruptive Behavior went down. This pattern remains when the data are separated by sex. The largest changes are seen in Disruptive Behavior. Please refer to table and graph below to further illustrate this:
44
46
48
50
52
54
56
Self- Concept Anxiety Depression Anger DisruptiveBehavior
47.8
51.9 51.4 53.3
54.6
52.2
50.2
48.1
51 51.5
Cross-Sectional Results from Initial to Final for Day Treatment Clients
Initial
Final
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Day Treatment Longitudinal Results - Beginning to End of Treatment for children of all ages & both sexes
Age *Self-Concept
Anxiety Depression Anger Disruptive Behavior
Initial 11.6 50.1 52.6 50.2 53.5 56.4
Final 12.4 51.5 51.1 48.6 52.6 53
Difference 1.4 -1.5 -1.6 -0.9 -3.4 *Self-Concept is scored in the opposite direction as the other variables. For Self-Concept, higher scores indicate better self-concept, while for the other variables, higher scores indicate more problematic feelings or behaviors
For the BYI-II Inventory: Intensive In-Home
This is our fourth year of data collection for the BYI-II; hence the data covered here is from May 2010 through March 2015. We now have BYI-II data on 163 children (62 girls, 101 boys). Most of our BYI-II comparisons are made on cross-sectional data. We currently have longitudinal BYI-II data (from beginning of treatment to end of treatment) for 36 children (9 girls, 27 boys).
Looking at the BYI-II cross-sectional data, at the beginning of treatment, most children report Average scores for Self-Concept, Anxiety, and Depression, and report Mildly Elevated scores for Anger and Disruptive Behavior. Comparing girls to boys, girls report lower scores for Self-Concept and more elevated scores for Depression, Anxiety, Anger, and Disruptive Behavior. By the end of treatment, for all children, all categories have changed in the desired direction: Self-Concept increased, while Anxiety, Depression, Anger, and Disruptive Behavior went down. For girls, report of Self-Concept did not increase.
For BYI-II Initial compared to Final Data (cross-sectional results) we have initial data on 152 children (57 girls, 95 boys) and final data on 51 children (15 girls, 36 boys). For both sexes and all ages, all categories changed in the desired direction from the initial average/mean scores to the final average/mean scores: Self-concept increased, while Anxiety, Depression, Anger, and Disruptive Behavior went down.
4446485052545658
50.1 52.6
50.2
53.5 56.4
51.5 51.1 48.6
52.6 53
Longitudinal Results from Initial to Final Results for BYI-II data for Day Treatment Clients
Initial
Final
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Beginning to End of Treatment (Cross-Sectional) for children of all ages and both sexes
# Age Self- Concept Anxiety Depression Anger Disruptive Behavior
Initial 152 12.1 45.9 54.4 54.1 55.2 55.2
Final 51 12.6 47.3 47.3 46.4 47.8 49
Difference 1.4 -7.1 -7.7 -7.4 -6.2 *Self-Concept is scored in the opposite direction as the other variables. For Self-Concept, higher scores indicate better self-concept, while for the other variables, higher scores indicate more problematic feelings or behaviors
BYI-II Beginning-of-Treatment to End-of-Treatment (longitudinal results) - Over the past four (4) years, we have beginning to end-of-treatment (longitudinal) data on 36 children (9 girls, 27 boys). For both sexes and all ages, all categories changed in the desired direction from the initial average/mean scores to the final average/mean scores: Self-concept increased, while Anxiety, Depression, Anger, and Disruptive Behavior went down. Please refer to table and graph below to further illustrate this:
Beginning to End of Treatment (Longitudinal) for 36 children (9 girls and 27 boys)
Age *Self-Concept Anxiety Depression Anger Disruptive Behavior
Initial 11.5 44.6 55.1 53.3 56.7 55.4 Final 12.3 49.4 48.4 46.8 48 49.7
Difference 4.8 -6.7 -6.5 -8.7 -5.7 *Self-Concept is scored in the opposite direction as the other variables. For Self-Concept, higher scores indicate better self-concept, while for the other variables, higher scores indicate more problematic feelings or behaviors
0
20
40
60
SelfConcept
Anxiety Depression Anger DisruptiveBehavior
45.9 54.4 54.1 55.2 55.2
47.3 47.3 46.4 47.8 49
Cross-Sectional Results from Initial to Final for BYI-II Data for Intensive In-Home Clients
Initial
Final
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For the UCLA PTSD scale, after our fourth year of data collection, we have UCLA PTSD Index data on 59 children (30 girls, 29 boys). We have 54 surveys completed by children and 49 completed by parents. The average age of the child at the time the inventory was completed was 11.8 years, with girls a little older than boys. Also, we have 42 parent-child data sets (where we have complete inventories from both the child and the child’s parent).
o For 29 of these parent-child pairs (69%), there is agreement on the presence or absence of trauma for the child (25 pairs agreed that the child experienced trauma, while 4 pairs agreed that the child had not experienced trauma).
o For 30 of the parent-child pairs (71%), there is agreement on whether the child is exhibiting enough symptoms to meet the criteria for a diagnosis of PTSD (19 pairs agreed that the child has enough symptoms for PTSD, while 11 pairs agreed that the child did not have enough symptoms).
