COA - Council On Accreditation

	Performance and Quality Improvement

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Administration and Management Narrative (CA-PQI):

The Administration and Management Narrative provides an overview of key practices that contribute to the performance and productivity of your organisation. This Narrative supports, but should not duplicate, evidence provided elsewhere in your self-study.

The Performance and Quality Improvement Administration and Management Narrative should provide the Peer Review Team with a clear concise description of how your organisation’s PQI programme contributes to good use of limited resources, and achievement of the organisation’s strategic and programme goals.

Purpose Standard: Performance and Quality Improvement (CA-PQI)

An organisation-wide Performance and Quality Improvement (PQI) programme advances prudent use of resources, efficient, effective service delivery, and the achievement of strategic and programme goals.

Provide responses to the following questions that address your organisation’s achievement of the PQI Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

1. Explain how your organisation defines and represents a culture that values quality, including:

how strategic priorities influence the quality improvement process;
how the CEO/Executive Director and senior managers promote a culture of service delivery excellence, customer satisfaction and continual improvement; and
fiscal and staff resources devoted to PQI.

2. How would your organisation describe its progress/status with implementing the PQI standards?

3. How do you know that your organisation's quality improvement process is working? Cite 2-3 examples of improvements that have been made in response to data/information generated by your PQI programme. Include at least one example of a service-delivery/client-related improvement and at least one example of an operations/management improvement.

4. Provide any additional details that would increase the Peer Team’s understanding of how your PQI programme is increasing the organisation’s viability and sustainability.

Attachments:

Completed List of Survey Recipients Form (See Stakeholder Survey Instructions).
Completed Survey Distribution Totals Form.
All COA-approved NA Requests.
A list of all NAs applicable to your organisation provided within the standards.

Note:

Organisations being accredited for the first time: Please provide information for the last year.

Organisations being reaccredited: Please provide information for the period since the last accreditation review.


	Self-Study Documents	On-Site Documents	On-Site Activities
CA-PQI 1 Leadership Endorsement of Quality and Performance Values*	Long-term or strategic plan (See CA-GOV 6.03) For organisations seeking re-accreditation: Pre-Commission Review Report (PCR) Final Accreditation Report (FAR) Maintenance of Accreditation (MOA) Reports for the three most recent years	Governing Body minutes	Interview: Goverance Chair Advisory/Governing Body members CEO Senior management
CA-PQI 2 The Foundation for Broad Use of PQI*	PQI Plan Short term/annual plan(s) Job description of primary personnel assigned to PQI coordinating responsibilities (CA-PQI 2.05) A document or chart that describes PQI structure including committees, work groups, and member lists, as appropriate		Interview: CEO Senior management PQI personnel Staff
CA-PQI 3 Support for Performance and Outcomes Measurement*	Description of what is being measured; including outcomes, outputs, indicators and tools and instruments. See PQI documentation provided with the Service Narratives	PQI committee minutes or other documentation of stakeholder involvement in choice of outcomes, indicators, etc.	Interview: PQI personnel Relevant staff Other relevant stakeholders
CA-PQI 4 Analysing and Reporting Information*	Sample reports of aggregated data See PQI documentation provided with the Service Narratives Stakeholder satisfaction survey instrument	PQI committees/work groups minutes for analysing PQI information Regulatory/licencing or other external reviews/reports (CA-PQI 4.04)	Interview: PQI personnel Relevant staff
CA-PQI 5 Use and Communication of Quality Information to Make Improvements*	Annual performance score card, reports of gains made against goals, or other summary documents or reports provided to internal and external stakeholders See PQI documentation provided with the Service Narratives	Evidence of improvements made from the analysis and use of PQI data, e.g., revised procedures, training conducted, or implementation of an improvement plan Board minutes	Interview: PQI personnel Personnel at all levels External stakeholder groups
CA-PQI 6 Staff and Stakeholder Support*	PQI information provided to stakeholders New personnel orientation materials (CA-PQI 6.02)	Documentation of PQI orientation received by personnel	Interview: PQI personnel Personnel at all levels

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights

RELATED FILES


	PERFORMANCE A measure of how well an organisational system provides services to consumers. Performance is often based on key indicators, such as rates of service, cost per consumer, degree of satisfaction with services, and extent of consumer access to services.


	QUALITY In this context, the extent to which contemporary and generally recognised standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	PROGRAMME A system of services offered by an organisation. For example, an organisation providing a mental health service may offer several mental health programmes to different populations, e.g., a mental health programme for adolescent teens. The word “programme” can be used interchangeably with the word “service” or to describe specific programmes.


	SERVICE One or more organisation-operated programmes or activities that have a common general objective and deploy the organisation’s material and human resources in a planned and systematic manner. An organisation that publicly promotes or identifies itself in writing as offering a service, is licenced to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	ADMINISTRATION The personnel responsible for management functions of the organisation, including fiscal management, human resources, and service delivery. Such personnel determine organisational goals, acquire and allocate resources to carry out a programme, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.


	PRACTICE Established actions or ways of proceeding in the regular performance of organisational duties. Policies and procedures often guide practice.


	PEER REVIEW An evaluation process in which professionals from similar backgrounds review the work of their associates.


	CULTURE The customs, habits, values, skills, technology, beliefs, and religious, social, and political behaviours of a group of people in a specific period of time.


	STAKEHOLDER Any person, group, or organisation that has a vested interest in the services provided by the organisation. Examples: clients, consumers, personnel, funding organisations, referral organisations, vendors, and governmental bodies.


	ACCREDITATION The formal evaluation of an organisation against accepted criteria or standards. A professional society, non-governmental organisation, or a governmental agency may conduct accreditation activities. A COA-accredited organisation has undergone a period of rigorous self-study and is capable of providing programmes and services that meet or exceed COA standards.


	MANAGEMENT See ADMINISTRATION


	EXECUTIVE DIRECTOR See CHIEF EXECUTIVE OFFICER


	CLIENT See SERVICE RECIPIENT


	GOVERNING BODY A person or persons with the legal authority and responsibility to set policy and oversee the operations of an organisation. Generally, the governing body is a group, such as a board of directors or board of trustees. While the exact responsibilities of the governing body depend on the nature and character of the organisation, the governing body has minimum fiduciary responsibilities to the organisation set by Letters Patent, statute, regulation, and case law, and typically assume responsibilities for long term planning, risk management, and evaluation and effectiveness of management.


	SENIOR MANAGEMENT Employees who assume administrative oversight for the organisation’s programmes. Senior management positions may include vice presidents, chief operating officers, assistant commissioners, directors, or other positions that involve management of programme administration. The term does not include supervisors of direct service workers.


	JOB DESCRIPTION Explicit obligations and specific tasks required of personnel as a condition of employment. Such descriptions are in writing and may include educational, experiential, and skill requirements associated with the job.


	PERSONNEL The body of employees and/or volunteers that carries out the organisation’s tasks under the organisation’s administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards.


	INDICATOR A described activity, event, outcome, or benchmark used for measurement in monitoring the quality and outcome(s) of service.


	SAMPLE A portion or representative percentage of a greater whole.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.