annual performance and quality improvement … annual report 2014 (2).pdfdischarge dates ranging...

ANNUAL PERFORMANCE AND

QUALITY IMPROVEMENT

REPORT 2014

ECI 2014 Performance & Quality Improvement Report Page 1

CONTENTS

Executive Summary……………………………………………………………………………….2

Introduction…………………………………………………………………………………….….2

Mission Statement…………………………………….……………………………………....…..3

Vision……………………………………………………………………………………………...3

Core Values……………………………………………………………….……………………….3

ECI Client Demographics…………………………………………………………………….…...4

Client Outcomes…………………………………….…………………………………….……….5

Client Satisfaction…………………………………………………….…………….……..5

Parent Satisfaction…………………………………………………….…………….…….5

Family Involvement………………………………………………….……………………6

Functional Status…………………………………………..………………………………6

Recidivism………………………………………….……………………………………..7

Length of Stay…………………………………………………………………………….9

Complaints & Grievances…………………………………………………………………….…10

Safety & Security……………………………………….……………………………………..…11

Client Sense of Safety…………………………………….…………………...…………11

Restraints………………………………………………………………….……………...12

Safety Related Incidents………………………………………….…………………...…13

PREA Statistics…………………………………………………………………………..16

Bed Utilization…………………………………………………………………………………...16

Staff Satisfaction & Retention……………………………………….……………...…………...17

Compliance…………………………………………………………...………………………….19

Internal Case Record Reviews…………………………………..………………………19

Internal Claims……………………………………………………...……………………20

Conclusion………………………………………………………………..……………………...21


Executive Summary

Edison Court, Inc. (ECI) has been providing specialized and general behavioral health services

for 11 years. Our goal is to deliver services to children, adults, and families across the Delaware

Valley in the most effective and efficient manner. To fulfill this goal, ECI has embarked on

creating a Performance and Qualility Improvement process to evaluate various quality indicators.

This report outlines the efforts made by ECI to improve the lives of our clients, maintain

accountability, and improve in areas where needed. Founded on strong priniciples and consistent

with the best practices outlined in the Council on Accreditation’s standards, ECI presents you the

2014 Performance and Quality Improvement Report.

Introduction

Edison Court, Inc. (ECI) is committed to the advancement of quality improvement principles

designed to promote the delivery of efficient and effective services to our clients. We use an

inclusive and transparent approach when establishing performance goals, benchmarks, and

determining how to measure our work. ECI’s Performance & Quality Improvement (PQI) Plan

consists of a process of assessing performance, making plans to improve, and reassessing results

with a focus on aiming to achieve the best possible outcomes.

Our overarching PQI Committee is comprised of both internal and external stakeholders,

representing both residential and outpatient programming. This committee meets quarterly and

is responsible for directing ECI’s performance improvement activities. Program level sub-

committees include staff from all departments who meet regularly to review service delivery and

develop quality improvement plans. All findings and recommendations are shared with ECI

personnel, the Board of Directors, as well as additional stakeholders.

ECI has selected a variety of performance areas to measure in order to ensure a broad-based

organization-wide process. These areas include:

Management & Operations

Service Quality & Delivery

Client & Program Outcomes

Client & Staff Satisfaction

Risk Prevention Effectiveness

The following PQI Annual Report provides significant positive developments, challenges, and/or

obstacles faced by ECI over the last year with regard to our performance and quality

improvement process.


Mission Statement

We are dedicated to providing responsive and innovative care to individuals and families

facing behavioral and mental health challenges.

Vision

To be the leading provider of forensic mental health services in the Delaware Valley by

providing best-in-class treatment programs with measurable outcomes delivered within a

framework of strict regulatory compliance.

Core Values

Treating clients with DIGNITY

Providing families with HOPE

Protecting the community from HARM

Delivering the most cutting-edge treatment as supported by BEST PRACTICES

Reducing RECIDIVISM

Improving client adjustment by enhancing EDUCATIONAL, VOCATIONAL, and

OCCUPATIONAL SKILLS

Repairing the harm done to the VICTIM AND THE COMMUNITY


ECI Client Demographics

ECI served children, adults, and families, primarily from Bucks and Montgomery Counties, but

also had relationships with six other Counties. Clients who received services over the past year

through ECI ranged from 5 to 72 years of age. In 2014, ECI served a total of 441 clients

throughout our continunum of care. The following client demographic information best

describes the population served. Our geographical profile during the year reached as far west to

Cumberland County and north to Pike County.