In looking at the initial severity ratings for both sexes and all ages, children tend to see themselves as more distressed than their parents see them. Girls report more distress than boys do. Parents of boys report more distress in their sons than the parents of girls report in their daughters. Girls see themselves as more distressed than their parents see them, while boys see themselves as less distressed than their parents see them. Please refer to table and graph below to further illustrate the findings:
Children’ Ratings Parents’ Rating (Number) Severity Score Range (Number) Severity Score Range
Total 54 27.5 2-57 (49) 26.7 2 to 56 Girls 29 29.8 7 to 57 (22) 23.9 2 to 56 Boys 25 24.8 2 to 46 (27) 29.0 5 to 55
0102030405060 44.6
55.1 53.3 56.7 55.4 49.4 48.4 46.8 48 49.7
Longitudinal Results from Initial to Final Results for BYI-II data for Intensive In-Home Clients
Initial
Final
0
20
40
Children’ Ratings Parents’ Rating
29.8 23.9 24.8 29
UCLA Index Severity Rating Children vs. Parents
Girls
Boys
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Parent Stress Inventory (PSI) Data: PSI data was collected from the mothers of 11 children (3 girls, 8 boys) at the beginning of treatment. The average/mean age of the children was 8.5 years. Our small group of mothers is reporting clinically significant distress at the beginning of treatment (Total Stress average/mean score is 298.9 -- Total Stress score at or above 260 indicates the need for professional intervention). The data reveals that the mothers are attributing the largest part of their stress to their children’s behavior (91% report problems with their children’s behavior in the clinically significant range).
PSI results at beginning of treatment
Age Child Domain Parent Domain Total Stress Life Stress Avg/Mean 8.5 155.1* 143.4 298.9* 11.1
Range 3-13 119-184 122-173 241-346 26-Feb
% Elevated 91% 33% 78% 45% * indicates score in the clinically significant range
We have PSI data from one mother at the beginning and end of treatment. All scores decreased in intensity, although child-related stress and total stress remained in the significant range.
Initial to End of Treatment PSI Data
Age Child Domain Parent Domain Total Stress Life Stress
Initial 10 170* 145 315* 21*
Final 12 156* 111 267* 8
Difference -14 -34 -48 -13 * indicates score in the clinically significant range
0
200
400
Total Stress Life Stress
315
21
267
8
Comparison of PSI results from Initial to Final for IIH parents/children
Initial
Final
0
100
200
Initial Final
170 156 145 111
Initial and Final Results of PSI Scale compared for Child vs. Parent Domain
Child Domain
Parent Domain
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For CST and PSR Outcome Management Report Card Data:
Questions 1, 2, 4, and 6 are reversed scored. Then the ratings are totaled to produce a wellness score, which has a possible range of 0 to 49. The higher the score, the better the client is functioning. Using the IMR/WMR model predicts that clients’ wellness scores will improve as treatment progresses.
For PSRs: We have five (5) PSRs from where we have 2500 useable report cards gathered from 195 clients during 2014 and the first 4 months of 2015. Most of these clients have been receiving the IMR/WMR for significant periods of time. The average (mean) number of months in the PSR is 7.4 (range 1 to 16), based on having at least 3 report cards. The average (mean) number of report cards per person is 12.8 (range 1 to 58). The average (mean) wellness score was calculated to be 37.6 (range 9 to 49). It should be noted that data from the Wilson PSR is only from the first quarter of 2014 as it changed its clinical model back to the Fountain House/Club House Model. There are 147 clients from whom we have 3 or more wellness scores, indicating that they have been in treatment at least 3 weeks. Overall, 45% (66/147) of these clients showed an increase in wellness scores from first to last, 17% (25/147) had wellness scores that were the same, and 38% (56/147) had a decrease in wellness scores from first to last. Below table and chart demonstrate this increase vs. decrease for the different PSRs.
PSRs # of People ↑Increase Same ↓Decrease
MHC 38 45% 13% 42%
JAX 15 40% 13% 47%
RM 47 49% 21% 30%
WILSON 21 33% 19% 48%
GVL 26 50% 15% 35%
TOTALS 147 45% 17% 38%
45% 40%
49%
33%
50% 42%
47%
30%
48%
35%
0%
10%
20%
30%
40%
50%
60%
MHC JAX RM WILSON GVL
PSR Wellness Scores: Increase vs. Decrease
↑Increase
↓Decrease
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For the same 147 clients when comparing their average initial wellness scores with their final average wellness scores, there is a slight overall increase in wellness. Below table and chart demonstrate the initial vs. final wellness scores for the different PSRs.
