1. 1 SQA STANDARDS AND QUALITY ASSURANCE Comprehensive Program Review May 29, 2015

2. SQA STAFF 2 Bill 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

3. 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. 3

4. 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) 4

5. 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 5

6. STAFF TURNOVER RATES 6 Data obtained from HR Staff Turnover and Retention Report

7. RETENTION RATES 7 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

8. STAFF TRAINING HOURS 8

9. 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 9 This an example of a WA evaluation Measuring increase in staff knowledge

10. WALK-THROUGHS SJS Programs: Quarterly Basis Watson Academy and CSMA & CSCT Programs: Semi-annual basis CS-SL: annual basis 10 Walk-ThroughInitial ReportBenefits 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

11. 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 11

12. 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) 12

13. 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 13

14. 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 Report o Development of SOPs o Development of CS CT auditing forms, scoring sheets and satisfaction survey o Drafting of CS NH auditing forms, scoring sheets and satisfaction survey o PREA o Other: (coming soon)  Utilization Rates compiled by SQA  SQA Department Satisfaction Survey  More newsletter articles including Quality Corner 14

15. 15 Proposed ObjectiveProposed Timeline Increase staff training hoursDecember 1, 2015 1.Assess training opportunities and include in IDPs 2.Existing resources i.e. PBS training CQI of SQA July 1, 2015 1.Compile data from SQA Satisfaction Survey by July 30 2.Submit report to key stakeholders 3.Conduct survey annually thereafter Smooth Transition to CJI July – December 2015 1.Hold meetings to share information about SQA with CJI 2.Fuse strengths and talents in projects, as feasible 3.Share resources

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