2014 MATHOM HOUSE

EASTON MANOR

RAVENHILL CLINIC

RAVENHILL CARP/CASE

MGMT

ADULT GROUPS

PENNS-BURY

SCHOOL

ECI TOTAL

GENDER Male 100% 100% 59% 93% 100% 72% 77% Female - - 41% 7% - 28% 23% ETHNICITY Caucasian 45% 36% 78% 65% 92% 64% 71% African American

36% 29% 13% 20% 3% 18% 17%

Latino 8% 14% 4.5% 7% 3% 6% 6% Asian (non- Pacific Islander)

- - 2.25% 2% 2% 1% 2%

American Indian /Alaska Native

- - - - - - 0%

Bi/Multi Racial 11% 21% 2.25% 6% - 11% 5% Other - - - - - - 0% AGE Under 5 - - - - - - 0% 76%5-9 - - 10% - - - 4% 10-14 17% - 17% 11% - 7% 12% 15-19 83% 79% 29% 86% - 93% 52% 20-24 - 21% 8% 3% 10% - 12% 25-34 - - 14% - 30% - 10% 35-50 - - 14% - 32% - 10% 51 and over - - 8% - 28% - 7% COUNTY Bucks 11% 22% 91% 45% 93% 99% 76% Montgomery 53% 57% 9% 55% 7% - 19% Philadelphia 15% - - - - 1% 2% Lehigh 6% 14% - - - - 1% Monroe 9% - - - - - 1% Delaware 2% 7% - - - - .5% Lancaster - - - - - - 0% Cumberland 2% - - - - - .25% Pike 2% - - - - - .25%


Client Outcomes

To ensure clients at ECI are receiving high quality and effective services, we have adopted a

variety of client driven and informed measures. This section of the report provides a brief

overview of the measures we use to evaluate that our values are being honored and embraced in

care, that clients are satisfied with the services they receive, and to assess that our services are

effective in promoting our client’s well being. As noted below, programs evaluated through our

PQI process expanded to Case Management and CARP during the year.

75

80

85

90

95

100

% S

atis

fact

ion

Client Satisfaction

2013 Avg. 2nd Qtr. 4th Qtr.

556065707580859095

100

% S

atis

fact

ion

Parent Satisfaction


Client Satisfaction Client Satisfaction measures continue to be

administered twice annually. In all programs

offered through ECI (that collected such

data), clients reported a high degree of

overall satisfaction with services received

and allowed us to meet or exceed our internal

benchmark of 85%. Dips in satisfaction

within outpatient programming are

hypothesized to be related to the closing of

the lower Bucks office and eliminating

psychiatric services. Other potential areas of

concern are currently being addressed in a

variety of ways, including increasing family

involvement and eliminating potentially

confusing language in the satisfaction

surveys.

Parent Satisfaction Parent Satisfaction measures were also

administered twice during 2014. All but

CARP rates met or exceeded our internal

benchmark of 85%. It should be noted that

the 4th quarter was the first time parent

satisfaction was measured for both Case

Management and CARP. Therefore, it is

expected improvements will be noted

moving forward as plans of correction are

implemented, as was reflected in the

increased parent satisfaction noted at

Mathom House and the Clinic.


*Family Involvement data related to Case Management and CARP

were first measured during the 4th

quarter.

The dip in family involvement at EM is a product of resident turnover and difficulties establishing

consistent engagement with a larger n of involved families. Similarly, the decrease in involvement seen

at the Clinic is attributed to three families with documented rationales.