PSRs # of People with 3 or more Avg Initial Wellness Score
Avg Last Wellness Score
MHC 38 37.2 37.6
JAX 15 34.8 32.8
RM 47 36.3 38
WILSON 21 38.4 36.7
GVL 26 34.1 35.2
TOTALS 147 36.3 36.7
For PSR, the results are not as strong as we had anticipated. In compiling the data, it was noted that there were many report cards that were not useable, suggesting that perhaps the directions were not clear or that clients needed more monitoring and assistance in filling them out. Another concern involves the clinical model itself. The model emphasizes staying on psychotropic medication and obtaining employment or being in school. Some of our clients are uncomfortable being on medication, and once stable, want to try functioning without it. Many of our clients do not desire employment or schooling and for those who do, there are limited opportunities in our communities. For CST programs, we have three (3) Community Support Teams. From these teams, we have 806 useable report cards gathered from 127 clients during 2014 and the beginning of 2015. Unfortunately, the only data we have from the Greenville program is for the first 4 months of 2014. The average (mean) number of report cards per person is 6.3 (range 1 to 24). The average (mean) wellness score is 34.2 (range 10 to 47).
37.2
34.8 36.3
38.4
34.1
37.6
32.8
38 36.7
35.2
30
32
34
36
38
40
MHC JAX RM WILSON GVL
PSR Initial vs. Last Wellness Scores Compared
Avg Initial Wellness Score
Avg Last Wellness Score
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CST Teams # of people Avg/Mean # of Report Cards range Average (mean)
Wellness Score Range
MHC/JAX 45 7.2 1-21 35.9 18-47
RM/Wilson 56 7.4 1-24 33.0 10-46
GVL* 26 2.5 1-7 33.2 14-43
TOTALS 127 6.3 1-24 34.2 10-47
* Data from the first 4 months of 2014 only. There are 84 clients from whom we have three or more wellness scores, indicating that they have been in treatment at least 3 weeks. Comparing their initial wellness scores with their final wellness scores, there is a slight overall increase in wellness.
Another way to look at this data is to see how many of these 84 people increased their wellness scores from the initial to the final. Overall, 55% increased their scores, 7% had the same score at initial and final, and 38% decreased their scores.
Unfortunately, our outcome data continue to be somewhat limited, nevertheless suggestive of positive results for CST clients in the lMR/WMR programs.
63%
49% 55%
23%
47% 45%
0%10%20%30%40%50%60%70%
MHC/JAX RM/Wilson GVL
CST Wellness Scores: Increase vs. Decrease
↑Increase
↓Decrease
35.3
32.1 33.5
36.9
32.9 33.3
28
30
32
34
36
38
MHC/JAX RM/Wilson GVL
CST Initial vs. Last Wellness Scores Compared
Avg Initial Wellness Score
Avg Last Wellness Score
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For Peer Review of Medication Charts: A peer review of medication charts was conducted by Dr. Junius Rose and by Dr. Robert Turton, both Medical Directors for Le’Chris during this fiscal year with Med Tech assisting in recording the findings. Due to changes with Medical Directors and time restraints, not as many charts were reviewed as intended, nevertheless the 36 charts that were reviewed gave us a good idea as to how the prescribers were doing and areas needed for improvement. It was concluded that all of the prescribers (Ruth Cox, FNP, and Donna Shelton, PA) had utilized good evidenced based prescribing practices, the appropriateness of each medication was found satisfactory for all and there is evidence that the AIMS test is being conducted more on a regular basis with persons prescribed neuroleptic medications – this was marked as an area of needed improvement during last year’s peer review.
Next Steps: For BYI-II and UCLA PTSD Index: Due to the cost of the tools and change in Clinical Directors, we are going to discontinue with these two outcomes. We are in the process of developing another tool in measuring effectiveness for our Day Treatment and Intensive In-Home services. For CST and PSR Outcome Management Report Cards: As our data suggests -- our IMR/WMR program is successful in that clients improve their functioning in the areas targeted by the program. This outcome will be continued, however the frequency will be changed to monitor these monthly instead of on a weekly basis.
For Peer Review of Medication Charts: This outcome will be continued as it will be used to improve the quality of services provided.
EFFICIENCY Strategies:
Efficient use of authorized hours: Not only is it important from a business perspective, but also from the perspective of persons served. Hence, we attempted to achieve the outcome of “85% of the authorized hours approved by Authorizing Agent will be delivered to our Consumers.” The strategy in getting this accomplished was first and foremost to inform all of the sites of our intent. Next, the Site Directors were tasked in collecting and reviewing the results from a report generated through ALPHAflex CM (our electronic medical record system). The report for each of the services was also to be generated by the QM Department at the end of fiscal year review for final data analysis.
Actions Taken: The directors of all sites were informed of the intent. The report generated by ALPHAflex CM was utilized which lists: 1) Client record number; 2) Start date for authorizations; 3) End date for authorizations; 4) Number of units authorized; 5) Number of units delivered; and 6) Type of service in question. Directors were asked to explain any discrepancies as to why not all hours were being delivered. The percentage was achieved by dividing the number of units delivered by the number of units authorized. At the end of the fiscal year, all data was compiled and analyzed. Overall averages were calculated for each service, along with a trend analysis of any comments received.
