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Sipe's Orchard Home shall maintain a process for continuous quality assurance and improvement using a systems approach to evaluate the effectiveness of all agency components. All personnel will have a role in agency improvement, addressing the agency's goals and objectives and participating in both short-term and strategic planning.
The objectives of the process shall be: Services
Board Approval: 11-11-99, 10-28-2008 For further information about performance and quality improvement at Sipe's, see below as well as the following documents: Strategic Plan 
PQI Plan
PQI Sub-committees
Structure and Function PQI functions at Sipe’s Orchard Home will be addressed by the staff at monthly PQI meetings. All supervisors and department heads attend these meetings, and all staff members are invited and encouraged to attend. A board member and community representative are also invited. Attendees will constitute the PQI Committee. The PQI meetings will be used to evaluate and revise an annual PQI plan, review & facilitate progress toward the goals of that plan, and maintain an ongoing agency-wide process of evaluation and improvement. The group will suggest changes in policy, procedure, and programs based upon information submitted by its members. The Administrative Vice president or other designated staff member will be responsible for any necessary coordination of schedules, assignments, etc. and for making regular reports to the board, staff, and other stakeholders. Schedule While any quality-related item may be discussed at any meeting, the following schedule will be followed to assure that all areas are reviewed regularly:
PQI Plan The committee establishes an annual PQI Plan which supports the agency’s short term and long term goals. The PQI plan includes goals, strategies for accomplishing the goal, implementation, and measurable outcomes. This plan is developed with input from staff, clients, and other stakeholders. This plan is revised at least annually before the beginning of the calendar year. Peer Review & Documentation The Administrative Secretary and appropriate staff conduct quarterly reviews of client files. When possible, supervisors make reviews who are not usually responsible for that program. Reviews will be performed on 100% (or a portion thereof) of open and recently closed files (within the last year) in each program. Samples are to be taken at random. Results of the review are shared at PQI committee meetings. For each record where a deficiency is noted, the peers will develop a corrective plan that includes: 1) A method to correct the problem, 2) Timeline for completion of correction, 3) Who is responsible for the correction, 4) A measurable indicator that the problem has been corrected. The administrative vice president will compile a summary of the reviews to show overall patterns of performance. Safety & Risk Management Regular reviews will insure that the following risks are adequately addressed and minimized:
The staff members listed above will report their progress, status, or challenges related to safety and risk management at PQI meetings. As applicable, those staff members will keep records such as dated and signed checklists, meeting minutes, logs, receipts, etc. as proof of compliance. Client Rights A separate Client Rights Committee meets at least quarterly to review restrictive intervention reports, critical incident reports, and incidents that require outside investigation. This committee also conducts grievance hearings as needed. The administrative secretary serves as the staff liaison for this committee which also consists, ideally, of individuals from the community and a current or former client. The administrative secretary schedules the meetings, compiles material for the committee’s review, records minutes, and reports at least quarterly to the PQI committee and to the board. The client rights committee, in conjunction with the PQI committee, will review Sipe’s policies and procedures regarding the implementation of client rights rules at least every three years. This review should verify that there is compliance with all applicable state and federal laws regarding services to the mentally ill and the developmentally disabled. The committee reports their findings to the board of directors. Fiscal and Assets Allocation The business manager is the focal point for the agency’s finances, including, but not limited to, payroll, Medicaid billing, accounts payable & receivable, budgets, investments, and insurance. The business manager works in concert with the president, the board’s Finance Development Committee, and outside advisors (auditor, insurance representatives, etc.) to ensure Sipe’s Orchard Home’s fiscal viability, accountability, and efficient use of resources. The business manager provides and reviews monthly financial statements with the board and PQI committee. Human Resources Through the Administrative Secretary (who maintains and reviews personnel files; credentialing, privileging, and supervision records; staff training calendar, etc.) the committee will review job descriptions, propose staff incentive plans, monitor & respond to staff complaints and suggestions, oversee the effectiveness of agency staffing patterns, and otherwise attend to employee needs. Outcomes & Measures In response to the established goals of the strategic, annual, and PQI plans, the PQI committee will oversee the gathering, analysis, and presentation of outcome data and will monitor the progress toward specific and agency-wide goals. Program supervisors will collect program information through standardized measurement tools and parent/client surveys; they will present this information to the PQI committee and make it available for agency needs such as grant proposals, licensing, accreditation, and public release. Likewise, the development office will distribute, compile, analyze, and present staff, community, and other stakeholder surveys. The types of information gathered may include the following:
Original Approval: 11-26-99 Revisions: 9-21-00, 11-15-01, 01-20-04, 2-14-06, 10-28-2008 |