Change in Functional Status ECI began the complex endeavor of measuring clients’ change in functional status the second

half of 2013. Since that time, data has been gathered and analyzed in order to establish a

baseline and determine benchmarks. We have expanded the programs measuring such

information to include both residential programs, the Ravenhill Clinic, and Case Management

and CARP services. Changes in the measures utilized combined with the incorporation of

additional programs make analysis difficult at this time. However, average changes in functional

status between quarters (where available) indicated a moderate increase in functionality with

regard to residential programs (decrease in areas of need as demonstrated through the CANS),

Case Management and CARP (internalizing behaviors as demonstrated through the BASC-2),

and the Clinic (strengths and physical health as demonstrated through the CHI & CHI-C).

50556065707580859095

100

% o

f C

ase

s

Family Involvement

2nd Qtr. 4th Qtr.

Family Involvement The involvement of families across

ECI programs was analyzed twice

in 2014. Comparative data from the

previous year was not available due

to changes in the measures utilized.

Residential programs are at an all

time high in availability of sessions

offered to families with three

family therapy professionals

working with a total of 39 potential

families. We have set our

benchmarks high despite the

inherent challenges related to our

specific population based on our

prioritization of including families

as much as possible in order to

improve treatment efficacy.

Barriers to increasing family

involvement such as distance,

financial hardships, and

intrafamilial trauma are current

topics of discussion within the PQI

level of care subcommittees in an

effort to improve the overall

participation of families in our

clients’ treatment.


Recidivism Recidivism, for our purposes, is defined as any convictions post-treatment resulting from acts

occurring post-treatment interval, collected on all individuals up to 5 years post-treatment

discharge. For the current data set, PA criminal record checks (residential programs) and

specified state portals (outpatient programs) were utilized to glean recidivism data.

Mathom House Recidivism Total Discharge n=104

Total Data n=51

Sexual Felony (0)

SexualMisdemeanor (1)

Non Sexual Felony(3)

Non SexualMisdemeanor (4)

Non Recidivists(43)

Easton Manor Recidivism Total Discharge n=33

Total Data n=16

Sexual Felony (0)




Non Recidivists(15)

Mathom House Sexual Recidivism- 2%*

Non Sexual Recidivism- 14%

Recidivism data was collected in

February and March of 2014. Data

Sources included state criminal

background checks and additional

interviewing of or relating to a population

of 104 clients who underwent residential

treatment with discharge dates ranging

from Jan 2009 to Dec 2013.

Of the recidivists, three out of the eight

were committed by individuals who were

discharged based on failure to adjust to

program requirements.

*At the time of data collection, one

additional client who failed to adjust in

the program and two successful graduates

had received sex-related charges that

were held for court.

Easton Manor Sexual Recidivism- 0%*



February and March of 2014. Data

Sources included state criminal

background checks and additional

interviewing of or relating to a

population of 33 clients who

underwent residential treatment with

discharge dates ranging from Jan

2009 to Dec 2013.

Of the one recidivist, one former

resident committed a non sexual

felony.

*At the time of data collection, three

additional clients who completed the

program had received sex-related

charges that were held for court

(same clients noted above related to

MH).


Recidivist Review(Residential) Upon learning that three former clients of our residential programs had been charged with sexual offenses

this year, a committee was formed internally to review the cases and determine if any lessons could be

learned in retrospect. One of these young men was identified to have sociopathic tendencies. Research

findings from within our residential programs suggest the higher possibility of diminished clinical impact

within our more sociopathic clients, bringing to bear the need for careful consideration of such a risk

factor to best predict client-program match. Another case emphasized the importance of prospective

lifestyle and occupational planning. Although adaptive community funtioning is predicated upon

adherence to clincial gains made, the degree to which the clinical team can facilitate a clear goal plan and

steps needed to attain the goal(s) has been highlighted. The third case posed the question had he had the

opportunity to remain longer within our care, a redundant reinforcement of prudence reflecting his Relaps

Prevention and Wellness Plans within the community might have been beneficial.

CARP Recidivism Total Discharge n=6

Total Data n=4 Sexual Felony (0)


Non SexualFelony (0)


Non Recidivists(3)

Case Management Recidivism

Total Discharge n=40 Total Data n=23

Sexual Felony (0)


Non SexualFelony (1)


Non Recidivists(19)

CARP Sexual Recidivism- 0%*


Recidivism data was collected in June of

2014. Data sources included the Public Web

Docket relating to a population of 6

discharged clients with discharge dates

spanning back approximately 1.5 years,

representing the commencement of the

program.