Evaluation of Results:
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In analyzing the data, it became obvious that many variables affected the units delivered to the units authorized, hence it can be concluded that this is not something that LeChris, as an agency, controls in its entirety. Some of the clients completed treatment in the middle of a cycle, hence a smaller amount of units used. Other reasons for discrepancies included non-compliance with treatment, hospitalizations, health & transportation issues which are beyond our control. Also, with the merger of MCOs new electronic billing systems, overlapping authorizations was an issue along with the fact that ALPHA CM started syncing authorizations from the MCO directly to our system while at the same time; some of these were entered manually causing yet another set of problems in analyzing the data efficiently. Needless to say, as the average overall percentage of all services revealed 84.3%, we barely missed our desired outcome. This is a significant improvement of previous year and it is evident that by tracking the authorizations used has assisted us in increasing the hours used. In looking at the average overall percentage per service, Intensive-In-Home services as a whole attained the highest percentage of used versus authorized hours (92.4%). Although improvement is evident, the lowest continue to be Day Treatment (71.9%) followed by Psychosocial Rehabilitative services (73.1%) which was somewhat expected as both of these programs are facility based rather than community based. The below graph provides further illustrations of the findings.
** Miscellaneous services include Outpatient Services such as Therapy, Assessments, med mgt.
Next Steps: Directors are to continue keeping track of service authorizations for all of the services provided in their sites to maximize billable hours, to ensure consumer engagement into services and to identify any potential staffing issues. Also, we have contacted AlphaCM to ensure that the electronic medical record is tracking the units used accurately which also resulted in turning off the syncing of authorizations; instead Directors are to enter each of the authorizations manually. We will continue with this outcome for the next fiscal year.
Access to Services Timely access to services is very important to our consumers. The division has guidelines as to the timeframes when a person needs to be seen. For routine care, the timeframe is 14 days, for urgent, it is 48 hours and for Emergent clients, the timeframe is 2 hours. It is evident that LeChris is meeting
0.0%20.0%40.0%60.0%80.0%
100.0%
ACTT Day Tx CST PSR IIH IDDservices
Misc.Services
85.7% 71.9%
85.5% 73.1%
92.4% 90.5% 90.8%
FY 2014-2015 % Authorizations used
% Used
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these timeframes for all assessments; however, when it comes to referrals to a specific service after the assessment, improvement is needed.
Strategies: Directors and Coordinators of each site were instructed to keep data on new consumers to our agency from referral to admission in hopes of reaching the desired goal of 90% of consumers will be seen within 10 days of the referral.
Actions Taken: Quality Management Department developed an Excel spread sheet to track this data along with existing referral and admission logs that Directors were instructed to use. Directors were asked to turn in data on a quarterly basis for this outcome, rather than wait until the end of fiscal year as was done previously in hopes of identifying any potential problems with data collection.
Evaluation of Results: Regarding assessments: Based on data received, 545 consumers were referred to Le’Chris for an assessment this fiscal year. Out of the 545, 568 received an assessment, revealing that 104.2% of the referrals being seen. The difference can be contributed to 23 of the clients being referred prior to fiscal year starting, nevertheless counted here as they were seen during this fiscal year. Out of the 568 clients that were seen, 552 were seen within the required timeframes revealing a 97.2% of our consumers received access to services within the timeframes; hence meeting our desired outcome. It should be noted that no data was received from our Morehead City site regarding assessments, hence more consumers were seen but the data was not available. This has been addressed with the Morehead City office and the Director is working on getting this resolved.
Regarding the next step in getting the consumer to the referred service within 10 days, the data shows a success rate of 74.7%, this is an increase from previous year by 6.4%. In reviewing the Directors’ comments regarding access to care to enhanced services, there continue to be several trends that appear to contribute to this. Some of the delay is still believed to be a direct reflection of sites not reporting the data as requested, i.e. some directors are still uncertain as to what truly makes a referral and how to determine the admission date. Education regarding this issue has been offered during QA meetings in the past four fiscal years and improvement is evident. When looking at the individual services, the following were reported as possible reasons hindering timely access to services: In the Day Treatment Setting, coordination needed among the district schools and then approval pending from the MCOs; sometimes clients had long gaps because they were recommended to start IIH first and then came into day treatment after getting IIH in place. Also with an added emphasis on making sure all criteria is clearly documented in the CCA on average takes the LPCs longer to go through their CCA, generate new QA checklist, write initial PCP, get approval of Clinical Director, and then submit the request for service. In the PSR setting, delayed admissions appear to be due to client no shows, rescheduling initial start date, and/or hospitalizations. Many of the sites have reviewed their process of the developed procedures as how to handle the referrals to ensure timely access to starting enhanced services and improvement is expected. The table below provides detailed information regarding the total number of referrals received, number of new admissions, and number of clients meeting the required timeframes, followed by the percentage of admissions meeting the timeframe per each quarter for the agency as a whole.
