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SQA

STANDARDS AND QUALITY ASSURANCE

Comprehensive Program ReviewMay 29, 2015

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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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