One former client committed 2 non sexual

misdemeanors.

*At the time of data collection, one

additional client who partially completed the

program had received sex-related charges

that were held for court (one of the clients

noted above related to MH & EM).

Case Management Sexual Recidivism- 0%



June 2014. Data sources included

Public Web Docket relating to a

population of 40 clients discharged

between June 2011 and May 2014.

Of the four recidivists, one former

client committed 8 non sexual

felonies, two committed 2 non

sexual misdemeanors each, and one

committed a single non sexual

misdemeanor.

All of the individuals included in

this sample completed Case

Management requirements.


Length of Stay

Residential Program Average Length of

Stay 2013

Average Length

of Stay 2014

Benchmark

Goal

Mathom House 24 months 23 months 18 months

Easton Manor 7 months 7 months 8 months

Length of Stay ECI has become increasingly attentive to the average length of stay in our residential programs

with an eye toward providing the most effective and efficient treatment possible. We understand

the importance of clients receiving care in the least restrictive environment while balancing the

importance of community safety. We routinely evaluate our process of implementating best

practices and make adjustments as necessary to ensure that clients remain in our residential

programs only as long as necessary to accomplish their identified treatment goals. Changes to

the Mathom House treatment curriculm were made toward the end of 2013 in order to eliminate

redundancies, ensure focus on pertinent risk factors, and integrate more Dialectical Behavior

Therapy (DBT) appear to have contributed to shaving off one month to the average length of

stay. Although we remain a distance from achieving our benchmark of 18 months, we are

moving in the desired direction.

Adult Sexual Offender Program

Total Discharged n=33 Total Data n=32

Sexual Felony (.5)

SexualMisdemeanor (.5)



Non Recidivists(30)

Adult S.O. Program Sexual Recidivism- 3%


Recidivism data was collected in June

of 2014. Data sources included the

Public Web Docket relating to a

population of 33 clients discharged

between June 2011 and May 2014.

Of the two recidivists, one former

client committed 2 non sexual

felonies and one former client

committed 3 non sexual

misdemeanors and 7 sexual felonies.

All of the individuals included in this

sample completed treatment

requirements.


Complaints & Grievances

Consistent with our values, we honor the voice of the client and their family, therfore providing

us another opportunity to improve services. In 2014, ECI received 15 client grievances, 14 of

which were voiced from Mathom House and one from Easton Manor. The year prior (2013) saw

a total of 18 grievances, all from Mathom House. It should be noted that Mathom House

strongly encourages the residents to utilize the grievance policy in order to empower themselves

and develop healthy conflict resolution skills. No formal girevances from families or employees

were filed over the year.

2

7 1

4

1

Client Grievances (n=15)

Complaints AboutPeers

Complaints AboutStaff

Rules/Expectations

Consequences

Food

Client Grievances The majority of grievances were

submitted by West Side residents who

are hypothesized to have gained the

confidence to verbalize their

frustrations in a more meaningful

manner. All grievances were handled

within ECI policy and addressed in a

timely manner. None of these

grievances rose to the level of an

administrative investigation. Please

see chart to the left for a breakdown

of areas of grievance.


Safety & Security

To ensure clients at ECI are receiving services within a safe environment rooted in Trauma

Informed Care, we have adopted a variety of client driven and informed measures. This section

of the report provides a brief overview of the measures we use to evaluate that we are

establishing, maintaining, and encouraging a safe environment in which our clients receive

services.

75

80

85

90

95

100

% O

f Th

ose

Wh

o R

esp

on

ed

in A

gre

em

en

t w

ith

Ass

oci

ate

d F

acto

rs

Client Sense of Safety Mathom House

2013 Avg. 2nd Qtr. (n=33) 4th Qtr. (n=27)

75

80

85

90

95

100

% o

f Th

ose

Wh

o R

esp

on

de

d in

Agr

ee

me

nt

wit

h A

sso

ciat

ed

Fac

tors

Client Sense of Safety Easton Manor

2013 Avg. 2nd Qtr. (n=3) 4th Qtr. (n=6)

Residential Client Sense

of Safety Measures related to the

perceived ‘Sense of Safety’ of

residential clients were

administered twice in 2014.