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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Totals for all services for
the Year
# of Referrals received during this quarter 379 281 294 310 1264
# of New Admissions 365 264 267 301 1197
% of Referrals to Admissions --> 96.30% 94.00% 90.80% 97.10% 94.55%
# of Clients that met the required timeframes for access to services 306 232 236 248 1022
% of Admissions meeting required timeframes 83.80% 87.90% 88.40% 82.39% 86.70%
Next Steps: Ensure that the required timeframes for an assessment continue to be met. Continue to work on improving and monitoring the process as to how to track the data from assessment referral to service admissions by educating the site directors on how to accurately gather the data as well as work through any barriers that hinder the process. This outcome will be continued next year.
Satisfaction Surveys - Consumer
Consumer Satisfaction surveys are conducted annually to assist LeChris in maintaining and improving the quality of services provided to our consumers. Furthermore, it gives us an opportunity to discover if our services are effective, if consumers are achieving their outcomes, and identify areas of what’s working and what is not working.
Strategies: Eleven separate surveys were designed to cover the following services we provide throughout our agency: Community Support Team (CST) Day Treatment (Day Tx) Intensive In-Home (IIH) Psychosocial Rehab (PSR) Assessments/Evaluations (Assmt) Therapy (Ther) IDD services (IDD) Supportive Employment (SE) Assertive Community Treatment Team (ACTT) Med Management/Doctor Services (Med Mgt) **Not all services are offered in each site (refer to graphs) Questions on the surveys were varied somewhat as they were tailored to the specific service being surveyed. Questions were designed to address access, efficiency, effectiveness and overall satisfaction for the services provided. Participants (consumers, parents, guardians, and/or caregivers) were asked to choose a statement best describing their experience with LeChris. Four response choices were provided: strongly agree, agree, disagree or strongly disagree. This is the same as the four previous years when a decision was made not to include the choice for “neutral” as trend was noted in that people tended to answer “neutral” rather than taking a more active role which in turn was believed to alter the results. We also continued to use the picture prompts in the form of smiley faces that coincided with the answer choice to assist respondents to choose their answer without only having to rely on reading the answer choices
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provided. The goal that we had set for ourselves was to achieve 90% of consumers/guardians sampled to report satisfaction with services received.
Actions Taken: Once surveys were designed and approved by the QM committee and the Corporate Team, they
were given to Directors of each site for distribution to our consumers. Consumers were assured confidentiality of the results and given a choice of either placing their surveys in a sealed envelope or mailing them directly to the QA Department. Microsoft Excel was utilized to capture the data and to assist in interpreting the results. Measures: The percentage (%) of satisfaction was calculated by the number of consumers answering
“Strongly agree” and “Agree” in the survey divided by the number of surveys completed for that site. In instances where no response was received for a specific question, the number of surveys was adjusted to reflect the number of responses received.
The percentage (%) of overall satisfaction was achieved by taking the average of satisfaction for all sites participating in the survey.
Evaluation of Results: Table below provides a percentage of satisfaction per each site and service along with the overall satisfaction per service.
SITE MCO
Day
Tx
Med
M
gt
AC
TT
CST
PSR
IIH
Ass
mt
TH
ER
AP
Y
I-D
D
RM
East
poin
te 96% 100% 100%
WILS 100% 95% 100%
BLA 98%
GVL
ECBH
99% 99% 96% 100% 100% 100%
NB 96% 79% 100%
MHC
Coa
stal
Car
e 93% 87% 100% 96% 98% 86% 97%
JAX 80% 96% 99% 100%
NH 95%
Overall % 95% 88% 96% 100% 97% 98% 96% 92% 100%
Observations: In evaluating the results, the data shows that we reached our goal of overall satisfaction of 90% for each of the services we provide; in fact the average overall satisfaction was 96% therefore our goal is met.
Note: Surveys were not received for IIH services from Jacksonville due to staff turnover
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Graphs below will further demonstrate the results:
1. % of Overall Satisfaction for the past 6 years 2. % of Overall Satisfaction per Service and Site 3. If the results were less than 90%, a breakdown of responses is offered to identify areas of possible
concern.
97% 97% 99% 97% 97% 96%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
FY 2009-2010 FY 2010-2011 FY 2011-2012 FY 2012-2013 FY 2013-2014 FY 2014-2015
Consumer Satisfaction Survey % of Overall Satisfaction for the last 6 years
Day Tx Med Mgt ACTT CST PSR IIH Assmt THERAPY I-DD
RM 96% 100% 100%WILS 100% 95% 100%BLA 98%GVL 99% 99% 96% 100% 100% 100%NB 96% 79% 100%MHC 93% 87% 100% 96% 98% 86% 97%JAX 80% 96% 99% 100%NH 95%
0.20.30.40.50.60.70.80.9
1
FY 2014-2015 Overall % of Consumer Satisfation Per Site /Per Service
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A closer look at each of the individual sites revealed two services that missed the desired goal. These were med management and therapy services. In light of the fact that projected goal was not reached, the individual questions and comments received was warranted to identify any trends and patterns.
For Therapy in New Bern, it appears that the biggest concern was the wait time, followed by the consumer feeling that they were heard which naturally lowers the overall satisfaction – please refer to the below chart. The comments appear to coincide with the scores. These results have been discussed by the Corporate Management team and being addressed in hopes of changing these trends.