Mathom House saw a 6%

improvement on average when

compared to 2013 while

Easton Manor saw an 8%

improvement. The most

significant improvements are

noted during the 4th quarter,

during which time a new

Director was hired. As a

result, changes in daily

operations such as increased

staffing and training,

expansion of recreational

activities, removal of clients

ill-fit for the program (MH),

and shifts in personnel have

undoubtedly had a positive

effect on residents’ sense of

safety.


70

75

80

85

90

95

100

Ravenhill Clinic Case Management CARP

% o

f C

lien

ts

Client Sense of Safety Outpatient Clinic


0123456789

10

1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr.

# o

f R

est

rain

ts

Restraints (n=23)

Risk to Assault Peer Risk to Assault Staff

Risk to Harm Self

Outpatient Clinic

Client Sense of

Safety Measures related to

clients’ comfort within the

therapeutic relationship

were administered twice

in 2014. Results exceeded

our internal bench mark of

90% within each program

assessed. Clients

expressed feeling

comfortable expressing

discomfort and/or

dissatisfaction, being

encouraged to take

responsibility for their

actions, and that their

wishes regarding

confidentiality were

respected by the treatment

provider.

Restraints Quarterly, ECI’s Risk Management

Committee analyzes restraint data to

determine any trends or patterns. As our

clientele has shifted to a more challenging

population (increased aggression and/or

mental health concerns), we have seen an

increase in our use of restraints. A total of

23 restraints occurred in 2014 (all at

Mathom House), up from a total of 9 the

year prior. Nine different residents

accounted for these restraints, with 7 of

the 9 needing to be restrained on multiple

occasions for repeated incidents of

aggressive behaviors toward others and/or

imminent risk to harm themselves. No

injuries were noted and proper procedures

were followed during all incidents. The

high turnover of clients during summer

months contributed to an unstable culture.

.amongst challenging clientele. The PQI Residential Sub Committee (now known as the ‘Culture Club’) began more thoroughly

addressing the underlying causes of the restraints during the 2nd

quarter. Improvements related to

security, the behavioral modification system, staffing (including increased clinical support in the

evenings), training, and recreational activities combined with the removal of residents no longer an

appropriate fit for the program led to an immediate decline in the number of restraints.

*Sense of Safety data related to Case Management and CARP were first measured during the 4

th quarter.


0

2

4

6

8

10

12

14

MedicationErrors

EmergencyRoom Care

Self InjuriousBehavior

SexualMisconduct

# o

f In

cid

en

ts

Safety Related Incidents

2013 Avg. 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr.

3

8

20

13

1

Medication Errors (n=45)

EM ResidentOverslept

Forgot toAdminister

MedicationUnavailable

ResidentUnavailable

Dosing Error

Safety Related

Incidents-Residential

Programs ECI’s Risk Management

Committee reviews a

variety of data related to

safety on a quarterly basis.

Providing a safe and secure

environment in which our

clients receive treatment is

a fundamental priority. We

selected medication errors,

emergency room care, self

injurious behavior, and

sexual misconduct as the

most significant safety-

related incidents to monitor

and address, as necessary.

As the chart to the right

demonstrates we have seen

a spike in such incidents

when compared to the year

prior. Further analysis can

be found below.

Medication Errors Throughout 2014 there were a total of 45

medication errors between both Mathom

House and Easton Manor. The chart to

the left breaks down the type of

medication errors experienced. The vast

majority (medication and/or resident

unavailable) appear the product of poor

planning and communication. Medication

was often unavailable due to inaccurate

medication counts, lack of pharmacy

delivery, and/or prescription not being

received by the pharmacy in time since the

psychiatrist was seeing the client the day

the medication actually ran out. Instances

where the resident was unavailable

included leaving for work, appointments,

community outings, court hearings, and/or

community visitation without taking

medication with them. Fine tuning efforts

to address this area of concern led to a

significant decrease in the number of

errors during the 4th quarter.


Self Injurious Behaviors As noted above, the emergency room was utilized on two occasions (same resident) for a

psychiatric consult in response to incidents of self injury. One incident involved making

superficial scratches on his arm with a plastic knife from the cafeteria. The other consisted of the

resident putting a belt around his neck which he pulled tight for approximately one second and

then released. On both occasions, the resident was assessed by clinical staff, placed on increased

safety observation, and evaluated at the hospital to determine the appropriateness of psychiatric

hospitalization (each time determined to be unnecessary).

2

1

3 4

1

2

Reasons for ER Care (n=13)

Sports Injury

Medication Error

SignificantComplaint AfterHoursPunched/KickedDoor/Wall/Window

Bee Sting (Allergic)

Psychiatric Crisis

Emergency Room Care Without medical personnel on site,

our residential programs rely on the

local hospital for emergency and/or

after hours medical concerns. All

incidents requiring services through

the emergency room were

determined to be consistent with the

residential level of care and

clientele. Incidents were addressed

in a timely manner and according to

program policy in order to ensure

the safety of all involved.


Once incident of a resident exposing himself to a staff member was also reported; both internally and to

the local police department. This resident has recently received charges for his behavior and the case is

being handled by Juvenile Court. The staff member has been reassigned to another program in an effort

to maintain an appropriate lack of contact with the resident.

The remaining incidents all involve a Child Care Worker showing pornography on his personal cell phone

to residents. Following his termination for unrelated reasons, residents came forward to report such

incidents. Both internal and external investigations took place (see PREA information below). An

Adverse Incident Ad Hoc Committee chaired by the CEO was quickly established and included key staff

from various departments with the goal of learning from this circumstance, identifying deficiencies and

vulnerabilities, and making any changes necessary. As a result of these meetings, amendments to two

policies were made. A Cell Phone Policy was established that bans any personal electronic device from

being on the milieu at Mathom House. The use of walkie-talkies has been implemented to account for

potential communication gaps throughout the building. Our Search Policy was amended to afford

increased protections to staff and residents alike. All clothing searches now include two staff members;

one who observes the staff member conducting the actual search. Additional changes included hiring

more Child Care Workers in order to allow our Shift Supervisors to perform their actual supervisory

duties (which had diminished over the years). Supervisors are now provided the opportunity to monitor,

mentor, and observe Child Care Workers. Improved hiring practices, orientation training, and ongoing

staff development have also been implemented in order to ensure the most qualified staff are both hired

and retained.

7

2

7

1

Sexual Misconduct (n=17)

Exposure AmongstConsentingResidents

Fondling BetweenConsentingResidents

Staff SexualMisconduct

Resident ExposureToward Staff

Sexual Misconduct All incidents of sexual misconduct occurred

at Mathom House; 15 out of the 17 did not

involve any physical contact (exposure or

showing pornography). Internal

investigations were promptly completed in

order to determine the extent of the

misconduct as well as ascertain any areas in

need of corrective action to daily

operations.

As noted in the chart to the right, 7

incidents of exposure and 2 incidents of

fondling amongst consenting residents

occurred. Improvements to the physical

structure (new bedroom doors with

narrower windows), direct observation

procedures, furniture arrangement, and

staffing plans have all be implemented in

order to minimize residents’ ability to

engage in such behavior.


PREA (Prison Rape Elimination Act) In December 2013, ECI began implementation of comprehensive ZERO Tolerance policies to ensure

compliance within our residential programs with the Federal Prison Rape Elimination Act (PREA) and its

Juvenile Standards. We successfully underwent our first PREA audit in March 2014, resulting in Mathom

House and Easton Manor becoming the first juvenile programs in the state of Pennsylvania to obtain the

designation of being PREA Compliant.

Bed Utilization

0

1

2

3

4

5

6

7

8

9

10

Youth-on-YouthSexual Abuse

Staff SexualMisconduct

SexualHarassment

PREA Incident Reports

98.1% 99.9%

96.9%

84.4% 80

85

90

95

100

Mathom House Easton Manor

Utilization Rates

2013 Utilization 2014 Utilization

Bed Utilization Mathom House narrowly

missed our internal benchmark

(97.5%) for bed utilization this

year. However, Easton Manor

experienced a much more

pronounced dip in utilization,

dropping to 84.4% (benchmark

of 99%). No one clear

underlying reason has been

identified. It appears to be a

combination of factors such as

fewer clients from Mathom

House needing a transitional

program, difficulty executing

new contracts, and minimal

direct referrals from existing

counties.