For Med Management in Jacksonville and Morehead City, the biggest concerns noted were with persons served feeling not being heard by the doctor. This naturally coincides with the low scores received in the area of services meeting consumer’s expectations and the overall satisfaction – please refer to the below chart. The surveys further support complaints that we have received from the consumers. These results have been discussed by the Corporate Management team and being addressed in hopes of changing these trends.
If I needto talk to
mytherapist,she/he isavailable
forme/retur
ns myphone…
I can tellmy
therapistmy
concernsand knowthat I am
heard
I am seenpromptly
asexpected.
Myconfidenti
ality iskept by
mytherapist
I amtreated
withrespect by
mytherapist.
Therapyprovidedto me ismeeting
myexpectations / myneeds
Therapyservices
hashelped
meincrease
myquality of
life
Overall, I am
satisfied with
services that are
provided by
Le’Chris
NB 83.33% 71.43% 57.14% 87.50% 87.50% 85.71% 85.71% 71.43%
83.33% 71.43%
57.14%
87.50% 87.50% 85.71% 85.71%
71.43%
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
% of Consumer Satisfaction with Therapy
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Although the other sites met the desired goal, it should be noted that many comments were received regarding their dissatisfaction about their hours being cut, this was especially true for CST and for PSR services. LeChris staff works diligently in attempting to get the hours needed to meet the needs of our consumers, however the State budget cuts are evident and do have an effect in our ability to serve the consumers as efficiently as before. All attempts are made in linking our consumers to natural supports away from paid supports. The consumer comments are greatly appreciated as they allow insight into what we are doing right and what we can improve upon, these were shared with the Corporate Team as mentioned above.
NEXT STEPS: Continue conducting satisfaction surveys on an annual basis to evaluate our performance with the consumers we serve to ensure quality services are in place.
Satisfaction Surveys - Employee Why conduct employee satisfaction surveys? The reason is simple; LeChris believes that a strong path to success begins with a great place to work. We solicit staff feedback through surveys on an annual basis to
Receptionist is
friendlyand
courteous
Myappointments are
scheduledin a
timelymanner(initial
appointment was
within 10days)
Mydoctor
listens tomy
concerns.
The staffhas beenhelpfulwhen I
have hadadditiona
lquestions
orproblems
Doctorservices
aremeeting
myexpectations / myneeds
Medicines
prescribed to me
have beenhelpful inreducing
mysymptom
s
Medicines
prescribed to me
haveimproved
myquality of
life
I would recomme
nd Le’Chris to others
Overall, I am
satisfied with
services that are
provided by
Le’Chris
MHC 100.0% 92.1% 76.6% 95.2% 82.5% 83.1% 81.4% 85.7% 85.7%JAX 90.9% 95.5% 63.6% 90.9% 76.2% 75.0% 70.0% 72.7% 81.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
% of Consumer Satisfaction with Med Management Services
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improve the workplace. Satisfaction of employees is important as it lowers employee turn-over, leads to higher consumer satisfaction, increases loyalty and improves profitability. Strategies: The questions on the survey were designed to assess level of agreement or disagreement in the areas of 1) understanding organization’s mission; 2) opportunity to learn & grow; 3) receiving adequate training; 4) safe work conditions; 5) Being treated with respect; and 6) Feeling being listened to and receiving clear instructions by the supervisor. Four response choices were provided: strongly agree, agree, disagree or strongly disagree. The goal that we had set for ourselves was to achieve 90% of employees sampled to report satisfaction with their employment.
Actions Taken: Once the survey was designed and approved by the QM committee and the Corporate Team, a flyer was e-mailed to Directors of each site for distribution to staff with instructions and timelines. Staff was encouraged to complete the survey on-line utilizing Survey Monkey; for staff that did not have access to the internet, a paper copy of the survey was provided. Both methods were used -- the paper survey responses received were then entered into the Survey Monkey by the QM Director to ensure that scoring would be uniform.
Measures: The percentage (%) of satisfaction was calculated by number of employees answering “Strongly
Agree” and “Agree” in the survey divided by the number of surveys completed. The percentage (%) of overall satisfaction was achieved by taking the average of satisfaction for
all of the responses received. Rating scale from 1-4 was utilized in interpreting the results. One (1) being the highest score
indicating “strongly agree” and four (4) being the lowest indicating “strongly disagree”.
Evaluation of Results: For this fiscal year, a total of 95 out of 184 employees completed the survey, revealing a 51% return rate. Our overall percentage of satisfaction was calculated to be 93.3% across all regions - hence the projected goal of 90% employee satisfaction was met -- this has been yet another tough year for private providers in the MH/SU/IDD field. In evaluating the combined summary results of all of the Le’Chris sites, the lowest rating revealed to be “Overall satisfaction with my job & would recommend employment with Le’Chris to others” (rating of 1.98 – falling to the right of “strongly agree” and closer to the “agree” statement) followed by receiving training & materials needed to do their job – rating of 1.96.
The next step was to review the employee comments as these provide invaluable feedback. When asked “What could Le’Chris do to increase your job satisfaction”, 67 responses were received and reviewed. The following three categories appeared to be leading contributors to this rating:
1) Getting paid consistently, same time every time, getting expense checks on time and have direct deposit (52 comments received); 2) Having needed equipment and supplies to do the job (17); 3) Recognition /Communication as to what is going on with the agency to increase morale and feel valued (17 comments). The first two concerns are believed to be a direct correlation with what is happening with the MH/SA/IDD field, but valid nevertheless. These were taken to the Corporate Team to be discussed and addressed.
The following graph displays a breakdown of staff positions responding to the survey – majority was QPs (qualified professionals) at 21.7%, followed by PPs (paraprofessionals) at 20.7%, etc.
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Other (3.3%): Indicates position chosen other than the ones listed - these were not specified
The graph below displays the length staff have been employed with Le’Chris -- it was noted that majority (31.5%) of the staff that responded to the survey have been with the company less than one year, followed by 28.3% with staff that had been with the company between one to three years.
The next graph shows the summary of responses of all Le’Chris employees for this survey followed by comparison of employee satisfaction for the last five years.
12.0%
8.7%
15.2%
18.5%
20.7%
21.7%
3.3% Which of the following best describes your job with us?
AP (Associate Professional)
Administrative/Office
Director/Coordinator
Licensed Professional
PP (Para Professional)
QP (Qualified Professional)
31.5%
28.3%
18.5%
21.7%
How long have you been employed with us?
Less than 1 year
1 to 3 years
3 to 5 years
More than 5 years
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Next Steps:
1.57
1.86
1.94
1.68
1.27
1.36
1.98
0.00 0.50 1.00 1.50 2.00 2.50
I am familiar with and understand the organization'smission and strategic goals
I have opportunities to learn and grow
I receive the training & materials I need to do my jobwell
My physical working conditions are safe
My supervisor treats me with respect
My supervisor listens to me and gives me clearinstructions
Overall, I am satisfied working at Le'Chris and wouldrecommend employment at Le'Chris to others
Level of agreement or disagreement with the following statements:
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
SouthernRegion
CentralRegion
NorthernRegion
Other All RegionsOverall
FY: 2009-2010 94.0% 98.2% 96.7% 97.1% 96.5%FY: 2010-2011 84.0% 98.7% 85.9% 97.6% 91.5%FY: 2011-2012 84.9% 91.1% 95.0% 100.0% 92.8%FY: 2012-2013 87.6% 91.8% 90.9% 100.0% 92.6%FY: 2013-2014 83.1% 98.7% 96.1% 91.4% 92.3%FY: 2014-2015 82.0% 96.9% 94.3% 100.0% 93.3%
% of Overall Satisfaction by Region for the past 6 years
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The results were shared with the QM members and the Corporate Team. Ideas are being solicited to address the areas of concern and to increase the overall satisfaction of the employees. As previously mentioned, it is very evident that all of the changes within the mental health/substance use system from the State and the MCOs have had a big impact on the employee issues; regardless, LeChris is committed to providing a great workplace for its employees and will continue to solicit feedback from the staff on an annual basis.
SATISFACTION SURVEYS – STAKEHOLDER The Stakeholder Satisfaction Surveys are conducted annually to assist LeChris in maintaining and improving relationships with our stakeholders as well as identifying areas of what’s working and what is not working. Furthermore, input is requested and collected to help determine the expectations and preferences of the organization’s stakeholders and to better understand how the organization is performing from the perspective of its stakeholders.
Strategies: LeChris chose to utilize “Survey Monkey” – a well-known on-line survey application in getting the survey out to our Stakeholders. The pros and cons were considered prior to executing the project. The cons of the system include: Spam/privacy issues, technical issues and ability to submit multiple submissions. The pros seem to outweigh the cons, they are the following: Has the same strengths as a paper version, it is better at addressing sensitive issues, it is cost efficient, it has faster delivery, quick response time and the ability to track and analyze the data is effortless. The survey was then designed to capture information about our stakeholders in general, such as type of agency they represent, types of services they utilize through LeChris, and specific LeChris locations they work with. Then more specific questions as how they would rate our work (see graphs below for the questions) - six response choices were provided: “Excellent”, “Good”, “Adequate”, “Poor” and “Not applicable”. The last four questions addressed overall quality of our services, confidence in our services, if our performance was getting better, and how likely was it that they would utilize LeChris in the future. The goal that we had set for ourselves was to achieve 90% of overall satisfaction with our stakeholders.
Actions Taken:
Once the survey was designed and approved by the QM committee and the Corporate Team, QM Director requested names of stakeholders from each of the Site Directors in order to send out a Survey to find out “How we are doing.” The following e-mail was sent to the Stakeholders:
Good Afternoon, You have been identified as one of our external stakeholders. As such, you are invited to participate in our Satisfaction Survey designed to gauge your opinion on “how we are doing”. This survey will ask about your interactions with LeChris within the past year, it will only take approximately three to five minutes to complete and all of your responses will remain anonymous. Your feedback will assist us in improving the quality of our services we provide. The link is uniquely tied to this survey and your email address; please do not forward this message. To access the survey, just click on the following link: https://www.surveymonkey.com/r/3LNBNQ9. If you have any questions regarding the survey, please feel free to contact me. Thank you in advance for your participation!