PREA Statistics After terminating the employment of a

Child Care Worker in August 2014 for

unrelated reasons, residents came

forward to report incidents of staff

sexual misconduct by this individual.

The incidents involved the staff

member showing pornography to

seven different residents on his

personal cell phone. No physical

contact occurred.

The matter was immediately reported

to local law enforcement which

investigated and ultimately pressed

charges. The Department of Public

Welfare also conducted an

investigation but determined the

incidents to be ‘unfounded’ due to the

definition of child abuse in place at the

time. This case is currently

progressing through the adult criminal

court. The final outcome will be

reported in next year’s PQI report.


Staff Satisfaction & Retention

ECI believes that our workforce is our greatest asset. As such, we strive to develop and

implement strategies, plans, and programs necessary to attract, motivate, develop, reward, and

retain the best people to meet our goals and objectives. This section of the report provides a

brief overview of measures we use to evaluate the level of personnel satisfaction and retention.

**Black dotten line depicts U.S. Mental Health Norms (ECI internal benchmark)

Staff satisfcation was once again surveyed during the first quarter of 2014. When comparing

agency-wide averages with data from the year prior, few differences are noted. However,

satisfaction with regard to pay showed improvements amongst residential staff. This change was

likely attributed to the creation of merit-based tiers for Child Care Workers as well as adjusted

pay rates in response to last year’s satisfaction data as well as a comparison to industry norms.

Satisfaction with coworkers amongst residential staff saw a decrease when compared to the year

prior. As noted in the next section, staff turnover increased significantly over the prior year

which likely impacted the comfort, trust, and overall satisfaction employees felt toward their

coworkers.

0

1

2

3

4

5

6

Staff Satisfaction

2013 ECI Wide (48) ECI Wide (55) Outpatient (7) Residential (41) Business Off (7)


**Total turnover rate for 7/1/13 through 6/30/14 was 43%

Employee Retention Compared to the year prior, ECI experienced a significant increase in employee turnover

throughout the agency but particularly in our residential programs. A total of 23 employees left

the organization between July 2013 and June 2014, compared to 14 the year prior.

Approximately 25% can be attributed to starting a family, relocating out of state, and health

related concerns. Another 25% is attributed to terminations and the remaining 50% appear

related to securing new positions both within and outside of our field. In line with historical

information, the role of CCW experiences the highest turnover rate. Efforts to improve security

and staff training in the areas of relationship building and crisis intervention aim to improve

feelings of safety and competency, while a newly implemented ‘treatment team’ aims to increase

CCW involvement and investment in the program. Residential administration is also working to

increase positive recognition and merit-based rewards and awards for positive attitudes, strong

work ethic, and efforts to excel.

A review of the available exit interviews (8 total) demonstrate high ratings for ECI’s policies &

procedures, performance reviews, and benefits. Mixed reviews were noted with regard to

opportunity for advancement, training received, responsibilities, support by management, work

load, hours, and salary. Several exit interviews made mention of increasing demands both

internally and externally, seemingly related to ECI’s process of becoming accredited as well as

achieving PREA compliance, while simultaneiously experiencing changes in program

leadership. Current stategic initiatives such as leveraging techonology for efficiency and

regulatory compliance as well as investing in staff development are expected to positively impact

both satisfaction and retention.

0%

10%

20%

30%

40%

50%

60%

70%

Employee Turnover Rates

2013 Rates 2014


Compliance

ECI uses Federal, State, County, and MCO guidelines to assess that clinical documents are

completed accurately, timely, and consistent to best practices and the regulations. This process

is another area for opportunity to improve quality on how we record services, and defeat system

or programmatic challenges. Consistent to our values, we feel that accurate recording of services

increases credibility and integrity. In the course of this year, ECI evaluated a total of 389 case

records (both open and closed), comparing each quarter’s performance score to the last in order

to gauge the effectiveness of quality improvement plans.

0

10

20

30

40

50

60

70

80

90

100


Residential Case Record Compliance

Clinical Medical ISP

Intake Medical2 Profile & Bkrnd

Outcomes Assessments Service Planning

Internal Case Record

Reviews- Residential

Programs The process by which

residential case records were

audited evolved throughout

the year. Mid year, the

programs leveraged our

EHR to automatize the

process; thus, the change in

reporting categories noted in

the chart to the right.

Overall, compliance has

improved significantly as a

result of implementing EHR

while simultaneously

increasing awareness

regarding the importance of

compliance to best practices

and regulations. Any dips

noted in the graphic

represent a shift in criteria

being measured in order to

expand our process of

continual improvement. *Dotted black line depicts our internal benchmark for 2014. The PQI Committee has

determined a 90% benchmark to be appropriate for 2015.


Internal Claims

2014 Ravenhill

Clinic

1/1-6/30

Ravenhill

Clinic

7/1-12/31

Mathom

House

1/1-6/30

Mathom

House

7/1-12/31

Easton

Manor

1/1-6/30

Easton

Manor

7/1-12/31

TOTAL CLAIMS 847 370 152 147 31

18

TOTAL RETRACTS 0 1 0 0 0

0

TOTAL RESUBMIT 0 1 0 0 0

0

TOTAL ERROR

RATE 0% .27% 0% 0% 0%

0%

ADJ. ERROR RATE n/a 0% n/a n/a n/a

n/a

AMT RETRACTED $0 $85.00 $0 $0 $0

$0

AMT TO BE

RECOUPED $0 $92.00 $0 $0 $0

$0

ACTUAL LOSS $0 -$7 $0 $0 $0

$0

0

10

20

30

40

50

60

70

80

90

100


Outpatient Clinic Case Record Compliance

Treatment Plan Documentation/Notes Condition of Chart

Stage of Change Psychiatric Tx Plan

Internal Case

Record Reviews-

Outpatient Clinic Case record

compliance for the

Clinic met or

exceeded internal

benchmarks

throughout the year.

EHR has been

instrumental in

automatizing the

process by which

clinicians document

services. The

outpatient PQI sub

committee plans to

expand the criteria

being measured

during audits for

2015.

*Dotted black line depicts our internal benchmark for 2014. The PQI Committee has determined a 90%

benchmark to be appropriate for 2015.


Conclusion

The goal and objective of our PQI process during 2014 was to build upon our initial plan

consisting of a cyclical process of assessing performance, making plans to improve, and

reassessing results with a focus on aiming to achieve the best possible outcomes. ECI evolved in

this initiative and the following performance benchmarks/goals for 2015 were determined:

Maintain client satisfaction above 80-90%, depending upon program and influence of

mandated participation, level of care, etc.

Maintain parent satisfaction above 85%

Achieve and/or maintain client sense of safety above 90%

Improve and subsequently maintain case record compliance above 90% (up from 85%)

Increase and mainatain family involvement above 85-90%, depending upon level of care

Effectively mitigate safety and security risks through the leveraging of electronic health

records and maintenance of a Safety Committee

Begin analyzing data related to personal searches and contraband in our residential

programs

Demonstrate effectiveness of forensic programming by reducing level of risk

Maintain better than national averages of recidivism

Show evidence of quality of care by improving the functional status of our population

Maintain a 0% error rate for all Medicaid claims

Maintain staff satisfaction scores which achieve or exceed national norms for our field

Reduce personnel turnover rates

Include the school program in the PQI process and more thoroughly include the Adult

Forensics

Our organization has seen tremendous benefits from the continued implementation of our

Performance and Quality Improvement process over the last year. An environment has been

cultivated where leadership and staff collectively strive to improve the quality of services and

outcomes for the individuals and families we serve. We have worked together to assess

performance, make plans to improve, and subsequently reassess results with a focus on aiming to

achieve the best possible outcomes. We look forward to maintaining this crucial process in the

coming year and beyond and expect to continue to see benefits in a variety of areas.

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