Measures: The percentage (%) of satisfaction was calculated by number of stakeholders answering
“Excellent” and “Good” for Question #5 in the survey divided by the number of surveys
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completed. In the other questions, the same method was utilized (1st two positive responses were utilized divided by the number of surveys completed)
The percentage (%) of overall satisfaction was achieved by taking the average of satisfaction for all of the responses received.
Rating scale from 1- 5 was utilized in interpreting the results. One (1) being the highest score indicating “Excellent” and four (5) being the lowest indicating “Unacceptable”.
Evaluation of Results: Participation of outside stakeholders to our survey this year was 23.5% (out of 51 requests for surveys 12 surveys were returned, none from either Rocky Mount or Wilson). According to statistics provided by Survey Monkey, the average response rate for an on-line survey is 30% which we did not meet this year, in fact this was the lowest response rate we have ever had. The sites that had the most participation were 1) Morehead City (33.3%), followed by Wilmington Day Treatment (25.0%). Most of the responses were received from Schools (50%). The service that received most responses was Day Treatment services (83.3%), followed by Therapy Services (58.3%). The average overall rating regarding the different aspects of our work revealed a score of 2.0 – rating of 1 being “Excellent” and 2 being “Good.” In rating the quality of our services, 50% reported them being as “Excellent,” 8.3% reported them as “Good”, and 33.3% reported them as “Adequate”. In collapsing the data for the Excellent and Good categories, it reveals a 58.3% positive score. When stakeholders were asked about their confidence level in our services, 42% revealed “Complete Confidence”, followed by 17% response who replied with “A lot of confidence.” According to the responses, 42% of the responses said the services were “Staying about the same” as before, followed by 33% of the responses that said our services were “Getting much better”. In the last question, we wanted to find out the likelihood of them using LeChris services again. 50% stated “Certainly, followed by 25% who chose “very likely” and “somewhat likely.” In evaluating the results, we did not meet our goal of 90% overall satisfaction. In fact this year reveals the lowest percentage in overall satisfaction over the last six years in every category – refer to the first graph. The tables and graphs following further illustrate the results of the survey. The questions asked are represented by the title of the graph.
8.3%
25.0%
8.3%
33.3%
8.3% 16.7%
Which one of our Sites do you primarily deal/have contact
with?
Greenville Wilmington Jacksonville
Morehead City New Bern Elizabethtown
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1.75
1.92
2.00
2.25
1.92
2.00
2.25
1.92
0.00 0.50 1.00 1.50 2.00 2.50
Understanding your organizational needs
Communicating clearly and effectively
Keeping you informed
Meeting timelines
Working with you and /or your team
Providing quality services
Responding promptly to problems
Meeting overall objectives
Please rate the following aspects of our work
50.0%
8.3%
33.3%
8.3%
Overall, how do you rate the quality of services we
provide?
Excellent Good Adequate Poor
41.7%
16.7%
25.0%
16.7%
What level of confidence do you have in us to deliver the
services that you require?
Complete
A lot
Some
Little
50.0% 25.0%
25.0%
Based on our performance, how likely is it that you will use us
in the future?
Certain Very likely Somewhat likely
33.3%
8.3%
41.7%
16.7%
Overall, is our performance ...
Getting muchbetter?Getting better?
Staying at aboutthe same level?Getting worse?
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Comments received from Stakeholders regarding suggestions on how Le’Chris could improve its services revealed that improvement is needed in the following areas: 1) Our intake system – specifically after the assessment is completed to start the services; 2) Timeliness in submission of authorizations and communicating significant changes that occur with the person served. 3) Ensuring that phone lines are being answered and that all staff is on the same page. The comments received definitely coincide with the overall satisfaction and assist us in understanding the areas needed for improvement.
Next Steps: LeChris continues to be committed to providing the best possible services. The results were shared with the QM members and the Corporate Team. Ideas were solicited to address the areas of concern and increase the overall satisfaction of the stakeholders. There are some definite trends for areas of improvement which include our referral process and access to timely services. It was recognized that these are both topics of conversation already during all staff meetings, corporate meetings and QM meetings; however it doesn’t seem to be working. Referrals and timely access to services are being tracked quarterly; however the data received from those does not appear to coincide with results from the Stakeholder satisfaction surveys. Internal audits conducted by the Quality Management Department further recognize that this is an ongoing issue and additional education on the importance of addressing issues in a timely manner along with documenting these issues have taken place. We have had a lot of turnover during the past year and it is believed that this too has played a part in the decrease of stakeholder satisfaction. LeChris will continue to solicit feedback from our Stakeholders on an annual basis to ensure quality of services and to assist us in identifying any areas of concern from outside sources.
